|Year : 2021 | Volume
| Issue : 4 | Page : 723-725
The dwindling art of bedside teaching: Lest we forget
Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi, India
|Date of Submission||05-Nov-2021|
|Date of Decision||12-Nov-2021|
|Date of Acceptance||17-Nov-2021|
|Date of Web Publication||29-Dec-2021|
Room 234, Department of Medical Oncology, BRAIRCH, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Tansir G. The dwindling art of bedside teaching: Lest we forget. Cancer Res Stat Treat 2021;4:723-5
One of the earliest introductions of a medical student entering with bated breath into the daunting world of medicine are these words by the pioneer physician himself. Sir William Osler, looking down from a black-and-white-framed photograph high up on a wall says, “Medicine is learned by the bedside and not in the classroom.” Another legendary quote by the same doyen of medicine, “To study the phenomenon of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all,” is imbibed by us when we start our own foray into the unknown. It is with this zeal in our minds that we pore over the unending syllabi and volumes of books, with the ultimate aim of being worthy of reaching the bedsides of our patients. The transition is not smooth; the ward is not the friendliest of places when one steps into it for the first time as an outsider. The Bachelor of Medicine and Bachelor of Surgery (MBBS) student looks at the organized chaos of the intermingling of life-saving, diagnostic, and academic operations with simultaneous emotions of awe and discomfiture. I clearly remember my 1st day in the Internal Medicine ward as a 2nd-year undergraduate, when I was struck by the ease with which the 1st-year postgraduate resident was saving the patients and teaching us at the same time. The way she interacted with the patients, examined them, and elicited findings had a major impact on me, and I believe she was one of the reasons for my subconsciously being so sure that I too wanted to become a physician. As a newcomer, you feel like an awkward cog in the wheel, not fitting in and maybe even causing a bit of disruption here and there. Yet, the bedside of the patient is where the maximum learning is imbibed and where the most enduring memories are made.
This line may have been used too often or even overused, but it is the undeniable truth that medicine is an art. You do not learn art. You imbibe it, audiovisually and tactilely. Hence, the representations in popular media of a doctor's world, solving cases with the two plus two of state-of-the-art diagnostic modalities, cover only a minuscule aspect. The making of a doctor commences from that first nervous encounter with a patient, who may have given the same history to two other people in the past few days and will rightfully be upset about it. The maturity of a doctor begins from the time one understands how to broach a sensitive topic, elicit a vital detail, and discover the elusive link that solves the case. The humanness of the medical profession is universal, as is the humaneness it demands. If the patients and their history form the basis for any doctor's bedside learning, it is the direction accorded by our superiors that seals it. Without the secret nudge of a senior on the rounds or an annoying hint by a consultant, we would not know the do's and don'ts of the job. I say this as a final-year super-specialty resident today that I am a firm believer in the bedside method of schooling, wherein the patient and your teachers both contribute in equal measure. You may be a master of the texts, but in the big, bad world of clinical practice, it is the core of your bedside learning that forms your foundation.
However, I must acknowledge that having spent almost 14 years in this field, I notice a difference in the way we function and acquire learning. I am sure this change has been gradual and has been underway from long ago, but its effects are quite apparent now. We are moving further away from the wards and into the confines of our offices, with PowerPoint presentations and case sheets overtaking the physicality of medical discussions. I believe the reasons for this shift are multipronged and signal a change at the level of students, teachers, and the hospital environs as a whole. Being a doctor means being a lifelong student and a teacher at the same time, and as a student, I would agree that the bedside is not the most comfortable space to be in. And no, this is not a comment on the leg cramps sustained after 4 hour long grueling rounds. As a student, one desires the easy alternative to conversing with a person already in distress while physically searching for the focus of pain in a person who may not be very forthcoming at that point in time. This makes the strategy of pan-testing for everything a convenient alternative. The resident orders every investigation that is known and available to create a panel of results so he/she can piece together the puzzle of the patient's illness. Well, drawing two extra vials of samples, or getting a radiological investigation will only over-discover and will not harm anyone, will it? Even as a teacher, I would probably not be able to offer as comprehensive information standing beside the patient as I could provide from a podium, narrating a lecture. Add to that, the rising patient load and the accompanying paperwork that a senior resident or faculty member has to deal with, which bog the teachers down too. Many hospital administrations press for rapid patient discharges and turnover leading to smaller and smaller windows available for bedside teaching. Hence, is it not relatively easier and maybe more rewarding to limit the dissemination of information to a “class” rather than the interrupted and less-organized setting of a ward? Well, no.
What we (students and teachers alike) must forever remember is that ours is an academic but a deeply humanitarian field at the same time. The fact that trainee doctors are spending a median of barely 2 minutes at the patient's bedside, while they are attending classrooms for more than 1 hour does not bode well. This is because the same trainees will spend the majority of their time diagnosing and treating patients in clinics and not conference halls. While at times, we feel that our repetitive attention to seemingly trivial details would irk our patients, most of them in fact, welcome the intimate interaction. The preciseness of guidelines and the rigidity of protocols can never define the treatment plan for every individual, because a clinician cannot operate in a machine-like fashion. The body follows patterns but not algorithms, hence, bookish knowledge has its limits– limits that are pushed by bedside learning.
Medical oncology is a field that postgraduate residents usually do not get much exposure to, prior to working in the branch itself. It gets extremely intimidating because there are too many guidelines, flow charts, and protocols to master. Notwithstanding the trials, there are numbers and graphs that you are expected to know by your teachers and your patients alike! As a resident working in this branch and living the oncologist's life on a daily basis, I too have been led to believe that oncology is just a game of figures and numbers. However, after spending 3 years in this field, I realize that it is, in fact, a strategist's game. There are data aplenty which have to be strategically tailored to each patient knowing the why and why not. Selection of a therapy is the easier part, the tougher one is knowing how to manage the adverse events that may follow. Moreover, the oncologist must remember not to view the patient as the endpoint of a treatment algorithm, rather they should acknowledge that the body needs supportive care as much as treatment, and that there will come a time when the best treatment will be palliation alone. That is why, we must broaden the tunnel vision that we develop while pursuing our quest for more information. Information is dynamic and must be acquired as we proceed in our careers, but bedside teaching is the tool which helps us in its application.
This fact gets driven home many times, when our tiny fallacies or oversights get picked up during rounds. There may be little details, pieces of history, or a finding here and there that we may have mistakenly overlooked and that are pointed out by our superiors. That pinching moment is humiliating and embarrassing, especially when you have been taking care of a patient and your fallacy gets discovered in front of the very same patient and his/her family. You feel further exposed if you have been reading up on that case despite your tiring schedule and know the data by heart. However, each one of us knows the value of that very moment and its relevance in shaping us as competent physicians. I can never forget the moment when we discovered a systolic murmur in a relentlessly febrile patient of varicella-zoster-induced Guillain-Barre syndrome. He had a vegetation in the mitral valve and improved after treatment for infective endocarditis. I will never undermine the relevance of a good neurological examination, remembering how we caught the early signs of spinal cord compression in a patient with multiple myeloma who reported vague bladder symptoms. I might know the grading of ifosfamide encephalopathy but would probably not have been able to recognize its subtle form had it not been for my consultant who picked it up in a patient and ensured I remembered it for life. It is etched in my memory how, when a sick patient with leukemia was admitted to the ward, my consultant confidently exclaimed that it could be hemophagocytic lymphohistiocytosis. Sure enough, milky blood appeared on the first draw in the syringe! The list is endless, and I am sure all the readers would have their own instances of realization and learning, which remain with them throughout. Moreover, it is not just one-sided for sure, there are definitely those little thrills to be gained when we “school” the tutor and give our superiors some new insights as well. The learning is mutual and fosters feelings of mentorship and bonhomie of a kind that is unseen in other fields. We all have a senior or two with whom our association started with evening rounds or classes in the wards and transformed into deep friendships for life.
The past 2 years have been extremely difficult for the medical community, and “survival” was the only aim whereas academics took a backseat. The world did not know how to deal with the havoc that a previously unknown virus was causing. There were critical patients with acute complications, who had to be managed while securing one's own safety. Hazmat suits were protective but obtrusive; patients were looking at headcovers and goggles and not faces, the only identification being the names scribbled on the suits. The circumstances for the patients were unimaginably lonely and difficult, and for us doctors, newer challenges were created. Through foggy glasses on COVID ward rounds, we discovered cor pulmonale, mucormycosis, evolving digital gangrenes, and instituted appropriate treatment. The relevance of clinical knowledge proved timeless even in the worst of times.
Online meetings and webinars are now commonplace and here to stay, but as we crawl back to normalcy, the tradition of bedside teaching should resume (with safety precautions needless to say). The bedside and classroom need not be mutually exclusive, and clinical skills need not stay alien to theoretical advances. For the best kind of learning, all three parties in the process should be on board with their ideas and expectations. Students can be assigned cases or topics beforehand so that they develop an interest in them when they read and are confident when they present their points to their colleagues and seniors. The most junior doctors of the team are the ones who are usually left out of the discussions, and they too must be involved in academics to pique their interest in the field. Teachers need not have absolute control over the class and should keep the method more conversant and less didactic; a non-patronizing superior who helps us to perfect our clinical skills is always a blessing! And our patients, if taken into confidence prior to initiating any clinical exercise, will more often than not provide us with all the vital information that we require. That is how bedside teaching always has and should function. It perhaps takes a little more effort than settling into a secluded corner and diving into one journal after another on a tablet, but bedside teaching is an invaluable component of our medical curriculum. For this art to never dwindle, we must remember that the uniqueness of medicine lies in the fact that the student is the greatest teacher, and the teacher is the greatest student.
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Conflicts of interest
There are no conflicts of interest.
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