Posts tagged Academic Emergency Medicine
Let's Go Back to the Bedside

There is clinical teaching… and then there’s bedside teaching. Some of our very best clinical teachers rarely go to the bedside with their learners, a trend that has worsened over the past two decades. Why? And how do we get our clinical teams back to the bedside?

Image from upsplash.com

Image from upsplash.com

Sir William Osler said it best, ‘‘Take [the student] from the lecture room, take him [her] from the amphitheater. Put him [her] in the outpatient department, put him [her] in the wards. No teaching without a patient for a text, and the best is that taught by the patient himself [herself].” 

Osler’s call was to bring students from the classroom or the laboratory to the bedside -- to perfect their physical examination skills, to observe the professional behaviors of their mentors, and to be observed performing patient care by their preceptors. Today, the challenge isn’t to get students out of the classroom, but rather away from the electronic medical record. Our learners are charting, billing, and physician-order-entering all day long… often on workstations on wheels, in hospital hallways, just yards away from their patients. 

These same patients desperately want time with their physicians. And they trust us less and less, as a profession, because they don’t see us hard at work taking care of them — in the hallway.

What changed?

The answer is likely multifactorial, with some obvious causes. Our hospitals are overcrowded. Clinical performance metrics push us to work faster, with a paradox of less time spent in direct patient care. Documentation is a time-intensive and complex task, a response to litigation risks and billing rules. Supervising physicians are pulled in many directions, but rarely in the direction of the bedside. 

And what’s worse? Trainees who are taught in hallways teach in hallways. Our profession is forgetting the bedside teaching skills that Osler so passionately endorsed.

There are expert medical educators among us who are trying to retrain faculty members to teach at the bedside. Two Stanford courses are noteworthy for those interested in becoming better bedside teachers: Stanford25 Skills Symposium: Promoting the Culture of Bedside Medicine and the Stanford Faculty Development Center Clinical Teaching Program. Similar training (or, retraining) courses are popping up around the country, should you be unable to make your way to Palo Alto to participate in one of these fantastic programs. I also refer you to the Society for Bedside Medicine if you want to learn more about this topic and opportunities for skill development.

In 2006, Amer Aldeen and I published Bedside Teaching in Emergency Medicine in Academic Emergency Medicine. This article reviews the critical importance of bedside teaching to medical education, the historical decline of this professional skill, and strategies to overcome the above listed challenges.

Check out the Stanford bedside teaching courses, the Society for Bedside Medicine, our article in AEM… and let’s go back to the bedside with our trainees.

July 26, 2019

Co-Author of original article: Amer Aldeen, MD – US Acute Care Solutions.

Ethical Dilemmas, Simulated

My most-cited publication to date describes a research project that I conducted during my Faculty Development Fellowship at Stanford University in 2003, “Assessment of Resident Professionalism Using High-fidelity Simulation of Ethical Dilemmas”. Medical simulation centers are wonderful venues for teaching high-risk tasks in low-stakes environments: the perfect settings for teaching medical ethics.

Image by upsplash.com

Image by upsplash.com

In 2003, medical simulation was still a relatively new teaching tool and the options for training seemed endless. I was particularly interested in medical ethics at the time and thought to marry that interest with my medical education training.

The design of the study was simple enough: emergency medicine residents who were managing a simulated clinical case would encounter an unexpected ethical dilemma – not all that dissimilar from day-to-day clinical practice. We designed a “Professionalism Performance Assessment Tool” as a checklist of dichotomous options for management of the case. Trainees either followed ethical and professional standards during their management of the simulated case or they did not, yes or no. A critical action was included in each case.

The ethical dilemmas selected in this 2003 research study are still important topics for trainees to learn about today. Five cases were used to test concepts in key domains: Patient Confidentiality, Informed Consent, Withdrawal of Life-sustaining Treatment, Practicing Procedures on the Recently Dead (Hint: Don’t do this!), and Do-Not-Resuscitate Orders.

I’ll always reflect fondly on this project because it was the first medical education research study that I designed and executed as the principal investigator. Thanks once more to my project mentors at the time, Drs. Rebecca Smith-Coggins and Phillip Harter. (Dr. Harter still co-directs Stanford’s Medical Education Scholarship Fellowship today!)

Read more about the study design, case development, and study outcomes in our article in Academic Emergency Medicine.

May 15, 2019

Co-Authors of Original Article: Rebecca Smith-Coggins, MD – Stanford University, Phillip Harter, MD – Stanford University, Robert C. Soltysik, MS – Veterans Affairs - Chicago Health Care System, Paul R. Yarnold, PhD - Northwestern University