This topic is a review of the basic principles, importance and literature findings related to skills required by bedside teachers for effective interviewing.
Context of Bedside Teaching
Bedside teaching is defined as the encounter that involves an instructing physician interacting with a patient in the presence of students 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 (Alpert 2009). Clinical teachers, students and patients are viewed as the three sides of the triangle of bedside teaching. Despite changes in the clinical setting of medical education, bedside patient-centred teaching will remain essential to the training of future clinicians. The presence of the patient is essential for optimal demonstration and observation of physical examination, medical interviewing and interpersonal skills, as well as role-modelling, professional and humanistic behaviour.
Teachers need to remember that the roles during bedside rounds are not static; this might demand adjusting to the skill level of students in order to ensure progressive development of their skills, while also ensuring patient's trust in the medical team (Gonzalo et al.2012). Effective bedside teachers will need not only to sharpen their physical diagnostic skills but also to learn how to better communicate with students, house staff, and patients.
Principles of Effective interviewing
A recently conducted qualitative study listed six steps for the bedside encounters including "discussion" as one step. One of the bedside teachers who were interviewed in the study highlighted the importance of an effective discussion or interview in the following quotation; "[It is] often a collaborative effort when we teach directly off of the patient. After [house staff] are done talking to the patient, if I want to elicit anything from the patient, that's when I'll jump in and add teaching points I want to make." (Gonzalo et al. 2012).
According to the reviewed literature, the principles of interviewing require that the teaching doctor be unbiased, translating patient complaints into medically significant terms. They must have a command of language, which is appropriate for and acceptable to the patient, thus avoiding errors in the perception and description of complaints. It is through these principles that students learn how to translate medical terms, ask questions and communicate with the medical team (Kraft and Neitzke 2000). There is much to be learned about the techniques and format of interviewing and the application of these concepts to bedside teaching. Therefore, learning interviewing skills is mandatory for bedside teachers. It should be emphasized that interviewing is a form of oral communication involving two parties at least one of whom has a preconceived and serious purpose, with both of them speaking and listening from time to time.
Goldstein et al. (2005) define teachers who master communication techniques at the bedside as: effectively balancing open-ended and closed questions, using active listening and silence effectively, making smooth transitions, skillfully controlling the interview, and responding to non-verbal cues. Alweshahi et al. (2007) reported that listening carefully to students is an important communication skill and a characteristic that defines ideal bedside teachers. It is not only important for the doctor-student relationship, but also for the doctor and student-patient relationship (Losh et al. 2005; Wiessman et al. 2006).
To be a good listener, teachers need to be attentive, allow others to complete statements without interruptions and leave space for others to think before answering (Silverman et al. 1998). Weissman et al. (2006) state that clarity of voice and pace of speech are important communication components, which are well appreciated by students and patients. Monoroux et al. (2009) consider shifts in the volume and pace of speech during the bedside encounter and the use of medical language in "hushed voices" as a barrier to effective bedside communication, which should be avoided.
There is agreement that the use of simple clear language by teachers is viewed as important for effective bedside communication by both students and patients (Alweshahi et al. 2007; Janick and Fletcher 2003). In Oman, an example of an Arabic culture, Alweshahi et al. (2007) mentioned that using simple and clear language for communication was seen by students as much more important than speaking Arabic.
The language challenge in the bedside teaching encounter resides in the presence of both students and patients in one setting. For students, the use of technical and medical jargon is an important mechanism through which they learn to talk as a doctor. However, this language acts to exclude the patients, ignoring their need to learn from the bedside teaching encounter. In order to address this challenge, Monoroux et al. (2009) suggested new ways of interacting that facilitate patient involvement in education; for example, students could explain their actions and findings to both patients and doctors using medical language plus a lay translation. This approach also helps the teacher gain a more complete understanding of the students' knowledge.
A bedside teaching encounter could be a challenge even to the best doctors because the interview setting necessitates a significant shift in behaviour from that to which we are accustomed in polite society. When indicated, teachers may cut patients short, request specific details, or tell them they are confused, whereas in a polite society we do not. Touching or laying-on of the hands implies healing and when used effectively it is helpful in facilitating control of the interview (Williams et al. 2008). Authors agreed that teachers must fulfill two simultaneous roles in order to control the bedside interview. They are diagnosing the patient's condition based on the data presented and at the same time they have to attend to their students' needs. Students can be assessed by directly observing a student's communication and physical exam skills or by asking effective questions (Janick and Fletcher 2003; Ramani et al. 2003). However, teachers have to prioritize the participants' issues, taking into consideration students' own issues, such as what would they like out of the session, and cater to their needs and deficiencies as well as patient issues such as case stability and patient cooperation.
Effective use of questions was another recurring theme for effective interviewing. Authors agreed that effective balance between open-ended and closed questions should be maintained (Losh et al. 2005). When questioning students, teachers need to avoid the following: questions of a "read my mind type", impossible questions, one-upmanship and asking a junior the same question that a senior failed to answer (LaCombe 1997; Ramani 2003).
Fig.1: Effective Interviewing Skills for Bedside Teachers
References and Further Readings:
- Alpert, J. (2009). Some Thoughts on Bedside Teaching.The American Journal of Medicine122 (3), pp. 203-204.
- Alweshahi, Y., Harley, D., and Cook, D. (2007). Students' perception of the characteristics of effective bedside teachers. Medical Teacher 29 (2), pp.204-209.
- Goldstein, E.A. , Carol. F., Sherilyn, S., Terry, J., , Ramoncita, R. , Hugh, M., Marjorie, D. , and Paul, G. (2005). Promoting Fundamental Clinical Skills: A Competency-Based College Approach at the University of Washington. Academic Medicine80(5), 423-33.
- Gonzalo, J.D., Heist, B.S., Duffy, B.L., Dyrbye, L., Fagan, M.J., Ferenchick, G., Harrell, H., Hemmer, P.A., Kernan, W.N., Kogan, J.R., Rafferty, C., Wong, R., Elnicki, D.M. (2012) The Art of Bedside Rounds: A Multi-Center Qualitative Study of Strategies Used by Experienced Bedside Teachers.J Gen Intern Med.2012 Nov 6. [Epub ahead of print].
- Janick, R.W., and Fletcher, K.E. (2003). Teaching at the bedside: a new model. Medical Teacher25(2), pp.127-30.
- Kraft, M. and Neitzke, G. (2000). Communication in medical education: Students' demands.Medicine, Health Care and Philosophy 3,pp. 85-190.
- LaCombe,M.A. ( 1997). On Bedside Teaching.Ann Intern Med.126, pp.217-220.
- Losh,D. , Larry, B., Richard, W., Theresa, M., Maresca, G., Storck, R., and Goldstein,E. (2005). Teaching Inpatient Communication Skills to Medical Students: An Innovative Strategy.Academic Medicine80 (2), pp. 118-124.
- Monrouxe, L.V., Charlotte, E. R., and Paul, B. (2009). The Construction of Patients' Involvement in Hospital Bedside Teaching Encounters QualHealth Res 19, pp. 918-930.
- Ramani ,S. (2003). Twelve tips to improve bedside teaching.Medical Teacher 25 (2), pp.112 -5.
- Silverman ,J., Kurtz ,S., Draper J. (1998). Skills for Communicating with Patients. Radcliffe Publishing Ltd; 2nd Revised edition edition.
- Weissmann, P.F., Branch, W.T., Gracey, C.F.,et al. (2006). Role modelling humanistic behaviour: learning bedside manner from the experts.Academic medicine 81(7), pp.661 -7.
- Williams, K., Ramani, S., Fraser, B., and Orlander, J. (2008). Improving Bedside Teaching: Findings from a Focus Group Study of Learners.Academic Medicine 83(3), pp.257-264.
Reviewed in January 2013 by:
Samar Aboulsoud, MD, MSc MEd, MAoME, FHEA
Assisstant Professor in Internal Medicine
School of Medicine, Cairo University