There is general agreement throughout academic medicine that bedside teaching and its concomitant honing of clinical skills have been eroded significantly by changes in the financial environment of academic medical centers, as well as by changes in residency work hours. The large-volume clinical care system that is currently in place in academic hospitals occurs at the expense of time for teaching medical students and residents. Medical education in the third year of medical school has become much more classroom/seminar oriented rather than hands-on bedside teaching. A variety of surveys involving medical students demonstrate that students still perceive hands-on bedside teaching as one of the most valuable components of their medical education.(1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12) Patients also view bedside teaching in a positive manner.(4, 9, 10)
Those of us involved in teaching medical students (undergraduate medical education) and residents (postgraduate medical education) have observed the problems involved in guaranteeing adequate hands-on clinical training during the third and fourth year of the medical curriculum. Duty-hour regulations imposed by the Accreditation Council for Graduate Medical Education on resident work efforts have had a definite negative impact on medical student perceptions of resident teaching.(13)
Bedside teaching involves the instructing physician interacting with a patient at the bedside to elicit the patient’s history, demonstrate key features of the physical examination, and discuss the best approach to diagnosis and therapy for the patient. Bedside teaching was first mentioned in the 13th century by Geilielmus, a physician who taught diagnosis and therapy at the bedside.(14) The original Hippocratic oath enjoins the physician to teach the craft to younger colleagues. Osler, the founder of our modern clinical medical education system, emphasized bedside interactions among the patient, the teacher, and the student. In fact, Osler requested that the epitaph on his grave should note only that he taught medical students at the bedside!
Thus, we have a serious conundrum in the 21st century: it is universally agreed by students, faculty, and patients that bedside teaching is important. Moreover, it is quite clear that skills are inadequately learned by students and residents when they receive insufficient training at the bedside. Finally, the quantity of bedside teaching, and hence, clinical bedside skills, have progressively deteriorated over the last 30 years.(14)
What can be done to remedy this serious problem? Clinical educators are stressed to the maximum because of reduced reimbursement rates for patient care. In the past, when more generous reimbursement rates existed, clinicians were happy, even proud, to donate their time and effort to educate medical students in clinical pursuits. The economic necessities of today have severely curtailed the ability of both private practitioners and academic clinician-educators to provide quality bedside teaching. What are we to do?
Faculty educators throughout the country have experienced this dilemma in recent years, and they have tried valiantly to preserve bedside teaching time by utilizing a significant portion of dollars from a variety of sources to support the teaching mission. Nevertheless, it is still widely felt among clinician-educators that we are still not providing adequate instruction in bedside teaching.
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— Joseph S. Alpert, MD
This article was originally published in the March 2009 issue of The American Journal of Medicine.
