Abstract
Bedside teaching encounters (BTEs) involve doctor–patient–student interactions, providing opportunities for students to learn with, from and about patients. How the differing concerns of patient care and student education are balanced in situ remains largely unknown and undefined. This video ethnographic study explores patient involvement during a largely student-centric activity: ‘feedback sequences’ where students learn clinical and practical skills. Drawing on a data subset from a multi-site study, we used Conversation Analysis to investigate verbal and non-verbal interactional practices to examine patients’ inclusion and exclusion from teaching activities across 25 BTEs in General Practice and General Surgery and Medicine with 50 participants. Through analysis, we identified two representations of the patient: the patient embodied (where patients are actively involved) and the patient as-a-body (when they are used primarily as a prop for learning). Overall, patients were excluded more during physical examination than talk-based activities. Exclusion occurred through physical positioning of doctor–patient–student, and through doctors and students talking about, rather than to, patients using medical jargon and online commentaries. Patients’ exclusion was visibly noticeable through eye gaze: patients’ middle-distance gaze coincided with medical terminology or complex wording. Inclusory activities maintained the patient embodied during teaching activities through doctors’ skilful embedding of teaching within their care: including vocalising clinical reasoning processes through students, providing patients with a ‘warrant to listen’, allocating turns-at-talk for them and eye-contact. This study uniquely demonstrates the visible nature patient exclusion, providing firm evidence of how this affects patient empowerment and engagement within educational activities for tomorrow’s doctors.
Highlights
Bedside teaching is a generic phrase that has commonly referred to any type of teaching and learning in the presence of a patient across the full range of modern healthcare settings in which the presence of a bed is not a necessary feature of the encounter (Bleakley and Bligh 2008; Bleakley et al 2011; Janicik and Fletcher 2003; Steven et al 2014)
Due to time and funding constraints, 47 Initiation–Response–Evaluation sequences (I–R–E) sequences were further transcribed and analysed to the level of non-verbal activities (comprising all 8 of the General Practice (GP) excerpts previously published (Rizan et al 2014) and all 39 from the General Surgery and Medicine (GSM) data). These sequences were embedded within different methods of consultation management by the doctor (Table 2 below), broadly categorised as (a) purely talk-based activities, and (b) physical examination activities
We have previously examined the opening phase of Bedside teaching encounters (BTEs) in our dataset and document how medical students are introduced to patients and describe how sometimes recaps of patient medical histories are shared if applicable (Elsey et al 2014)
Summary
Bedside teaching is a generic phrase that has commonly referred to any type of teaching and learning in the presence of a patient across the full range of modern healthcare settings in which the presence of a bed is not a necessary feature of the encounter (Bleakley and Bligh 2008; Bleakley et al 2011; Janicik and Fletcher 2003; Steven et al 2014) This triadic doctor–patient–student interaction within bedside teaching encounters (BTEs) serves the dual purpose of patient care and medical student learning (Celenza and Rogers 2006; Chacko et al 2007; Wang-Cheng et al 1989). A fine-grained analysis of video footage of BTEs can discover how patients are interactionally included or excluded during the different phases of BTEs and how BTEs are interactionally managed by clinicians in real-time
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