Correspondence
Bedside Presentations and Patients' Perceptions of Their Medical Care
N Engl J Med 1997; 337:714-716September 4, 1997
- Article
To the Editor:
In discussing the limitations of their study, Lehmann et al. (April 17 issue)1 omit an important one — the very premise of the study. Bedside and conference-room presentations are not mutually exclusive and are but two components of an educational process that may take the “firm” (an incredibly non-Oslerian term) to the radiology department, the catheterization laboratory, the autopsy room, and so forth. In a given case, some of the attending physician's functions may be facilitated by a blackboard and others by a demonstration of the art of taking a history and performing a physical examination. Although it may be acceptable in some situations to expose the patient to the fumbling of physician apprentices, I can think of many instances in which conversations are best held outside the patient's room, if only to protect privacy and confidentiality from inevitable eavesdropping by roommates, who may be more or less discreet.
It is saddening to see patients so easily duped into seeing 10 minutes of bedside presentation by the firm as of more value than 6 minutes of undivided attention. The teaching function represented by daily rounds does not exonerate the attending physician from the responsibility of more personal interactions with the patient, without which the appropriateness of the trainees' decisions and actions may not be verifiable.
Finally, I find it alarming to read that on the Osler medical service of one of the most prestigious American universities, 80 percent of patients are attended to by chief residents. This illustrates vividly a galloping trend in this country's medical educational system, which consists of delegating clinical teaching — a function requiring experience, maturity, and self-confidence — to senior trainees or junior faculty members who, no matter how bright and talented, rarely have the elusive qualities that make an effective role model.
1 ReferencesRodolphe Ruffy, M.D.
4228 S. Park Terr., Salt Lake City, UT 841241
Lehmann LS ,Brancati FL ,Chen M-C ,Roter D ,Dobs AS . The effect of bedside case presentations on patients' perceptions of their medical care. N Engl J Med 1997;336:1150-1155
Full Text | Web of Science | Medline
To the Editor:
The article by Lehmann et al. on the effect of bedside case presentations raises an important question about clinical care and teaching that concerns these presentations. Are they primarily for the patients or for the trainees? Ninety-four percent of the patients thought that the primary purpose of the presentation was to teach medical students and residents, rather than to improve their own medical care.
I believe that physicians and trainees should know as much as possible about their patients and their problems before making bedside rounds and that the focus should be on the patients, not the trainees' case presentations. Why did 49 percent of the patients in this study think that the presentations did not help them understand their illness, and why did 46 percent think that too much terminology was confusing? The reason is that the focus is on the presentation, not the patient and his or her needs. When physicians are at the bedside, patients want their physicians to talk to them, not about them in case presentations.
At the bedside physicians can listen to patients to understand their thoughts and feelings better; they can examine them and decide about plans of care with them. This use of time is much more valuable for both patients and physicians, because it helps meet the needs of both. Bedside rounds of this type also serve as a model for teaching, one in which trainees can observe experienced physicians working together with patients to make decisions about their care. Lehmann et al. remind us of Osler's principle: “The best teaching is that taught by the patient himself.”1
1 ReferencesPaul S. Bellet, M.D.
Children's Hospital Medical Center, Cincinnati, OH 45229To the Editor:
The thought-provoking article on bedside case presentations has provided an incentive for editorialists at the Journal 1 and elsewhere2 to propose much wider use of bedside presentations as a teaching tool. However, since our main charge as clinicians is primum non nocere (“first, do no harm”), the finding by Lehmann et al. that 13 percent of patients were upset by bedside presentations is of great concern. This figure is almost identical to the proportion of patients who showed either objective signs of tension or subjective distress with bedside presentations in one of the articles cited by Lehmann et al.3
If bedside presentations are unsettling to so many patients, why do patients support them? Patients crave contact with their physicians, and in the article by Lehmann et al. bedside presentations resulted in nearly twice as much contact between physician and patient. The favorable comments by patients about bedside presentations (for example, that they helped the patients understand their illnesses) and the criticisms (that the patients wanted the opportunity to say more) both suggest that the increased patient–doctor contact during the teaching exercise of the presentation may be a partial substitute for inadequate doctor–patient contact outside that context.
I am concerned about bedside presentations in several other respects. From the patient's point of view, discussing the differential diagnosis broadly in his or her presence will often lead to the mention of the word “cancer,” which seems to frighten patients no matter how many reassurances are subsequently provided. Exposing patients to disagreements between physicians, as is especially likely to happen when the attending physician doing the teaching is not the one providing the care, almost always disrupts patients' confidence in their medical care. Finally, as a teaching tool, a bedside case presentation to a large group with diverse backgrounds does not allow the teaching to be focused at a specific level; the needs of the third-year medical student are quite different from those of the chief resident.
In summary, I think that a bedside case presentation whose primary purpose is to teach trainees is a poor substitute for insufficient doctor–patient contact outside that context — an interaction that is a critical part of the patient's medical care and is not related to teaching.
3 ReferencesAllan R. Glass, M.D.
4853 Cordell Ave., Bethesda, MD 20814-30221
Thibault GE . Bedside rounds revisited. N Engl J Med 1997;336:1174-1175
Full Text | Web of Science | Medline2
LaCombe MA . On bedside teaching. Ann Intern Med 1997;126:217-220
Web of Science | Medline3
Romano J . Patients' attitudes and behavior in ward round teaching. JAMA 1941;117:664-667
Author/Editor Response
The authors reply:
To the Editor: Dr. Bellet argues that the focus of bedside rounds should be the patient and not trainees' case presentations. We agree that if trainees were more cognizant of this goal, the use of confusing terminology at the bedside would most likely diminish and perhaps more patients would better understand their illnesses. Indeed, our study delineates some aspects of bedside rounds that need improvement. The challenge to the clinician-educator is to teach trainees how to present a case sensitively in front of a patient while simultaneously teaching physical diagnosis and engaging the patient in a dialogue.
Dr. Ruffy and Dr. Glass fear that bedside rounds may become a substitute for personal contact between the patient and the physician. Clearly, bedside rounds should not supplant, but rather supplement, one-to-one interaction between patients and physicians. At Johns Hopkins, bedside rounds are only one of several daily opportunities for patients to interact with their physicians. House staff who have conducted bedside case presentations do not feel absolved of a responsibility to spend time listening to their patients. Instead, bedside rounds heighten their awareness of issues needing further discussion.
Drs. Ruffy and Glass suggest that bedside rounds may not always be the best option. We agree that for pedagogic purposes the conference room can, and should, complement the bedside. Similarly, physicians should exercise judgment in deciding when bedside rounds may be inappropriate. However, our study suggests that global concern about the patient's discomfort should not routinely turn physicians away from the bedside to the conference room.
Dr. Ruffy expresses dismay at the proportion of patients on the Osler service who are attended to by chief residents and is quick to conclude that house staff do not have effective role models. We would like to clarify the fact that bedside rounds are only one component of house-staff education at Johns Hopkins. Each house-staff firm includes a cadre of 12 experienced faculty members from a variety of disciplines who conduct separate teaching rounds, often at the bedside. Thus, we advocate bedside case presentations as one part of an overall training program aimed at imparting a love of patient care and the art and science of clinical medicine to a future generation of physicians.
Lisa Soleymani Lehmann, M.D.
Massachusetts General Hospital, Boston, MA 02114Frederick L. Brancati, M.D., M.H.S.
Adrian S. Dobs, M.D., M.H.S.
Johns Hopkins University School of Medicine, Baltimore, MD 21205Author/Editor Response
Dr. Glass thoughtfully suggests a number of possible adverse consequences of bedside rounds, all of which are issues that everyone involved should bear in mind in order to minimize any negative effect of the rounds. In no way should rounds be viewed as “a partial substitute for inadequate doctor–patient contact.” On the contrary, they are most successful and useful when there is extensive contact between doctor and patient outside the rounds. One of the main purposes of the rounds is to teach that the doctor–patient relationship is at the center of excellent patient care.
George E. Thibault, M.D.
Brigham and Women's Hospital, Boston, MA 02115
