Bedside Skills Research Articles

A dinosaur roars

In this issue of Neurology ®, Schuh et al.1 report on internal bias and interrater reliability of the residency-based neurology clinical skills evaluation (NEX). I began training in the pre-MRI era and that qualifies me as a dinosaur. Forces combine to erode the quality of bedside clinical skills that serve as the backbone of our profession and define us as neurologists. Residents are consumed by duty hours restrictions, patient handoffs, electronic medical records, diagnostic antibody panels, high-tech imaging, and systems-based practice, and their faculty members are strapped for time as never before. Bedside clinical skills may become extinct. For many years, the American Board of Psychiatry and Neurology (ABPN) and others have recognized the problems associated with testing fundamental clinical skills 1-2 years following completion of training and view the residency as the most logical and appropriate time for evaluating such skills. It seems most fair to the trainee and their patients to have deficiencies recognized in a timeframe that allows for improvement and remediation. The Accreditation Council for Graduate Medical Education (ACGME) requires our training programs to evaluate clinical skills during residency and the program director (PD) signs a letter upon completion of residency testifying that the graduate is competent …

Use of simulators in vascular training

Rapid advances in technology and the public and institutional demand to improve quality and safety have led to an increased use of simulation technology in medicine. What is simulation? It...

Inconvenient truths about effective clinical teaching

I’ve been teaching clinical medicine for more than 30 years but it seems to be getting harder, not easier. Conventional wisdom in the USA holds that the problem is time and money (or, more precisely: time is money). Hospitalised patients, discharged before doctors can get to know them, are sicker and quicker today. Outpatient teaching is no less awkward, 10-minute offi ce visits and outdated Medicare reimbursement rules gumming up the works. Long overdue restrictions on resident work hours won’t solve these problems. Too little time and money for clinical teaching betokens lack of respect too. Most academic centres in the USA don’t provide adequate support for clinician-educators’ salaries despite substantial government subsidies for postgraduate education. This shortfall is not an oversight; it is a calculated budgetary decision. Insult compounds injury when physician-researchers openly disparage the academic gravitas of physician-educators on the same faculty. This situation raises the obvious question: is clinical teaching today not only more diffi cult but also less eff ective? One might assume that our research-proud profession would know the answer. In fact, despite shocking indictments of the quality, safety, and equity of US medical care, we know little about the eff ect of clinical teaching on learners or patients, nor even how to measure it. Worse, we don’t seem very concerned about this situation. In 2006, four major medical journals (BMJ, JAMA, Lancet, and New England Journal of Medicine) and four medical education journals (Academic Medicine, BMC Medical Education, Medical Education, and Medical Teacher) published a total of one original outcomes study of this kind (which found no correlation between measures of teaching eff ectiveness and patients’ clinical outcomes). Lacking evidence, I do what clinicians do when we don’t have the data we need: I go with my gut instinct. My gut tells me that clinical teaching today—my own and others’—is less eff ective than it used to be and needs to be. Among those who will disagree are many academic leaders and quality gurus who don’t even acknowledge the question. They maintain plausible deniability by looking elsewhere: we need better systems, they say, not better doctors. No doubt they are right about the systems. I propose that the decline of clinical teaching in our training programmes is, like global warming, an inconvenient truth. Even if we saw evidence as eerily convincing as Al Gore’s pictures of melting polar ice-caps, many in academic medicine would look the other way. Rather than take remedial action, we will be tempted to do the greenhouse-gas-shuffl e: blame it on random variation or transient aberration (anything but ourselves) and hope the hurricanes and heat waves just go away. Doubly inconvenient would be to learn that fi xes from the past might not work in the present. For example, due to digital information systems, clinical trainees inevitably review patients’ laboratory data and diagnostic images before they do a history or physical examination. This change portends more than the devaluation of bedside skills; it is nothing less than complete inversion of the conventional diagnostic process. The good news is that innovation in medical education eventually catches up with advances in science and technology. The bad news is that the pace of change is glacial. Worse, we know so little about medicine’s informal curriculum (clinical training) that it’s hard to know where to start. In this spirit, I describe eight habits of exemplary clinical teachers I have known and try to emulate still.

OSCE in Internal Medicine for Undergraduate Students Newly Encountered with Clinical Training

Abstract This resource is an objective structured clinical examination (OSCE) designed for fourth-year medical students. The aim of this exam is to assess the bedside skills of students in history ...

Albert Einstein College of Medicine of Yeshiva University.

Albert Einstein College of Medicine of Yeshiva University.

Bedside cardiology skills training for the osteopathic internist using simulation technology.

Medical practice changes that limit patient availability, instructor time, and advances in technology have led to a greater use of simulators and multimedia computers in medical education. These systems address the problem of inadequate bedside skills training and poor proficiency among all health care providers. While studies have shown their effectiveness among medical students, residents, and practicing physicians, none has focused on the osteopathic internist population--one that is becoming more responsible for conducting initial and follow-up physical examinations. This report describes the use of "Harvey," the cardiology patient simulator, and the UMedic Multimedia Computer System at a workshop conducted at the American College of Osteopathic Internists' 61st Annual Convention and Scientific Sessions. Participants in this study significantly improved their ability to identify common cardiac auscultatory events, as indicated by pretest-to-posttest scores. Workshop participants were nearly unanimous in their belief that they would like to use these tools for learning and assessment.

Development of a reliable multimedia, computer-based measure of clinical skills in bedside neurology.

This study reports the development of reliable multimedia, computer-based measures of bedside neurology skills. A consortium of neurologists and medical educators (1) identified bedside skills and (2) created a computer-based test. Test-item stems were multimedia clips of standardized patients. Options appeared as text. Sixty-one junior medical students responded to these items. The 77-item test yielded a reliability coefficient of 0.85. Subgroup item analysis resulted in reliability coefficients of 0.73 for the 20-question "pretest" (Test A) and 0.75 for the 20-question "posttest" (Test B). Two sets of test items were developed that can be used as outcome measures in studies that assess the effectiveness of educational interventions in bedside neurology.

The Quotable Osler

Sir William Osler (1849-1919), a dedicated and caring physician, was the prolific author of more than 1600 works in his lifetime, including The Principles and Practice of Medicine, one of the first comprehensive medical textbooks. Such was his output, his great personal following and the large number of eponymous signs and diseases he gave rise to, it is unsurprising that his sayings have endured. Many a lecturer has embellished his talk with an Oslerian quote or two. A Canadian by birth, he worked in his native country, the United States and finally in Oxford as the Regius Professor of Medicine, so his influence spanned two continents. The Quotable Osler is a collection of quotations compiled from his various publications by three American editors. The book is divided into themes such as personal qualities, the art and practice of medicine, diagnosis and science and truth. The selected quotes portray Osler as a deeply moral, committed and enthusiastic doctor whose capacity for hard work was immense. He believed ‘that the practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head’. His bedside skills and manner were widely admired by students and colleagues. He was a passionate educator of medical students and advocate of lifetime learning, believing in the value of careful examination of the patient and the study of medical texts. ‘To study the phenomena of disease without the books is to sail an uncharted sea, while to study books without patients is not to go to sea at all’. The chapter on Men, Women, Aging and History provides some of the most surprising and colourful quotes. Osler's ambivalent views on women in medicine are aired. On the one hand he applauded the decision to allow women entry to medical school but, on the other hand, he considered women more suited to science than to medicine: ‘a larger proportion of women than men are unfit for practice... and what they [women] lack in initiative and independence is counterbalanced by a more delicate technique’. It is easy to criticize 100 years on but Osler's reservations reflected the views of his generation. He had some advice on marriage—‘Choose a freckle-faced girl for a wife: they are invariably more amiable’—and considered it important for a physician to ‘marry well’. Osler possessed some amusing ageist views on ‘the comparative uselessness of men above forty’ and considered that ‘a very large proportion of the evils [of the world] may be traced to sexagenarians’, who account for the greatest political and social mistakes, the worst poems and the worst sermons. Not surprisingly, he felt ‘men above 60 should retire’. The Quotable Osler is a fascinating insight into the life and beliefs of one of the greatest physicians. It is mainly of value as a historical account rather than of direct relevance to today's practice. Osler enthusiasts will doubtless disagree. This book will enthral retired physicians, and doctors with even the slightest interest in medical history.

Whither bedside teaching? A focus-group study of clinical teachers.

Previous reports document diminishing time spent on bedside teaching, with a shift towards conference rooms and corridors. This study explored faculty's perceptions of the barriers to and their strategies for increasing and improving bedside teaching. Four focus groups consisting of (1) chief residents, (2) residency program directors, (3) skilled bedside teachers, and (4) a convenience group of other Department of Medicine faculty from the Boston University School of Medicine's affiliated hospitals were held in May 1998. Each session lasted 60-90 minutes. Sessions were audiotaped, transcribed, and analyzed using qualitative methods. The most significant barriers reported were (1) declining bedside teaching skills; (2) the aura of bedside teaching, a belief that bedside teachers should possess an almost unattainable level of diagnostic skill that creates intense performance pressure; (3) that teaching is not valued; and (4) erosion of teaching ethic. Focus-group participants suggested the following strategies for addressing these barriers: improve bedside teaching skills through faculty training in clinical skills and teaching methods; reassure clinical faculty that they possess more than adequate bedside skills to educate trainees; establish a learning climate that allows teachers to admit their limitations; and address the undervaluing of teaching on a department level with adequate recognition and rewards for teaching efforts. Skilled teachers, in particular, stated that a bedside teaching ethic could be reestablished by emphasizing its importance and challenging learners to think clinically. Bedside teaching is regarded as valuable. Some barriers may be overcome by setting realistic faculty expectations, providing incentives for teaching faculty, and establishing ongoing faculty development programs.

Effectiveness of a Cardiology Review Course for Internal Medicine Residents Using Simulation Technology and Deliberate Practice

Background: Objective evaluations of residents' clinical skills reveal serious deficits. Purpose: To develop, implement, and evaluate outcomes from a review course in cardiology bedside skills for internal medicine residents. Methods: We used a 1-group pretest-posttest design with historical comparisons.The study was conducted at the University of Miami School of Medicine as part of the internal medicine residency program from July 1999 to June 2000. A total of 67 2nd- and 3rd-year medicine residents received an educational intervention involving deliberate practice using simulation technology. A total of 155 4th-year medical students in one intervention and one comparison group (n = 53) served as historical comparisons. Outcome measures were a reliable computer-delivered pretest and posttest that evaluate cardiology bedside skills. Results: Residents who received the review course and medical students who received a comparable educational intervention showed large and statistically significant pretest-to-posttest improvement in bedside skills. These 2 groups are also significantly and substantially different at posttest from a comparison group of 4th-year medical students that did not receive a specific educational intervention. Conclusion: Educational interventions using simulation technology that engage learners in deliberate practice of clinical skills produce large improvements in a relatively short time, with little faculty involvement.

Provision of clinically based information improves patients' perceived length of stay and satisfaction with EP

We conducted a focused, prospective, randomized study to evaluate whether periodic personal provision of clinically based information to patients during an Emergency Department (ED) visit improves patients' perceptions of physician's excellence and efficiency of patient care. Six hundred nineteen consecutive adult patients or proxy informants, who were evaluated in the ED and subsequently discharged, were randomized into the standard of care (n = 307) and intervention group (n = 312). Under supervision by ED attending physicians, a single research assistant periodically provided patients with process and medical information at 15-minute intervals, starting at arrival and continuing through until discharged from the ED. At discharge, patients were handed a previously validated questionnaire to fill out and drop off at the ED exit. Outcome measures included actual and patients' estimate of the wait time (WT) and length of stay (LOS), ratings of registration personnel, and ratings of bedside and technical skills of nurses and Emergency Physicians (EPs), by using a 5-point Likert scale (5 = excellent, 4 = very good, 3 = good, 2 = fair, 1 = poor). There were no statistically significant differences in age, sex, insurance data, intensity of service, actual WT, actual LOS, and patients' perceived WT to see a physician between the 2 groups. The perceived LOS was, however, significantly shorter (92.6 vs. 105.5 min, P =.027) and the proportion of patients who rated the Emergency Staff Physician as “excellent” or “very good” was significantly higher in the intervention group (Bedside: 87.1% vs. 80.5%, P =.033; Technical skill: 86.8% vs. 80.1%, P =.032). Patients' perception of nursing skills were, however, statistically similar in the 2 groups (Bedside: 83.1% vs. 83.0%, P =.942; Technical skill: 84.5% vs. 82.7%, P =.613). Given the sample size and observed proportions, the χ2 analysis of perception of nursing skill had a power of 4.8% (registered nurse [RN] bedside) and 7.5% (RN technical skill). Periodic personal interaction and provision of clinically based information in the ED is thought to improve patients' perceived LOS, efficiency, and clinical skills of EP after an ED visit. (Am J Emerg Med 2002;20:506-509. Copyright 2002, Elsevier Science (USA). All rights reserved.)

Problems and Suggestions Based on my 7 Years Teaching Basic Bedside Skills in Japan

Problems and Suggestions Based on my 7 Years Teaching Basic Bedside Skills in Japan

Developments in the use of simulators and multimedia computer systems in medical education

Medical practice changes that limit teacher time and patient availability and advances in technology are stimulating the greater use of simulators and multimedia computers in medical education. Such systems address the problem of a decline in bedside skills training and proficiency. For over 30 years,The University of Miami Center for Research in Medical Education, in collaboration with 12 other university medical schools, has developed simulation teaching and assessment systems for multiprofessional training. 'Harvey', the Cardiology Patient Simulator, teaches bedside skills that are transferrable to live patients. The UMedic Multimedia Computer cardiology curriculum has been fully integrated into all years of medical school and postgraduate training and also assesses bedside skills. Programs are being developed in oncology, neurology and emergency medicine. Our Emergency Medical Skills programs utilize simulation technology and standardized patients to train multiprofessional populations, including paramedics/firefighters.The expanded use of simulation for training and certification is inevitable.

Intensive care psychiatric nursing – psychoanalytic perspectives1

Based on unobtrusive observations, a parallel is drawn between general and psychiatric intensive care nursing. The correlation between bedside skills and the incidence of physical contact between nurse and patient in each setting is considered. The phenomenon of physical attacks by patients on carers and the process of restraint in the psychiatric intensive care unit (ICU) is then examined. It is suggested that attack by and subsequent restraint of a disturbed patient may be considered in terms of an unconscious re-enactment of an early skin-on-skin object relation. It is argued that the physical holding of a psychotic patient is functional in re-establishing their bodily ego. Some thoughts are offered on how the intensive care of psychotic patients might be carried forward in the future.

Cardiac Auscultations Skills of Physicians in Training-Reply

In Reply —Dr Nadoolman suggests that the simple detection of an auscultatory abnormality (without being able to better define it) might be sufficient. We disagree. First, it is not so easy to detect that something is wrong (many of our findings were missed entirely). Moreover, an acoustic event per se may not necessarily require much workup. For example, many systolic murmurs are benign. As Frye 1 noted, the extraordinary increase in use of echocardiography reflects a growing dependence on sophisticated imaging technology, even in settings where obtaining a thorough history, physical examination, chest x-ray film and electrocardiogram may suffice for clinical decision making. Dr Lewis argues that Butterworth and Reppert used different methods than ours, that physicians' ability to recognize recorded sounds may correlate poorly with bedside skills, and that subtracting clinical history from physical examination eliminates an important guidance. These are all valid points, and we did acknowledge them in our article.

The Pericardium: A Comprehensive Textbook

Pericardial diseases can be considered to represent an orphan specialty. The subject spans the various medical and surgical specialties. Scientific advances have changed this field less than many other fields of medicine. Bedside skills and clinical judgment based on experience are still paramount with pericardial disease. A small number of "pericardiologists" write many of the textbook chapters and review articles. One of the most prolific is Dr David Spodick, who has now collected his thoughts and experiences in this monograph. The subtitle "comprehensive textbook" perhaps promises too much. The book is of moderate size and reflects primarily the author's personal experiences and opinions. An interesting introductory chapter explains the perspective that influenced the project. Experimental studies are skipped, except for the conclusions. The history of the topic is skipped, perhaps because it has been amply covered elsewhere, including by Spodick.¹Coverage is deliberately unbalanced in length and detail,

Observation of Emergency Medicine Residents at the Bedside: How Often Does It Happen?

To determine how often trainees in emergency medicine (EM) are observed while performing a history, a physical examination, or specific procedures. The 26 members of the National Consensus Group on Clinical Skills in Emergency Medicine affiliated with an EM residency program were asked to circulate a survey to their residents during February and March 1994. Twenty-one programs participated, surveying a total of 514 residents. The residents were asked how many times they had been observed by an attending physician while they performed a history, a physical examination, endotracheal intubation, or central vein catheterization during training. The residents also were asked about observation of specific components of the physical examination, such as the heart, lung, and genitourinary systems. Three hundred nineteen residents (62%) responded to the survey. Thirteen percent of the residents reported that they had never been observed taking a history during training. During their PGY1 training, 19% of the residents reported that they had never been observed taking a history, 42% had been observed one to three times, 25% had been observed four to 12 times, and 13% had been observed > 12 times. Six percent of the residents reported that they had never been observed doing a physical examination during training. During their PGY1 training, 10% of the residents had never been observed performing a physical examination, 38% had been observed one to three times, 34% had been observed four to 12 times, and 18% had been observed > 12 times. Many residents report that they are infrequently observed performing histories and physical examinations during their EM training, with a significant number of residents reporting that they were never observed performing basic bedside clinical skills. More direct observation with trained faculty observers may provide an opportunity for better evaluation and remediation of bedside clinical skills.

Practice Guidelines for Acute Pain Management in the Perioperative Setting

Practice Guidelines for Acute Pain Management in the Perioperative Setting

Diagnostic Agreement between Primary Care Physicians and Neurologists

The ability of primary care physicians (PCPs) to diagnose neurologic disorders was assessed from the records of 166 patients referred to the neurology outpatient clinic in one year. At the time of referral, 74.7% were correctly diagnosed. Primary care physicians were competent in the diagnosis of cerebrovascular accidents, epilepsy, space-occupying lesions, dementia, extrapyramidal and cerebellar disorders. More specific diagnosis was difficult at the primary care level in cases of headache, spinal cord and peripheral nerve disorders. The implications of these results and possible reasons for them are discussed. Solutions to improve on this situation are recommended with emphasis on both undergraduate and postgraduate training in neurological bedside skills. The complementary roles of the primary care physician and the neurologist are stressed.

Preceptors for an introduction to clinical medicine course: needs of volunteer and full-time faculty

Recruiting clinicians to teach bedside skills is often a challenge for Introduction to Clinical Medicine (ICM) course co-ordinations. Little data is available concerning what motivates a faculty to participate in these programmes. Better understanding of these factors might allow enhanced faculty involvement. We surveyed full-time and volunteer faculty as to what forces promote and hinder participation as preceptors for an ICM course. Results documented that both faculty groups found student interactions and teacher fulfillment their major reward, with little perceived academic or patient recognition. Personal time limitations was the greatest deterrent to participation. Assessing faculty needs has allowed focused course changes and new activities to facilitate involvement.