Postgraduate Training
Bedside rounds versus board rounds in an emergency department Andrew Muck1, Christopher McNeil1, Patrick McHugh2, Vikhyat Bebarta3 and Bruce Adams1 1
Emergency Department, University of Texas Health Science Center at San Antonio, San Antonio, Texas USA 2 Emergency Department, Fredericksburg Emergency Medical Alliance, Fredericksburg, Virginia, USA 3 Department of Emergency Medicine, San Antonio Military Medical Center, San Antonio, Texas, USA The impact on teaching or patient care has not compared between [board and bedside rounding]
SUMMARY Background: Our objective was to gain insight into whether bedside rounding at shift turnover in the emergency department improved education quality, as compared with board rounds. Board rounds are commonly used in the emergency department, where the teams review the patient and transfer care near a computer screen or written board, rather than at the patient’s bedside. The impact on teaching or patient care has not been extensively compared between the two approaches. Methods: We conducted a prospective study in an academic emergency department to compare bedside rounds versus board
rounds. A convenience sample of 408–hour clinical shifts were randomised to either bedside or board rounds. Data collected included frequency of discussion of differential diagnosis, questions asked per patient, total time for which alternative therapies were discussed, total time for which alternative tests were discussed, total time for which exam findings were discussed and demonstrated, and resident impression of education quality. Results: The randomisation of 20 shifts in each cohort provided a total of 274 patient cases. Our primary outcome was an increased frequency of discussion of the differential diagnosis, which
occurred more often in the bedside group (72 versus 53%). We also detected that with bedside rounding more questions per patient were asked, and alternative therapies and tests, exam findings and results were discussed more often. Conclusions: Bedside rounding in the emergency department, as compared with board rounding, appears to increase the frequency of learner education measures. Emergency medicine residents reported the quality of education was better with bedside rounding. Bedside rounds took on average 4 minutes longer, without achieving statistical significance.
94 © 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2015; 12: 94–98
tct_12271.indd 94
3/11/2015 11:59:14 AM
INTRODUCTION
We hypothesised that bedside rounding would improve education and increase resident satisfaction
B
edside rounding is considered by many to be an effective means to teach history and physical examination skills.1,2 Bedside rounding allows other skills to be patterned and evaluated, such as professionalism, communication and patient education.3 The use of bedside rounding has declined, however. During the 1900s, as much as 75 per cent of rounding occurred at the bedside.4 A 2009 survey of internal medicine residents reported that presentations occurred at the bedside 25 per cent of the time.5 Instead of at the bedside, rounding often occurs at a common meeting area (monitor or board). In this form of ‘board rounds’, patient information is summarised away from the bedside. Variable preferences for bedside rounding compared with board rounding have been demonstrated by internal medicine residents.6 Perceived reasons for not performing bedside rounding have included lack of respect for the patient, time constraints, attitude of faculty staff and an over-reliance on technology;7 however, bedside rounds do not take longer than rounding away from the bedside.8 Some have recognised that patients may prefer bedside rounding.9 To our knowledge, bedside rounding during the emergency department turnover has not been extensively compared with board rounding in relation to education or emergency medicine resident perception of education. The primary objective of our study was to gain insight into whether bedside rounding at shift turnover in the emergency department improved the quality of education of residents, as compared with board rounding, through an increase in discussion
of the differential diagnosis. We hypothesised that bedside rounding would improve education and increase resident satisfaction within a busy emergency department.
METHODS Study design and setting We conducted a randomised, prospective study in a single, large academic emergency department in a 1–year study period. The study was approved and monitored by our local institutional review board. Methods of measurement and collection and processing Forty clinical shifts of different time blocks were selected and randomised to either bedside or board rounds. The format of rounds was announced by an independent observer prior to each shift. An introduction was presented to the attending physician by the observer at the beginning of each designated data collection period. Board rounds were conducted with a standard approach by discussing patients in front of the computerised board, and identifying all patients and chief complaints. Bedside rounds were conducted at each patient’s bedside. The rounding teams were similar groups regardless of rounding type, and consisted of an off-going or on-coming
attending physician, and a first-, a second- and a third-year resident. Trained data collectors recorded information during the designated rounding sessions. The data collected included total time of rounds, number of patients, number of questions asked, if the differential diagnosis was discussed, if alternative therapies were discussed and if physical exam findings were discussed (for a complete list, see Table 1). The visual analogue scale has been found to be a reliable and valid alternative to study bedside-teaching exercises.10 Each off-going resident completed an internally designed and validated survey using a 100–point visual analogue scale (VAS) to evaluate their satisfaction with their education during rounds. Only residents (not attending physicians) were surveyed. The residents in the bedside and board rounding overlapped, and were not independent resident groups. The resident survey included questions regarding whether the rounding approach affected changes in patient management, drug therapy, diagnostic tests ordered or disposition. Primary data analysis The data were collected with the primary intent of investigating
© 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2015; 12: 94–98 95
tct_12271.indd 95
3/11/2015 11:59:15 AM
During bedside rounds there was an increase in the average number of questions per patient
Table 1. Results of educational discussions for board rounds versus bedside rounds Variables
Board rounds
Number of rounds observed Total number of patients Average number of patients per round Average time for rounds (minutes) Total number of questions asked
20
20
139
135
7
6.8
13.2
17.5
382
Total time for which the differential diagnosis was discussed Average number of questions per patient
Bedside rounds
p
510
74 (53%) 2.8
97 (72%) 3.8
0.002* 0.004*
Total time for which alternative therapies discussed
35 (25%)
61 (45%)
0.0006*
Total time for which alternative tests were discussed
46 (33%)
64 (47%)
0.02*
Total times for which exam findings were discussed
48 (34%)
69 (51%)
0.007*
3 (2%)
18 (13%)
0.0005*
40 (29%)
57 (42%)
0.02*
Total times for which exam findings were demonstrated Total times imaging results discussed Total times imaging results demonstrated
2 (1.4%)
Total times ECG or cardiac monitor reviewed
12 (8.6%)
0 21 (15.6%)
0.5 0.1
ECG, electrocardiogram *Unpaired Student’s t–test p value for ‘Average number of questions per patient’; all others are Fisher’s exact test p values.
Data collector name: Date: 1500 Time of shift turnover (circle one): 0700 Board Style of rounds (circle one): Bedside
RESULTS 2300
1. What was the quality of education during Rounds today? Mark below on a scale of 0 – 100 the quality of your education (0 indicating none and 100 indicating exceptional).
0
100
2. Did your patient management change based on Rounds? (circle) Yes No 3. Did you change any of the following as the result of Rounds today? (circle) Drug Therapies: (circle one): Yes No Diagnostic Tests: (circle one): Yes No Admission or Discharge Decision: (circle one): Yes No
Figure 1. Emergency medicine resident survey
whether bedside rounding at shift turnover in the emergency department improved the quality of education of emergency medicine residents through the primary outcome measure of the number of times the differential diagnosis was discussed. A 100– point VAS (Figure 1) was used for the data collection of resident satisfaction with bedside versus board rounds, evaluated using an unpaired Student’s t–test. The
questions used on the survey were not previously validated, and to our knowledge no validated measures exist. All other data collected were evaluated with Fisher’s exact tests or chisquare tests. As we did not have validated measures to measure education, discussion of the differential diagnosis was used as a presumptive measure that may equate to education during rounds.
Characteristics of study subjects We enrolled observations for rounds on 274 patients: 139 patients in bedside rounds and 135 patients in board rounds. We surveyed 111 emergency medicine residents (58 residents in the board round cohort and 53 in the bedside cohort). Main results The discussion of the differential diagnosis, our primary outcome, was more frequently discussed at bedside rounds: 72 versus 53 per cent (p < 0.002). In addition, during bedside rounds there was an increase in the average number of questions per patient, in the total time for which alternative therapies were discussed, in the total time for which alternative tests were discussed, in the total time for which exam findings were
96 © 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2015; 12: 94–98
tct_12271.indd 96
3/11/2015 11:59:15 AM
Table 2. Results of resident survey completed after rounds Question
Board rounds % (n = 135)
Bedside rounds % (n = 139)
p
Did patient management change as a result of rounds?
18
29
0.27
Did drug therapy change as a result of rounds?
8
10
0.61
Did the diagnostic tests ordered change as a result of rounds?
9
19
0.016
Did admission or discharge disposition change as a result of rounds?
4
9
0.68
Bedside rounding may supply an environment for providing more education than is the case with board rounding
Fisher’s exact test used to determine the p values.
discussed and demonstrated, and in the total time for which imaging results were discussed, compared with the board rounds. Imaging results were reviewed only twice at board rounds, and never during bedside rounds (Table 1). Residents were also surveyed as to whether board rounds or bedside rounds affected the management of the patients who were discussed (Table 2). Diagnostic tests were changed more commonly with bedside rounds (p < 0.016). There were no differences between groups for patient management changes following bedside rounds, change in drug therapy and disposition. There was no statistical difference between groups in the average time length of rounds. The average total time of bedside rounds was 4.3 minutes (95% CI 3.2–5.4 minutes) longer than board rounds. Resident impression of the quality of education during bedside rounds compared with board rounds was greater by 19.2 points (19.2%) on the VAS (bedside rounds 59, board rounds 40; p ≤ 0.0001).
DISCUSSION We found that bedside rounding in the emergency department compared with board rounding significantly increased the frequency of discussion
of the differential diagnosis. Furthermore, during bedside rounding we detected an increase in the average number of questions asked during rounds, the average time for which alternative therapies and tests were discussed, the average number of times exam findings were discussed and demonstrated, and the total number of times that imaging results were discussed. Emergency medicine resident impression of the quality of education was higher with bedside rounding. The diagnostic tests ordered changed more frequently during bedside rounding. To our knowledge, the impact of the type of rounding on education and clinical care in the emergency department has not been reported to any appreciable degree. Survey studies have reported that internal medicine residents felt that bedside rounds provided improved patient care, but those who performed bedside rounds did not believe it to be any more educational;8 however, these studies did not record objective metrics of education during rounds. In our study, we studied emergency medicine rounds, recorded representative educational metrics during rounds and surveyed residents for their opinion of the education during rounds. Based on our results, bedside rounding may supply an environment for providing more
education than is the case with board rounding. The inherent belief of the study that more discussion and questions is a proxy for education may not be entirely valid at all times, but we believe that this is the best measure for education that we could attain. Our study often focused on the quantity of activities as proxies for actual education. We assumed that increased discussion on such topics as the differential diagnosis might lead to increased teaching. The increased lengths of time for questions, for the discussion of alternative therapies and tests, for the discussion and demonstration of findings from physical examination, and for the discussion of imaging results would suggest that there are further educational opportunities for the residents. In addition to these metrics, the residents did perceive that there was increased education occurring on bedside rounds. We did not assess patient perceptions of bedside rounds, but would like to study these in the future through either an additional VAS immediately after rounds or through patient call-back. Interestingly, imaging was discussed more frequently during bedside rounding than during board rounding, despite never being demonstrated. This is a concerning sacrifice for bedside rounding, as there isn’t the opportunity to demonstrate imaging during rounds.
© 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2015; 12: 94–98 97
tct_12271.indd 97
3/11/2015 11:59:15 AM
Emergency medicine residents felt the quality of education was better with bedside rounding
We detected an increase in time spent on bedside rounds by an average of 4 minutes. Although the difference wasn’t statistically significant, this could be considered a considerable period of time in a busy emergency department. This increased duration of rounds must be balanced against the improved education. Previous studies have shown that the quality of teaching and clinical productivity isn’t at odds in an academic emergency department.11
CONCLUSION
LIMITATIONS
REFERENCES
We used frequency of questioning and discussions as surrogates for education quality. These surrogates may not reflect better education but were objective measurements of frequency that would imply an increase. The residents in the board and bedside rounding groups overlapped, and weren’t independent groups. A convenience sample was used; however, we performed a randomised sample of all shifts. We didn’t pilot our study nor assess inter-rater reliability.
Bedside rounding in the emergency department, as compared with board rounding, significantly increased the frequency of discussion of the differential diagnosis and other measures of learner education. Emergency medicine residents reported that they felt the quality of education was better with bedside rounding compared with board rounding. The length of board rounds and bedside rounds was similar.
1. Langlois JP, Thach S. Teaching at the bedside. Fam Med 2000;32:528–530. 2. LaCombe MA. On bedside teaching. Ann Intern Med 1997;126:217–220. 3. Aldeen AZ, Gisondi MA. Bedside teaching in the emergency department. Acad Emerg Med 2006;13:860–866. 4. Reichsman F, Browning FE, Hinshaw JR. Observations of undergraduate clinical teaching in action. J Med Educ 1964;39:147–163. 5. Gonzalo JD, Masters PA, Simons RJ, Chuang CH. Attending rounds and bedside case presentations:
medical student and medicine resident experiences and attitudes. Teach Learn Med 2009;21:105–110. 6. Tariq M, Motiwala A, Ali SU, Riaz M, Awwan S, Akhter J. The learners’ perspective on internal medicine ward rounds: a cross-sectional study. BMC Med Educ 2010;10:53. 7. Williams KN, Ramani S, Fraser B, Orlander JD. Improving bedside teaching: findings from a focus group of study learners. Acad Med 2008;83:257–264. 8. Gonzalo JD, Chuang CH, Huang G, Smith C. The return of bedside rounds: an educational intervention. J Gen Intern Med 2010;25:792–798. 9. Lehmann LS, Brancati FL, Chen MC, Roter D, Dobs AS. The effect of bedside case presentations on patients’ perception of their medical care. N Engl J Med 1997;336:1150–1155. 10. Celeza A, Rogers IR. Comparison of visual analogue and Likert scales in evaluation of an emergency department bedside teaching programme. Emerg Med Australas 2011;23:68–75. 11. Berger TJ, Ander DS, Terrell ML, Berle DC. The impact of the demand for clinical productivity on student teaching in academic emergency departments. Acad Emerg Med 2004;11:1364–1367.
Corresponding author’s contact details: Andrew Muck, University of Texas Health Science Center at San Antonio, Emergency Medicine Department, 7703 Floyd Curl Drive, MC 7736, San Antonio, Texas 78229, USA. E-mail: [email protected]
Funding: None. Conflict of interest: None. Acknowledgements: None. Ethical approval: Ethical approval was obtained from the Institutional Review Board of Brook Army Medical Center, Fort Sam Houston, San Antonio, Texas, USA. doi: 10.1111/tct.12271
98 © 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2015; 12: 94–98
tct_12271.indd 98
3/11/2015 11:59:15 AM
Bedside rounds versus board rounds in an emergency department Andrew Muck1, Christopher McNeil1, Patrick McHugh2, Vikhyat Bebarta3 and Bruce Adams1 1
Emergency Department, University of Texas Health Science Center at San Antonio, San Antonio, Texas USA 2 Emergency Department, Fredericksburg Emergency Medical Alliance, Fredericksburg, Virginia, USA 3 Department of Emergency Medicine, San Antonio Military Medical Center, San Antonio, Texas, USA The impact on teaching or patient care has not compared between [board and bedside rounding]
SUMMARY Background: Our objective was to gain insight into whether bedside rounding at shift turnover in the emergency department improved education quality, as compared with board rounds. Board rounds are commonly used in the emergency department, where the teams review the patient and transfer care near a computer screen or written board, rather than at the patient’s bedside. The impact on teaching or patient care has not been extensively compared between the two approaches. Methods: We conducted a prospective study in an academic emergency department to compare bedside rounds versus board
rounds. A convenience sample of 408–hour clinical shifts were randomised to either bedside or board rounds. Data collected included frequency of discussion of differential diagnosis, questions asked per patient, total time for which alternative therapies were discussed, total time for which alternative tests were discussed, total time for which exam findings were discussed and demonstrated, and resident impression of education quality. Results: The randomisation of 20 shifts in each cohort provided a total of 274 patient cases. Our primary outcome was an increased frequency of discussion of the differential diagnosis, which
occurred more often in the bedside group (72 versus 53%). We also detected that with bedside rounding more questions per patient were asked, and alternative therapies and tests, exam findings and results were discussed more often. Conclusions: Bedside rounding in the emergency department, as compared with board rounding, appears to increase the frequency of learner education measures. Emergency medicine residents reported the quality of education was better with bedside rounding. Bedside rounds took on average 4 minutes longer, without achieving statistical significance.
94 © 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2015; 12: 94–98
tct_12271.indd 94
3/11/2015 11:59:14 AM
INTRODUCTION
We hypothesised that bedside rounding would improve education and increase resident satisfaction
B
edside rounding is considered by many to be an effective means to teach history and physical examination skills.1,2 Bedside rounding allows other skills to be patterned and evaluated, such as professionalism, communication and patient education.3 The use of bedside rounding has declined, however. During the 1900s, as much as 75 per cent of rounding occurred at the bedside.4 A 2009 survey of internal medicine residents reported that presentations occurred at the bedside 25 per cent of the time.5 Instead of at the bedside, rounding often occurs at a common meeting area (monitor or board). In this form of ‘board rounds’, patient information is summarised away from the bedside. Variable preferences for bedside rounding compared with board rounding have been demonstrated by internal medicine residents.6 Perceived reasons for not performing bedside rounding have included lack of respect for the patient, time constraints, attitude of faculty staff and an over-reliance on technology;7 however, bedside rounds do not take longer than rounding away from the bedside.8 Some have recognised that patients may prefer bedside rounding.9 To our knowledge, bedside rounding during the emergency department turnover has not been extensively compared with board rounding in relation to education or emergency medicine resident perception of education. The primary objective of our study was to gain insight into whether bedside rounding at shift turnover in the emergency department improved the quality of education of residents, as compared with board rounding, through an increase in discussion
of the differential diagnosis. We hypothesised that bedside rounding would improve education and increase resident satisfaction within a busy emergency department.
METHODS Study design and setting We conducted a randomised, prospective study in a single, large academic emergency department in a 1–year study period. The study was approved and monitored by our local institutional review board. Methods of measurement and collection and processing Forty clinical shifts of different time blocks were selected and randomised to either bedside or board rounds. The format of rounds was announced by an independent observer prior to each shift. An introduction was presented to the attending physician by the observer at the beginning of each designated data collection period. Board rounds were conducted with a standard approach by discussing patients in front of the computerised board, and identifying all patients and chief complaints. Bedside rounds were conducted at each patient’s bedside. The rounding teams were similar groups regardless of rounding type, and consisted of an off-going or on-coming
attending physician, and a first-, a second- and a third-year resident. Trained data collectors recorded information during the designated rounding sessions. The data collected included total time of rounds, number of patients, number of questions asked, if the differential diagnosis was discussed, if alternative therapies were discussed and if physical exam findings were discussed (for a complete list, see Table 1). The visual analogue scale has been found to be a reliable and valid alternative to study bedside-teaching exercises.10 Each off-going resident completed an internally designed and validated survey using a 100–point visual analogue scale (VAS) to evaluate their satisfaction with their education during rounds. Only residents (not attending physicians) were surveyed. The residents in the bedside and board rounding overlapped, and were not independent resident groups. The resident survey included questions regarding whether the rounding approach affected changes in patient management, drug therapy, diagnostic tests ordered or disposition. Primary data analysis The data were collected with the primary intent of investigating
© 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2015; 12: 94–98 95
tct_12271.indd 95
3/11/2015 11:59:15 AM
During bedside rounds there was an increase in the average number of questions per patient
Table 1. Results of educational discussions for board rounds versus bedside rounds Variables
Board rounds
Number of rounds observed Total number of patients Average number of patients per round Average time for rounds (minutes) Total number of questions asked
20
20
139
135
7
6.8
13.2
17.5
382
Total time for which the differential diagnosis was discussed Average number of questions per patient
Bedside rounds
p
510
74 (53%) 2.8
97 (72%) 3.8
0.002* 0.004*
Total time for which alternative therapies discussed
35 (25%)
61 (45%)
0.0006*
Total time for which alternative tests were discussed
46 (33%)
64 (47%)
0.02*
Total times for which exam findings were discussed
48 (34%)
69 (51%)
0.007*
3 (2%)
18 (13%)
0.0005*
40 (29%)
57 (42%)
0.02*
Total times for which exam findings were demonstrated Total times imaging results discussed Total times imaging results demonstrated
2 (1.4%)
Total times ECG or cardiac monitor reviewed
12 (8.6%)
0 21 (15.6%)
0.5 0.1
ECG, electrocardiogram *Unpaired Student’s t–test p value for ‘Average number of questions per patient’; all others are Fisher’s exact test p values.
Data collector name: Date: 1500 Time of shift turnover (circle one): 0700 Board Style of rounds (circle one): Bedside
RESULTS 2300
1. What was the quality of education during Rounds today? Mark below on a scale of 0 – 100 the quality of your education (0 indicating none and 100 indicating exceptional).
0
100
2. Did your patient management change based on Rounds? (circle) Yes No 3. Did you change any of the following as the result of Rounds today? (circle) Drug Therapies: (circle one): Yes No Diagnostic Tests: (circle one): Yes No Admission or Discharge Decision: (circle one): Yes No
Figure 1. Emergency medicine resident survey
whether bedside rounding at shift turnover in the emergency department improved the quality of education of emergency medicine residents through the primary outcome measure of the number of times the differential diagnosis was discussed. A 100– point VAS (Figure 1) was used for the data collection of resident satisfaction with bedside versus board rounds, evaluated using an unpaired Student’s t–test. The
questions used on the survey were not previously validated, and to our knowledge no validated measures exist. All other data collected were evaluated with Fisher’s exact tests or chisquare tests. As we did not have validated measures to measure education, discussion of the differential diagnosis was used as a presumptive measure that may equate to education during rounds.
Characteristics of study subjects We enrolled observations for rounds on 274 patients: 139 patients in bedside rounds and 135 patients in board rounds. We surveyed 111 emergency medicine residents (58 residents in the board round cohort and 53 in the bedside cohort). Main results The discussion of the differential diagnosis, our primary outcome, was more frequently discussed at bedside rounds: 72 versus 53 per cent (p < 0.002). In addition, during bedside rounds there was an increase in the average number of questions per patient, in the total time for which alternative therapies were discussed, in the total time for which alternative tests were discussed, in the total time for which exam findings were
96 © 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2015; 12: 94–98
tct_12271.indd 96
3/11/2015 11:59:15 AM
Table 2. Results of resident survey completed after rounds Question
Board rounds % (n = 135)
Bedside rounds % (n = 139)
p
Did patient management change as a result of rounds?
18
29
0.27
Did drug therapy change as a result of rounds?
8
10
0.61
Did the diagnostic tests ordered change as a result of rounds?
9
19
0.016
Did admission or discharge disposition change as a result of rounds?
4
9
0.68
Bedside rounding may supply an environment for providing more education than is the case with board rounding
Fisher’s exact test used to determine the p values.
discussed and demonstrated, and in the total time for which imaging results were discussed, compared with the board rounds. Imaging results were reviewed only twice at board rounds, and never during bedside rounds (Table 1). Residents were also surveyed as to whether board rounds or bedside rounds affected the management of the patients who were discussed (Table 2). Diagnostic tests were changed more commonly with bedside rounds (p < 0.016). There were no differences between groups for patient management changes following bedside rounds, change in drug therapy and disposition. There was no statistical difference between groups in the average time length of rounds. The average total time of bedside rounds was 4.3 minutes (95% CI 3.2–5.4 minutes) longer than board rounds. Resident impression of the quality of education during bedside rounds compared with board rounds was greater by 19.2 points (19.2%) on the VAS (bedside rounds 59, board rounds 40; p ≤ 0.0001).
DISCUSSION We found that bedside rounding in the emergency department compared with board rounding significantly increased the frequency of discussion
of the differential diagnosis. Furthermore, during bedside rounding we detected an increase in the average number of questions asked during rounds, the average time for which alternative therapies and tests were discussed, the average number of times exam findings were discussed and demonstrated, and the total number of times that imaging results were discussed. Emergency medicine resident impression of the quality of education was higher with bedside rounding. The diagnostic tests ordered changed more frequently during bedside rounding. To our knowledge, the impact of the type of rounding on education and clinical care in the emergency department has not been reported to any appreciable degree. Survey studies have reported that internal medicine residents felt that bedside rounds provided improved patient care, but those who performed bedside rounds did not believe it to be any more educational;8 however, these studies did not record objective metrics of education during rounds. In our study, we studied emergency medicine rounds, recorded representative educational metrics during rounds and surveyed residents for their opinion of the education during rounds. Based on our results, bedside rounding may supply an environment for providing more
education than is the case with board rounding. The inherent belief of the study that more discussion and questions is a proxy for education may not be entirely valid at all times, but we believe that this is the best measure for education that we could attain. Our study often focused on the quantity of activities as proxies for actual education. We assumed that increased discussion on such topics as the differential diagnosis might lead to increased teaching. The increased lengths of time for questions, for the discussion of alternative therapies and tests, for the discussion and demonstration of findings from physical examination, and for the discussion of imaging results would suggest that there are further educational opportunities for the residents. In addition to these metrics, the residents did perceive that there was increased education occurring on bedside rounds. We did not assess patient perceptions of bedside rounds, but would like to study these in the future through either an additional VAS immediately after rounds or through patient call-back. Interestingly, imaging was discussed more frequently during bedside rounding than during board rounding, despite never being demonstrated. This is a concerning sacrifice for bedside rounding, as there isn’t the opportunity to demonstrate imaging during rounds.
© 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2015; 12: 94–98 97
tct_12271.indd 97
3/11/2015 11:59:15 AM
Emergency medicine residents felt the quality of education was better with bedside rounding
We detected an increase in time spent on bedside rounds by an average of 4 minutes. Although the difference wasn’t statistically significant, this could be considered a considerable period of time in a busy emergency department. This increased duration of rounds must be balanced against the improved education. Previous studies have shown that the quality of teaching and clinical productivity isn’t at odds in an academic emergency department.11
CONCLUSION
LIMITATIONS
REFERENCES
We used frequency of questioning and discussions as surrogates for education quality. These surrogates may not reflect better education but were objective measurements of frequency that would imply an increase. The residents in the board and bedside rounding groups overlapped, and weren’t independent groups. A convenience sample was used; however, we performed a randomised sample of all shifts. We didn’t pilot our study nor assess inter-rater reliability.
Bedside rounding in the emergency department, as compared with board rounding, significantly increased the frequency of discussion of the differential diagnosis and other measures of learner education. Emergency medicine residents reported that they felt the quality of education was better with bedside rounding compared with board rounding. The length of board rounds and bedside rounds was similar.
1. Langlois JP, Thach S. Teaching at the bedside. Fam Med 2000;32:528–530. 2. LaCombe MA. On bedside teaching. Ann Intern Med 1997;126:217–220. 3. Aldeen AZ, Gisondi MA. Bedside teaching in the emergency department. Acad Emerg Med 2006;13:860–866. 4. Reichsman F, Browning FE, Hinshaw JR. Observations of undergraduate clinical teaching in action. J Med Educ 1964;39:147–163. 5. Gonzalo JD, Masters PA, Simons RJ, Chuang CH. Attending rounds and bedside case presentations:
medical student and medicine resident experiences and attitudes. Teach Learn Med 2009;21:105–110. 6. Tariq M, Motiwala A, Ali SU, Riaz M, Awwan S, Akhter J. The learners’ perspective on internal medicine ward rounds: a cross-sectional study. BMC Med Educ 2010;10:53. 7. Williams KN, Ramani S, Fraser B, Orlander JD. Improving bedside teaching: findings from a focus group of study learners. Acad Med 2008;83:257–264. 8. Gonzalo JD, Chuang CH, Huang G, Smith C. The return of bedside rounds: an educational intervention. J Gen Intern Med 2010;25:792–798. 9. Lehmann LS, Brancati FL, Chen MC, Roter D, Dobs AS. The effect of bedside case presentations on patients’ perception of their medical care. N Engl J Med 1997;336:1150–1155. 10. Celeza A, Rogers IR. Comparison of visual analogue and Likert scales in evaluation of an emergency department bedside teaching programme. Emerg Med Australas 2011;23:68–75. 11. Berger TJ, Ander DS, Terrell ML, Berle DC. The impact of the demand for clinical productivity on student teaching in academic emergency departments. Acad Emerg Med 2004;11:1364–1367.
Corresponding author’s contact details: Andrew Muck, University of Texas Health Science Center at San Antonio, Emergency Medicine Department, 7703 Floyd Curl Drive, MC 7736, San Antonio, Texas 78229, USA. E-mail: [email protected]
Funding: None. Conflict of interest: None. Acknowledgements: None. Ethical approval: Ethical approval was obtained from the Institutional Review Board of Brook Army Medical Center, Fort Sam Houston, San Antonio, Texas, USA. doi: 10.1111/tct.12271
98 © 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2015; 12: 94–98
tct_12271.indd 98
3/11/2015 11:59:15 AM
