Medical education has adapted over time to gradually incorporate informal teaching sessions, simulations, and mini lectures in addition to traditional bedside teaching. Despite the evolution in medical education, bedside teaching remains an integral part of post-graduate medical education. A recent systematic review evaluated learning outcomes related to bedside teaching and most studies found that bedside teaching was useful, improved communication and encouraged ongoing attempts to facilitate its use in medical education [6]. Previous studies have suggested a decrease in bedside teaching quantity given increases in other clinical demands, lack of comfort, and fear of exposing inadequacy [18, 19].
Analysis of our results showed that the total average bedside teaching time by attending physicians on rounds was 17 min per day which represented 12% of total rounding time. This is on par with current estimates and other recent studies evaluating the quantity of bedside teaching [ 14, 15, 20]. The total time of bedside rounds was consistent despite increasing patient load and rounding time. This does indicate that the total time per patient decreased with increasing census but demonstrated persistent commitment to bedside teaching by the ICU physicians despite time limitations.
While 12% of the recorded time spent on bedside education may seem like a low proportion of morning rounds, medical residents perceived the time and quality of bedside teaching to be adequate. With advances in modern medicine, there are now many more ways to learn and teach than in the days of Osler. Particularly in the age of COVID-19, many residency programs have adapted their curriculum to embrace more virtual options [21]. To illustrate this broad range of learning, consider the experience of a resident spent in the medical ICU at our institution: daily didactic lectures from internal medicine (in- person and virtually), recurring small group simulation sessions (both for procedures and situation-oriented cases), multiple daily 10–15 min talks on patient-specific diseases during rounds, monthly review of the latest publications in the medical literature via journal club, and in the afternoon an informal session with the ICU faculty or fellow at least weekly to review ICU-specific subjects in more depth (ventilators, vasopressors, sedation and analgesia). Beyond these methods, many critical care attendings incorporate ultrasound training, ventilator wave form demonstration, blood gas analysis, and chest x-ray interpretation into daily rounds. Given such an abundance of education, there is a risk of decreasing time spent with the patients [21]. This study did not evaluate these other forms of teaching that occur during the day and did not consider other educators within the team (fellows teaching residents, residents teaching residents, etc.). Any of these factors may be why residents rated the time and quality of education highly.
The study had several strengths. The data was independently obtained by our pharmacy colleagues on rounds. This data was then cross-referenced with resident data about the amount of time that was spent teaching on rounds and impression of the quality of teaching. The attending physicians were blinded to the study occurrence, knowing neither the details of the study timeframe nor that bedside teaching was being evaluated. This study was also conducted over 4 months, capturing the bedside teaching of many different physicians and found the level of bedside teaching to be consistent throughout the department.
There are several limitations for this study. This study was limited to one medical intensive care unit in an academic tertiary care hospital. This study was conducted during the COVID-19 pandemic which may have affected results, although the number of COVID-19 patients in the state and hospital stayed low until October-November 2020. Due to changes in visitation policy, no families were present in the ICU during this time. In the ICU, bedside teaching includes modeling of family discussions and, as a result, this may have impacted the total time of bedside teaching [10]. Without the pandemic-related limitations for visitors, time spent at the bedside for family discussions would have been even higher than in our study. The impact of COVID-19 on bedside teaching has been acknowledged elsewhere [22].
This study is also observational, and survey based, which could lead to bias. However, median bedside education time on survey and independent observer data was not significantly different, arguing against bias. We also did not assess the inter-rater reliability of our pharmacists prior to conducting the study, which may have affected results. The exclusion of weekends and holidays may also have affected the true reflection of bedside teaching, but since the team structure is mostly unchanged on the weekend, it was unlikely to have fluctuated significantly. Over the weekend and on holidays, there is less time constraint due to the lack of noon didactic conferences. As a result, there may have been increased bedside teaching during these times. We also acknowledge that learner perception of quality is only the 1st Kirkpatrick level of learning evaluation [23]. Despite conducting the study over 4 months, the response rate was low, which may have led to survey bias. As discussed previously, residents considering other forms of teaching into overall perception of teaching may have elicited bias into the survey data. Use of other methods for assessing outcomes related to bedside teaching in future studies may allow for additional information regarding patient outcomes, acquisition of knowledge and/or change in behavior.
The study results are generalizable to academic intensive care units but may not be as transferable to other units due to differences in workflows and rounding styles. There is evidence that there is a decrease in bedside medical education over time. However, our study supports that bedside teaching is alive and well within the medical ICU. Given the success of bedside education, the medical ICU could serve as a model moving forward in studying bedside education and implementing other types of education. Our study also provides additional baseline information for future studies to explore optimal time spent at the bedside as well as ways to engage faculty to increase bedside teaching skills.
Further research could be done with an intervention of one of the ICU teams participating in a lecture series on the importance of bedside teaching and tips to improve this important form of education. This could be compared to a standard group to evaluate both attending and resident perception of bedside teaching as well as the total time spent teaching compared to the control group. Such studies have been done with Internal Medicine house staff and the intervention improved attending confidence as well as increased time spent in bedside teaching and residents found the intervention favorable [24, 25]. Similar studies could also be conducted in different settings to provide a greater breadth of information regarding bedside teaching over multiple different types of hospitals (community vs. academic) and ICU models (open vs. closed) as well as increase the amount of survey data available.
