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Overcoming the challenges of bedside teaching in the palliative care setting
  1. Dylan G Harris
  1. Correspondence to Dr Dylan G Harris, Department of Palliative Care, Prince Charles Hospital, Merthyr Tydfil CF47 9DT, UK; dgharris{at}doctors.org.uk

Abstract

Bedside teaching is the process of active learning in the presence of a patient and is one of the most traditional teaching techniques used in undergraduate medicine. Students and patients both appear to benefit from the experience of bedside teaching. However, bedside teaching with medical students and palliative care patients presents a number of challenges for the patient, the learner and the educator. Key considerations for bedside teaching in the palliative care context include: sensitivity to ‘protection’, of palliative care patients by colleagues in relation to their involvement in bedside teaching; consideration of the patient's carer/relative as they will often be present for prolonged periods at the bedside; a maximum of one or two students (not the ‘up to six’ traditionally used in this type of teaching); multiple short encounters with several patients as opposed to a longer encounter with one patient; and sensitivity to the potential impact of the session on the learner as undergraduate medical students and junior doctors may find that while worthwhile and rewarding, the teaching session is also personally emotionally challenging.

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Bedside teaching is the process of active learning in the presence of a patient.1 2

All medical students will encounter patients with advanced and incurable illness during their training and first years as a doctor. Historically, medical training has failed to prepare junior doctors in this area and death and dying have been conspicuous by their relative absence in undergraduate medical curricula.3,,5 More recently, the need for teaching specifically involving palliative care patients has become widely advocated as a core component of the undergraduate medical curriculum.4,,7 Bedside teaching is, however, challenging in this context for the medical student, the patient and the teacher.

This discussion paper describes the role of bedside teaching in medical education in general and then the specific considerations that are relevant when this teaching technique is used in the palliative care context. Several practical recommendations are made for adaptation of this teaching method when used in palliative care. This article reflects the experiences of the author, referenced to the literature where available, but does not profess to be a systematic review of the subject. The author welcomes comments from readers of this journal reflecting on their own experiences, to add to the opinions and discussion presented here.

Bedside teaching in medical education

Bedside teaching is one of the oldest and more traditional teaching techniques used in medicine.8 9 Osler commented that there should be “no teaching without the patient for a text, and the best teaching is often taught by the patient himself”.10

One could argue that there is no need to use bedside teaching at all in palliative care (with the use of alternatives such as actors in communication skills teaching). However, what no other method can emulate is the fundamental interaction between the learner and a human being with a story to tell and an expert account of the experience of an illness in real life, not just its physical presentation but its wider effects on psychosocial and spiritual well-being.

Use of role play (with peers or actors as patients), small group tutorials, lectures or simulated patient scenarios may add to the experience and learning gained from clinical interaction with a patient with a terminal illness. While these alternative teaching methods may therefore supplement bedside learning, they are not a complete alternative as these medical students confirm: “I realised that no matter how much I had been taught in the classroom about the medical-legal jargon of palliative care/end of life issues, it was this very real patient encounter which taught me the most.”3 “I don't think you can be taught these things [death and dying] … it's good that we are presented with those things because if we weren't, then we'd be totally unprepared.”5

While there are some potential disadvantages to bedside teaching (such as fear of patient discomfort, lack of privacy/confidentiality and time pressures in a busy clinical environment), there are also many benefits.10 Bedside teaching facilitates teaching and direct observation of a student's history and examination skills, use of understandable and non-judgemental language and professionalism.2 10,,14 This is similar to the recent move in postgraduate education towards work-based assessments in the real clinical world to assess competence rather than pure reliance on theoretical or simulated examinations.15

It also empowers the patient as a teacher, in their role as an expert in their own illness, and may also help increase the patient's insight into their illness.10

In fact, not only do learners appear to find bedside teaching valuable for learning clinical skills,1 14 but patients also largely appear to enjoy it as they feel that it shows physicians are interested in them, it gives them the opportunity to ask questions, it facilitates a better understanding of their own illness and they feel an integrated part of trainee teaching.2 10,,13 16 17 Bedside teaching may therefore enhance patient autonomy.

Bedside teaching: maximising educational value

To make the experience educationally valuable, various strategies are recommended: adequate preparation (eg, ensuring the teacher is familiar with the clinical curriculum); orientating the learners to the objectives of the session; agreeing the ground rules (eg, that any sensitive discussions are postponed until the group have left the patient); deciding how they (the teacher) will challenge the learners' minds without humiliating/intimidating them (eg, by giving gentle corrections, and emphasising that as the educator you are willing to learn from the trainees as well as the patient); and, debriefing and reflection after the encounter with the patient to resolve any unanswered questions or sensitive issues.12,,14 As Ende18 suggests, bedside teaching “should be lively, challenging, and fun. No one should be hurt, no one should dominate, and everyone should learn”. A group of less than six learners is recommended in order to prevent disruption to other staff on the ward, promote active learner participation, keep noise levels to a minimum, avoid overcrowding and reduce potential distress to the patient.2

To ensure the session is considerate of the patient, consent should be gained ahead of time,10 with clear information imparted to the patient to explain who the teacher is, who the learners are and what the purpose of the session is.10 13 If the teacher arrives at the bedside already with a group of medical students, the patient will feel pressured to agree even if inwardly they do not wish to participate.

During the session the teacher should clarify for the patient when theoretical discussions arise that these do not apply to them.13 In fact, there is an argument for complete avoidance of ‘what if’ theoretical lines of discussion (eg, ‘what if Mr Smith also had …’) as this may confuse the patient.10

The teacher should also assist the learners to avoiding technical language: Janicik and Fletcher10 cleverly suggest that one learner could be assigned the task of noticing the language and bringing this aspect of the patient's comfort to the attention of the group. A summary and ‘thank you’ to the patient should end the session.13 The final pastoral care of the patient should take place after the teacher has ended separate discussions with the learners, with a return visit to the patient to clarify misunderstandings and answer questions.10 12

These strategies, both to assist the learner and protect the patient, have been assimilated into various models of bedside teaching which broadly encompass three phases: preparation before approaching the patient; the actual teaching at the bedside; and, the aftercare and reflection with the learners.

Cox19 describes two component interlocking cycles: the ‘experience’ cycle and the ‘explanation’ cycle. During the experience cycle, the teacher should explore the learners' prior knowledge and brief them with an overview of the session, followed by the clinical interaction and debriefing. During the explanation cycle, the teacher should stimulate the learners to reflect on the experience and how it fits with their prior learning, what unanswered learning questions remain (and how they will answer them) and how it will influence their future encounters with their next patient. It is important to remember that the patient component is only half the learning experience with the learner reflection afterwards adding a whole other cycle of learning. In fact, some authors state that the patient encounter may form as little as a third of the overall learning experience.20

Bedside teaching: specific considerations in the palliative care setting

There is little direct research on the role of bedside teaching in the palliative care setting. Anecdotal evidence suggests that student learners highly value bedside teaching in this context because the experience helps reduce fears and concerns about talking to dying patients.5 20 There is also some evidence that direct interaction with cancer patients (as opposed to patients without a life limiting diagnosis) has a more positive effect on overall communication skills.21 Equally, medical student interaction with patients with advanced cancer does not appear to be burdensome or harmful to the patient, to the contrary as patients seem to find such interaction beneficial.22 23

While there are limited empirical research data, bedside teaching with patients with terminal illness has been discussed as an area worthy of specific consideration in the medical education literature.3 23 Most of the (limited) previous exploration of this area has focused around patients with advanced cancer, whereas in reality there are many hospitalised patients with non-malignant disease to whom this discussion topic will also apply.

This is particularly relevant as the model of palliative care has changed (from purely an aspect of the very final stages of a patient's illness to one that begins at first diagnosis and gradually becomes increasingly important as the active treatment options fade). It has become widely recognised that palliative care is as relevant to these non-malignant conditions as it is to cancer with which it has traditionally been associated. The following discussion may therefore apply to far more hospital inpatients than one may initially think and is certainly not limited to patients who are inpatients in a hospice.

Barriers in the palliative care setting

There are also some additional barriers reported in the literature, including the increased ‘protection’, particularly from nursing staff, against bedside teaching with this group of patients.20 This may in effect be unintended paternalism: with best intentions, an assumption is made about what the patient may autonomously decide but without directly confirming with the patient that this assumption is correct. This is in contrast to intended paternalism where the professional has made their own decision about what they personally feel is ‘best’ for the patient.24 It may be helpful to ask the ‘protecting’ colleague to accompany you when seeking consent from the patient, so that they are satisfied that no undue pressure has been applied and you are satisfied that the patient has been able to make the decision for themselves.

A further barrier or difficulty may arise from the unpredictability or rapidly changing condition of palliative care patients: a patient who has consented to teaching a short time before may become suddenly unable to participate. Wee suggests that this unpredictability (and therefore the need for a change in the teaching brief by the teacher) can actually be turned into an advantage as it helps the student learners to appreciate clinical unpredictability and uncertainty.20

Finally, an added consideration is that the patient's relative or carer will usually be at the side of the patient for prolonged periods in the palliative care setting. As it the patient who is the focus of the teaching, they should be asked beforehand whether they wish a family member to be present. The teacher may return to the patient to find friends or relatives whom the patient did not consent to have present. Asking the patient if they want their friends or relatives to leave for the teaching session is a weighted question (the patient will feel pressured to say ‘no’). It may therefore be wiser to simply say “I can see you have visitors at present, is it convenient to continue with our teaching session? We are very happy to come back another time”. This therefore gives the patient the opportunity to politely decline but without having to give a specific reason.

Adapting the bedside teaching model in palliative care

The previously discussed basic principles of bedside teaching and potential gains for the learner and patient are all still relevant in the palliative care setting (box 1).

Box 1 Seven tips for bedside teaching with palliative care patients

  1. Be sensitive to increased ‘protection’ by colleagues preventing palliative care patients engaging in bedside teaching: allow the patient their own autonomy to decide if they wish to participate.

  2. When preparing/planning teaching, consider the potential for rapid change in a patient's condition and therefore a need to amend your teaching plan at short notice.

  3. Seek the patient's consent for their carer/relative to be present in the session as they will often be present for prolonged periods at the bedside in the context of palliative care patients.

  4. Given the context and sensitivity of the situation, a maximum of one or two students may be preferable to the ‘up to six’ traditionally used in this type of teaching.

  5. Given the prevalence of fatigue, lethargy and depression in this patient group, consider multiple short encounters with several patients as opposed to a longer encounter with one patient.

  6. Always return to the patient (and carer) afterwards to check for any unresolved questions or issues that have now been uncovered.

  7. Be sensitive to the potential impact of the session on the student (as well as the patient): undergraduate medical students and junior doctors may find that while worthwhile and rewarding, the teaching session is also personally emotionally challenging.

Respectful and tactful handling of ‘protection’ from ward staff towards the patient may be necessary and the patient must be allowed to exercise their own autonomy in deciding whether they would be happy to participate in teaching by asking them in person before the session (and without the group of learners present).

Given the context and sensitivity of the situation, smaller groups of one or two students may be wiser than the ‘less than six’ quoted earlier. Given the high prevalence of weakness and fatigue in this patient group, the teacher should also aim to spend less time at the bedside than one would with a ‘fitter’ patient. Depression is also prevalent in this patient group (although often under-diagnosed) and should also be given consideration, particularly as it may reduce the patient's autonomy.

In hospital medicine, one might use the same patient with sequential groups of learners if they have ‘good clinical signs’ or give a good history. However, in the palliative context, one should avoid repeatedly using the same patient for those reasons, after all every patient has a story to tell and therefore something to teach. Indeed, it has been suggested that learning can be staged in palliative care by learning different aspects through short encounters with different patients.20 These modifications should still facilitate beneficial learning from a dying patient but reduce the potential burden to the patient of the experience.

Finally, much of the focus in the literature relates to ensuring the comfort and sensitivity of the patient. It is the challenging part of the “lively, challenging and fun” ethos of bedside teaching cited earlier that is most likely to apply in the context of bedside teaching with a terminally ill patient. Not just the challenge of assessing a complex patient with complex symptoms and a complex medication regime but also the emotional challenge of talking to a dying patient. This could be seen as a negative factor, however, there is evidence that students (while acknowledging this emotional challenge) find this learning experience valuable to prepare them for the challenges they will face as doctors and one which cannot be gained from any other teaching alternative.3 5

While models of bedside teaching suggest that the teacher should return to the patient to ensure the session has not left any unanswered questions or caused distress, in the palliative care context this pastoral role should extend to the learner. It is also therefore important to ascertain beforehand, in confidence, whether any of the learners have current or past personal events that may influence their participation in the session (eg, if they have a relative with a similar diagnosis to the patient to be included in the teaching session).

Conclusion

Bedside teaching is a widely recognised method of teaching a variety of skills to medical learners. There are a number of strategies that the teacher should consider both for the learner and for the patient to ensure that everyone experiences maximum benefit and minimal harm.

Bedside teaching is not incompatible with the palliative care setting, but some extra thought and planning is required (box 1). In particular, the use of smaller groups of students with shorter patient interactions is advised. The teacher should be sensitive to intended or unintended protectionism from ward staff toward frail patients and also to relatives and carers who are more likely to be present than in other clinical contexts. Finally, there is a larger pastoral requirement on the teacher to ensure minimal distress and emotional upset for both the patient and the learner who may find the encounter emotionally challenging. Finally, there are always benefits for the teacher, and while bedside teaching in palliative care is challenging, it is worthwhile to remember “you will learn that your students have a great deal to teach you, and that patients do as well”.12

References

Footnotes

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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