Introduction to Bedside Teaching

Additional Info

• Audio File:uab/ua165.mp3
• Doctors:Mullins, Haddon;Willig, James
• Featured Speaker:Haddon Mullins, MD | James Willig, MD, MSPH
• CME Series:Quality and Outcomes
• Post Test URL:https://cmecourses.som.uab.edu/mod/quiz/view.php?id=4350
• Guest Bio:Haddon Mullins, MD is a General Surgery Resident. 
  
  James H. Willig, MD, MSPH, is the Associate Dean of Clinical Education in the School of Medicine. He attended Medical School at the Instituto Tecnologico de Santo Domingo (INTEC) and completed his residency at the University of Virginia Roanoke-Salem. At UAB, Willig has earned an M.S. in Public Health and completed an Infectious Diseases Fellowship. 
  
  
  Learn more about James Willig, MD, MSPH 
  
  Release Date: November 9, 2020
  Expiration Date: November 9, 2023
  
  Disclosure Information:
  
  Planners:
  James Willig, MD, MSPH
  Professor, Infectious Diseases
  
  C. Haddon Mullins, IV, BS, BA
  UAB Medicine
  
  Jill Deaver, MA, MLIS
  UAB Medicine
  
  Adam Roderick, M.ED.
  UAB Medicine
  
  Anne Zinski, PhD
  UAB Medicine
  
  Caroline Harada, MD
  Associate Professor, Geriatric Medicine
  
  Ronan O’Beirne, EdD, MBA
  Director, UAB Continuing Medical Education
  
  Katelyn Hiden
  Physician Marketing Manager, UAB Health System
  
  The planners have no commercial affiliations to disclose.
  
  Presenter:
  James Willig, MD, MSPH
  Professor, Infectious Diseases
  
  Dr. Willig have no financial relationships related to the content of this activity to disclose.
  
  There is no commercial support for this activity.
• Transcription:UAB Med Cast is an ongoing medical education podcast. The UAB division of continuing education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA category 1 credit. To collect credit please visit www.uabmedicine.org/medcast and complete the episode’s posttest.
  
  Melanie Cole (Host):  Welcome to UAB Med Cast. I’m Melanie Cole and today, we’re discussing an introduction to bedside teaching. In this panel, are Dr. James Willig. He’s the Assistant Dean of Clinical Education at UAB Medicine and Dr. Haddon Mullins. He’s a General Surgery Resident at UAB Medicine.
  
  James Willig, MD, MSPH (Guest):  Welcome to the first episode of The Medical Educator podcast series. Haddon Mullins and myself, James Willig have decided to discuss a lot of important topics about medical education, looking at both the perspective of a clinician who has been teaching on the wards for about 15 or let’s just say, far too long to mention and Haddon who has carefully reviewed the evidence available to a lot of the things that we do. And our goal with this podcast, is to really fuse both some experiential learning about teaching on the wards and clinical education in general and to contrast and with the evidence that’s available, so that we may all become more evidence based educators and offer the best of both worlds to our students. So, with that, Haddon, tell us about the topic for today.
  
  Haddon Mullins, MD (Guest):  So, the topic for today, is bedside teaching. And this is an introduction. So, we’re asking the question why bedside teaching? Why should clinicians be concerned with taking teaching to the bedside, performing bedside rounds with students and making sure that they follow certain steps during that encounter with the patient? What’s the advantage of a bedside round over a conference round? Or what’s the advantage of just say interaction with the patient that doesn’t necessarily meet specific criteria?
  
  To begin the conversation though, I think it would be smart to define bedside teaching. So, I have some definitions that have been defined by clinicians in the literature but what would your offhand definition of beside rounding be?
  
  Dr. Willig:  So, to me, I think beside rounding really involves going to the bedside, interacting directly with both the patient and the family and really having the conversation where you update them about the news of the day, and you have the opportunity to field their questions and provide them information so that they know which direction treatment is going to take. What’s the literature say?
  
  Dr. Mullins:  Well there’s a number of definitions in the literature. I think one of the best ones is defined by Gonzalo and others in 2010, defined as bedside teaching rounds as a minimum of two physicians attending or house staff, performing all three of the following at the bedside in the presence of the patient. One, case presentation and history. Two, performance of at least one physical exam skill and three, discussion of the patient’s daily plan of care. Other definitions of what could also be considered rounding included walk rounds, which was any form of interaction with the patient by a minimum of two physicians that did not meet all three of the parameters above. And any form of rounding that did not include patient interaction was defined as a card flip.
  
  Dr. Willig:  I see. Well those certainly are comprehensive definitions. So, really it talks about the elements and has to be more than one clinician in the room and then the other three elements are that you both present the case, that you perform or demonstrate at least one physical exam finding, and ultimately, that things are patient-centered in terms of discussion of the case and the plan and the questions are fielded and answered.
  
  Dr. Mullins:  Correct. And I also think it’s important to define the vocabulary for what we are comparing against too. So, walk round, or a card flip or a conference round.
  
  Dr. Willig:  What are those?
  
  Dr. Mullins:  So, a walk round would be an interaction with the patient but maybe let’s say you don’t perform a physical exam finding. Or you don’t present the case. You interact with the patient, but you don’t meet all three criteria.
  
  Dr. Willig:  So, if I’m going rounding across the wards and we are presenting in the hallway and I step in and I say heh, say a couple of words to the patient and maybe answer a question or two; that would be more of a walk round as opposed to a bedside round.
  
  Dr. Mullins:  Exactly. That is a walk round. And then they define it as a card flip a conference round would be in a conference room. The patient is not involved at all in any way.
  
  Dr. Willig:  Certainly, we do that particularly for time limitations is we are post call, or sometimes to get initial presentation but one thing that really bares out in clinical practice that sometimes we have a combination of these strategies where you might start with discussing something in the conference room and then combining that with some bedside interaction, maybe not to the level of to be considered bedside teaching, but at least to have sort of a walk rounds. But surely, it’s a hybrid of a couple of strategies.
  
  Dr. Mullins:  Right and so we can talk about that and there’s some literature that asks that same question or tries to ask the same question in terms of out of those three categories, what is happening on the wards or in inpatient round. Most of this data that I have is from inpatient medicine wards, which would be your experience. So, again, offhand or from your experience, if you could put a number on it, that would be great or just in generalities what is occurring. Are people meeting those three criteria every time? Is it more of a walk round? How many physicians prefer just a conference room? What about your personal preference? You could start with that.
  
  Dr. Willig:  Okay, so personally, I think I’ve seen an evolution in what I’ve done over the last decade. Initially, I was much more focused in presenting findings outside of the room and just kind of getting in there and for efficiency sake, just try to move through rounds in that way and I felt that that provided the best efficiency. Then in subsequent years, was introduced to literature talking about how if you take a seat in the patient’s room, there’s a perception that you spend more time there despite you spending an equivalent amount of time whether you are standing or you’re sitting. The clinicians that were sitting, really people feel like they spent a lot more time with them and that was a more meaningful interaction.
  
  The move towards the bedside for me really came and I think it adds efficiency for me and I think in the last five years, I’ve probably been I would say over 90% bedside because I do think that it speeds me up. When I hear the students or the residents present the case and I’m standing by the bedside, I’m inspecting the patient, I can interject with some questions over there and get reconfirmed facts of the presentation or the physical exam right there as I’m hearing the presentation. It helps me remember stuff better. It helps me sort of target my physical exam as I’m there. And it gives me a ton of time to observe the interactions between the residents and the patients. It gives me a ton of time to observe the interactions between the patient and their other family members whether they hear strange findings, who do they look to for reassurance, are they scared, do they seem to be – what’s the family dynamic there?
  
  And that’s all information that I can help as I try to move folks towards a treatment plan that we’re going to recommend, understanding the dynamics and who they – which family members are really involved, which family members do they rely on. I think that that allows me to include the right people in difficult discussions going forward. So, now, I really feel that bedside rounds really speeds me up and about the only time that I do what you would consider a card flip, would be on post call rounds where the night call resident is presenting to me and they’re not going to go out there and round with me. So, I’ll go ahead and hear the presentation. The only other time I might consider doing things outside is I’ll ask the residents is there anything of a sensitive nature that you feel would be counterproductive to discuss in the patient’s presence? Sometimes there’s sensitive things. Sometimes there’s a difficult history. I can imagine cases of sort of drug seeking behavior or cases where there really is – is there a suspicion of domestic violence and I have both partners in the room. Those are types of situations that it will help me know a little bit more about them ahead of time or any insight into the dynamics in the room that might help me more likely move towards a good treatment plan.
  
  So, other than those two instances, for most of my rounds, I would say that I go right to the bedside and have that discussion there with the patient at the center of it.
  
  Dr. Mullins:  That’s great. And that seems to be what – it’s a little complicated in the literature. Because you deal with how do people categorize and how different studies define what a bedside round is. So, we’ve already come up with a definition for bedside rounds and for that definition, was Gonzales 2010, found that percentage of attendings hitting all three criteria was less than 1% of bedside rounds. Other people when you are a little more lenient with it, and say well, some people might be in a combination of strategies such as [00:09:59] 1986 found that 77% had a combination of conference room and beside. So, I feel like that’s a little more realistic that different attendings have different barriers or different inclinations at different times to get towards the bedside or go to the conference room.
  
  Another study, found that hallway rounds was the most preferred 58% but that could mean that part of it’s being done in the hallway, part of it’s being done at the bedside like you initially did. So, it seems that there is bedside teaching going on but maybe not an entire clinical encounter so often or they are some of it’s done in the conference room like you said.
  
  Dr. Willig:  Now just to clarify, those are studies. You mentioned some dates on them. There was something as recent as 2010, but I believe you quoted some literature from the late 80s and – I wonder what – if this has evolved over time or if you found evidence in the literature that bedside rounds are more prevalent nowadays as opposed to a few decades ago.
  
  Dr. Mullins:  Yeah, so, that’s a good question. It’s a little bit of a complicated question. A lot of the literature lists two particular studies to quote the decline of bedside teaching as I stated and it’s in a lot of introductions and they’ll say bedside teaching has decreased from 75% to 16% are kind of the numbers over the past 30 years. and it’s a little misleading. The two studies that they are quoting are 1964 study by Reichmann quoted 75% of attendings and students see the patient together during or after case presentations.
  
  So, it’s a liberal definition. But that 75% of the time, they saw the patient together at some point. And then the other study is Collins from 1978 that said 16% of time during rounds occurred at patient bedside. So, when they say it’s a decrease from 75% to 16%, it’s from two different studies that are using two different definitions of bedside rounds. So, there is some indication that bedside rounding has dropped off and there are a number of other studies that people use the same study from 1986 that had 77% of the combination also reported 8% of teaching rounds done only at the bedside. So, that’s 8% of people recorded in 1986 are doing what you say you do now and that the whole encounter is done at the bedside.
  
  The most recent from 2017, was who listed 58% at hallway rounds. So, if you look at the 1986 and they say 8% of teaching is done only at the bedside and then you look at 2017 and say 58% is done in the hallway with 19% done only at the bedside; that indicates either actually an uptrend in strictly bedside teaching or probably more likely staying close to the same where people are teaching in the hallway and at the bedside, in the conference room and at the bedside or a combination of any of those.
  
  Dr. Willig:  So, comments about all of that, that you just shared with us. I mean certainly these are very different decades and the evolution of rounding and the patient interactions in terms of the societal norms of judging those interactions or facilitating those interactions have probably changed over time. So, it’s in some ways, it might be factors like what role does that play. What role do the specific institutions or the size of these studies or the methodology used. I guess it’s tough to quantify exactly how much it’s occurred but it seems like the more recent literature really points to a combination of strategies whether it’s around 19 to 20% exclusively bedside but it sounded like it was in the high 70s where people were doing what we would define as hallway rounds where they would discuss the case but then go in and interact with the family and the patient directly. So, really, it seems like rounding overall, has rounded out or has migrated out of a conference room into at least the hallway and the room overlapping those two areas or really, migrating entirely into the patient room in at least one out of every five locations by the latest literature that you quoted.
  
  Dr. Mullins:  Right and so, like I said, some of these papers in the literature quote these two very old studies, the 75% to 16%. That’s a little misleading and not necessarily a good representation of what is actually going on. But all of these studies and the big problem with all of these studies is that they are low numbers, low response rates and what we can talk about here in a second is individual barriers are going to vary as well. And reasons for doing certain things are going to be everything from practical to theoretical, I guess you could say.
  
  Dr. Willig:  Well let’s pull on that thread. Because I know that this was a part of your literature review. Why do bedside rounds not occur? The barriers that people point to, what are the things in the literature that say stand between us and the beside to have these rounds?
  
  Dr. Mullins:  Right so, initially, there were a number of studies done decades ago that really point towards patient comfort and concern. There was a lot of studies done to test that. Does presenting at the bedside, concern the patient or is it even some studies ask the question is it traumatic for patients? As recent as 2009, Gonzalo 2009, reported 75% or respondents believed that rounding prevented freedom of discussion, 66% were concerned for patient comfort and another 66% had concerns for patient’s feelings.
  
  Dr. Willig:  And these are clinicians being asked about what is your perception of how this interacts with the –
  
  Dr. Mullins:  Yes, these are clinicians.
  
  Dr. Willig:  This is very interesting because I think I see some of that reluctance in some of our learners. And certainly some of our attendings. And yet, I think that prefacing around conversation with some comments like heh, listen, all of us are working together to find the best possible solution for you. So, we’re going to engage in some discussion to find the best way that we an collectively come together with because none of us is as smart as all of us together. So, here we go. And sometimes, you can see people’s anxiety, particularly when we slip into jargon, when we use strange vocabulary and you can sort of see the eyes darting around and people getting nervous. But I found that prefacing with those types of comments I’ve heard a lot of appreciation from people that actually see us working, that actually see us having discussions about the risks, the benefits, and when we take the extra step to go from the jargon to really explain things in plain language; for the most part, I’ve encountered a lot of comfort and appreciation where people see their physicians being very honest and they don’t have all the answers and they also see you working through things, trying to provide them the best care that we can do collectively.
  
  My impression is that it almost elevates every learner in that room in the eyes of the patient. Because they can see, they are engaged, they are participating members, they are all contributing to the discussion and I think that has for the patients that I’ve treated, for the most part, created more of a sensation of comfort and understanding that this team really cares about you.
  
  Dr. Mullins:  Yes and there are – in spite of that one study, and those concerns, there are a number of studies that have looked at and surveyed and questioned and even measured blood pressure and as far as norepinephrine levels of patients during bedside rounds and the consensus is that to not perform bedside rounds due to patient concern is not a legitimate reason to not perform bedside rounds.
  
  Dr. Willig:  What do you mean?  
  
  Dr. Mullins:  Patients from surveys, surveyed from 1989 had 85% of patients like presentations at the bedside. From 1980, 94% were pleased with bedside rounds and believed they should continue. 1941, most patients preferred discussions especially if they had experience with bedside rounds before, which is something we can return to again. 1997, patients with bedside presentations reported doctors spent more time with them, 2003, you have inpatient exam, in room exams, patients had greater satisfaction working with medical students, 2010, patients received bedside rounds preferred them and perceived more time spent at bedside.
  
  And that is a number of studies saying patients, for a large majority, prefer bedside rounds especially if they had experienced them before. And that’s interesting and it leads me to another point in that one of the main barriers to bedside rounds or a barrier to bedside rounds, it’s kind of interesting, in the literature that attendings seem to prefer them and if they don’t have time or they don’t – there are different practical barriers that prevent them from going to the bedside. They still believe, tend to believe in the educational value of bedside rounds and want to perform them.
  
  House staff, on the other hand, residents, interns, and students tend not to prefer bedside rounds. They tend to prefer a conference presentation in conference rooms. Namely because sometimes they believe a bedside round can undermine their authority if they appear to not know the answer in front of the patient or from a student perspective, stress, nervousness, they feel more comfortable in the conference room or from a personal experience, and from literature as well is that students also had these concerns about patient comfort.
  
  So, that tends to be a barrier as well but from the same literature that studies a lot of this and asks a lot of different questions to patients and residents and students at the same time, is that the more students are exposed to bedside rounds, the more they tend to prefer them. So, and that tends to be an important distinction in terms of why take students to bedside rounds if they don’t prefer them. Or why should you make the effort to overcome that barrier to bedside rounding.
  
  Dr. Willig:  It’s very interesting that a lot of the barriers really come more from our side than from the patient’s side who across decades of literature, clearly prefer that discussion at the bedside. And I do think that there’s things that you can do to show respect to your learners, to ensure that you are discussing things clearly with them, that you’re not – that you’re including them in the decision making, that you’re not just throwing what they said off to the side or being very mindful of being respectful and inclusive to your learners can decrease some of that sensation. And sometimes a subtlety that I will do is I’ll wait – if I have feedback on the quality of the presentation or on things that the student can do better; I will wait to provide that feedback, back in the hallway. But the discussions about the case, often the student will read something about the case, and I give them their time to really say okay what have you read about this. What are your thoughts? How about consider this treatment course?
  
  But I do think that treating the learner with a measure of respect and really including them in the decision making that’s going on there, can really take away some of these negative feelings. An interesting quirk is that I’m often asked by students well, how do I get honors? How do I get honors in the rotation? And I always sort of say that you get honors when you do things that I don’t directly observe but that really are patient-centered and patient-focused. And sometimes I don’t have a window into that. Other people come up and tell me things or patients will sit and share their appreciation of the student with me. One thing that I can see, is when we’re in the room, and sometimes I will make a suggestion in terms of the management to the patient and there will be a moment where the patient will look over quickly at the medical student and the medical student will imperceptibly nod in agreement and then the patient will look back at me and say, okay, we can do that doc.
  
  And it always makes me smile because how I read that interaction is this strange man over here is telling me to do something let me turn to the doctor that I trust who has spent hours with me, has educated about my disease, has shown interest and has earned my trust, okay, they agree with this relatively strange attending at the foot of the bed so, now they turn back to me as the attending and they say, okay, we can do this. That to me, speaks about the hours that the student has spent in that room and how much they’ve earned the trust of that patient and their family. And that to me really gives me an insight into who that – what type of professional that student is and how they’ve gone the extra mile with that patient and the family.
  
  Dr. Mullins:  That’s great. Another study that assesses not just patient concerns but some other concerns among physicians, analyzed barriers to bedside teaching. Romani 2003 was a series of focus group interviews and these are different from patient concerns. And I think they are interesting to talk about. He had the most significant barriers to bedside teaching were one, and this is physicians, this is attending physicians. Declining bedside teaching skills, the aura of bedside teaching or belief that bedside teachers should possess an always unattainable level of diagnostic skill that creates intense performance pressure, three that teaching is not values and four, an erosion of teaching ethic.
  
  So, those were four things mainly on the attending side that they perceived as reasons either not to go to the bedside or maybe – and I think this is interesting because it mainly focuses on physical exam. And it correlates back to that definition that we had that a bedside round, a component of a bedside round and we can talk about this in a little bit too, I think an essential component of the bedside round is demonstration of a physical exam finding. And it seems here that in 2003, that a lot of the attendings did not feel comfortable with that particular component of the bedside encounter.
  
  Dr. Willig:  That’s very interesting. And I mean I can see how those would be valid concerns. But again, I think that team based approach to this and the ability to discuss things as a group and the belief that again, none of us is as smart as all of us but we are in a team working through it together. I almost tell my team we have to be sort of a wireless interconnected network of brains working to find the best collective solution to this problem. And the reality is, that none of us is going to have 100% of the answers. The best answer is probably a certain percentage in each of our brains. And if we have a culture where we can discuss things openly, and share ideas, the amalgam of those ideas and the evidence supporting those management decisions is probably what’s best for the patient. So, I’ve found that – I’ve certainly felt – I’ve worked with learners that far exceed me in many areas of medicine in terms of their diagnosis skill or their fund of knowledge, but I’ve found that keeping that open climate where sometimes I will know more but sometimes you will know more.
  
  I tell my students actively listen, the last time I read about topic X, might have been when I was studying to be recertified on my board exam a couple of years ago. But you, you read about it last week. And you have the latest evidence in your mind, and I think that what this patient deserves is the greatest evidence, the benefit of my experience, your knowledge of the latest literature and evidence together, are going to provide better treatment.
  
  So, I’ve really sort of that flattening that gradient and just sort of saying almost as the attending, I am a learner, everything I know is here for you, and likewise, we should be making each other better. So, I know that there’s things that you know better than me, but the success is all of us sharing what we know best to serve this patient and their family. That environment, I think has helped me get over some of those concerns that I can understand them.
  
  Dr. Mullins:  Let’s talk a little more about some of the other advantages to bedside teaching. And now, kind of get to the point of why go to the bedside. The big study done on the value of bedside teaching Gonzolo 2013, identified six main themes for the advantages of the bedside teaching. Skill development for learners, observation and feedback, role modeling, team building among trainees, attendings and patients, improved patient care delivery through a combined clinical decision making and team consensus and the culture of medicine as patient-centered care. Do any of those particularly resonate with you.
  
  Dr. Willig:  You know several of them do, honestly. I mean the modeling is so key. I mean we’ve discussed our learners as being all of us are a combination of the skills, knowledge and attitudes. And certainly, the experiential part of how do you treat someone. How do you navigate a difficult conversation? How do you go through an uncomfortable topic? How do I give someone bad news? How do I really deal with a very – an angry family member? The discussion about a near miss or a medical error. How do I discuss someone who is very anxious about what’s going on with their family member? Or how do I just have an honest discussion with someone about heh, this is where you are, and these are the changes that I think you need to make to your health to have success longitudinally?
  
  The feedback that I get from learners over the years is some of them are sort of surprised about some of the things that we discuss at the bedside. And frankly, I think shying away from this topic, from sensitive topics doesn’t really help us or the patient get to where they need to get to in order to have the most success that they can as defined by their condition. But just being frank, saying heh listen, I see here in your history that you have a history of injection drug abuse, that you have a history of addiction to this, or you have some pain seeking behaviors, that concerns me. How are we going to navigate that amongst ourselves? It’s tough to bring that up and people sometimes react or will say things but honestly, I sit there, I look them in the eye, and I try to have a frank conversation. When I leave the room, we can have frank discussions with the team about heh, how does the patient’s history affect my thinking? How does it bias my decision making? Being aware of those things, being aware of sort of why we think what we think, that level of metacognition, I think we do better work when we’re honest with the patient and with ourselves about all of these elements.
  
  So, the role modeling to me, is very important. I think it leads to better care because we can have more frank conversations. And I think people seeing you have those conversations prepares them. Because you can do the best [00:30:18] work in the world but if you fail at how you treat people, you’re not going to get great outcomes. Patient satisfaction is a real outcome. I think we’re in a service profession. And knowing how to treat others with respect and really be patient-centered and patient-focused, I think makes the care that we provide to be better.
  
  I often give an example of a very ill family member of mine who ultimately expired and they – I went to a hospital and I spoke with a neurosurgeon and it was almost my – what I remember from those difficult interactions, my family member would go on to expire in about thirty days but the things that I remember about that hospital stay were a nurse coming to take my uncles coat and hanging it. Someone coming in with a cup of coffee for my elderly uncle. That hand on the shoulder when difficult news was delivered. None of these things are quantifiable or show up in our evaluations. But you see the skill of the clinicians was expected. They are working in a quality hospital. The skill is expected. The humanity has so much to do with the care. And when learners can watch you do that, when I tell a learner if someone’s sick enough to be in that bed, it’s not just them, but their whole family. There’s an impact created around an illness. And we all need to contribute to the different facets.
  
  There’s a lot of things that we can do to provide care and when we don’t have a cure, we can still provide care. And modeling that and being patient-centered and family-centered, I think is a great gift that we give to our learners that ultimately, they can pass on to us and our family when it’s our turn to be on those hospital beds. So, all those things resonate, to a large degree, with me.
  
  Dr. Mullins:  And that’s exactly what lines up with what I’ve read in the literature. Common theme, especially going back to some of the literature that was PhD written literature on education in the clinical setting and as recent as 2009 from an attending opinion survey, professionalism, 72% from Gonzolo 2009 ranked very important or somewhat important for learning. And the physician-patient communication skills 83%. Again, these aren’t things like you said that are quantifiable and I guess you can get into a discussion on how to quantify these things, but it is the subtlety and the nature of the disposition that is demonstrated by the physician and observed by the student. And only at the bedside is the implication in the literature.
  
  Dr. Willig:  I think that’s very interesting. And I know that in the – in future talks we going to get into the structure of bedside rounds and what can be done about it. So, let me take us to the end here. if I were to ask you, make the case, make the case based on the evidence why should bedside rounds occur?
  
  Dr. Mullins:  Well I think some of the biggest evidence comes from something that we touched on a little bit, haven’t exactly hammered down yet, is physical exam and clinical skills. And you have a number of studies from 1994 that tried to do a year long teaching lecture series for residents and interns, not only did not improve their own physical exam skills but before and after, were controlled by fourth year medical students showed no difference. Then you have another study in 2004, that did another intervention directly at the bedside teaching physical exam skills had a 66% increase in correct diagnosis.
  
  Dr. Willig:  Wow.
  
  Dr. Mullins:  So, that’s a pretty strong evidence compared to a year long lecture series, no increase, compared to fourth year medical students among house staff and then you have a study in 2004 where ten physicians completed forty five minute sessions directly at the bedside and had an increase in 66%. So, I think that’s some strong evidence. I think going to the bedside, it was one of our components listed as a definition performing a bedside physical exam maneuver. I think another thing is time. And I think a lot of physicians are time constrained, have time limitations and a number of people have tried to actually standardize the beside round and say we are going to monitor and assess adherence and you’re going to do these X components. And we could go through what all those components are and what factored into them but for the majority of studies, bedside rounding standardized compared to a control, so either a walk around or how ever else you are going to do it; was either the same or decreased time. So, some studies showed decreased time.
  
  Funny enough, one study had actually showed a decrease in time, but it was perceived as taking longer by students. So, that’s I guess somewhat of a catch, but you can decrease time, you can ensure that you are performing physical exam skills in front of the students. Another big part that we will get into later is you can give direct feedback to students which is a component that is also key I think and was listed as one of the main advantages of bedside rounds and then as we talked about, I think the main advantage is the modeling of professionalism, patient-physician interaction, team building among your team and those intangibles that can only be experienced by a young medical student at the bedside.
  
  Dr. Willig:  Well Haddon, you’ve convinced me. I think that those are all very compelling reasons to pursue bedside rounds and we want to thank everybody for spending some time with us today. and hopefully, you can bring some of these strategies and some of this evidence to bear in your teaching at the bedside. Have a wonderful day. Thank you.
  
  Dr. Mullins:  Thank you.
  
  Host:  And a community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. That concludes this episode of UAB Med Cast. To refer your patients or more information on resources available at UAB Medicine, please visit our website at www.uabmedicine.org/physician. Please also remember to subscribe, rate and review this podcast and all the other UAB Medicine podcasts. I’m Melanie Cole.
• Hosts:Melanie Cole, MS