INTRODUCTION:

Sir William Osler (1849-1919)described medicine as both an art and science taught at the bedside [1] and known as a proponent of introducing bedside teaching (BST) to modern medicine. Medical educators realize bedside teaching is a fundamental tool in teaching medicine. As the name has denoted, bedside teaching is a clinical teaching method in the presence of a patient [2]. It emphasizes on history taking and physical examination skills, which play a vital role in getting the

diagnosis. According to La Combe, bedside teaching helps students’ to improve history taking, examination skills, and knowledge of clinical ethics. Moreover, in budding doctors bedside teaching fosters professionalism, good communication, and role modeling skills [3]. This module of teaching was widely practiced during the 1960s and early 70s and declined substantially (75% to 8-19%) [4], this decline is probably due to the recent improvement in diagnostic facilities and technology. Furthermore, the assumed violation of patients’ right, the shortened hospital stay, quick turnover rate and the implementation of daycare units are the learned contributors to decline in BST.

The reduced significance of BST from past to present resulted in poor performance of budding medical doctors in the physical examination of patients. The decline worried the clinical educators noticing the migration of BST from patient-centered teaching and learning method to the conference room. Medical education is the dynamic process which needs to have excellent quality guaranteed. Generally, the efficacy of the teaching process depends on teaching methods which are understood by examining the students. Currently, the productivity and quality of medical students are measured by grading the results of the examination. Most medical schools focus on the well-structured examination, which grades the efficiency of clinicians. These exams make use of patients or simulated patients to test the students' clinical skills and ability. Therefore, for the students, they should be familiar with BST experience in their clinical years to improve their clinical skill and increase in acquisition with professionalism, communications, and ethical manner. However, it is a complex teaching process as the students should take their time to build up the learning curve.

The teaching and learning in the clinical environment are not as simple as classroom teaching; which involves people with different views, feelings, concerns, and expectations. The World Health Organization Advisory Committee on Medical Teaching (1992) recommends BST should increase the teacher-student and patient-student relationship [5]. Indeed, bedside teaching method benefits students in enhancing their reasoning skill, implementing skill to problem-solving, and learning in evidence-based medicine; which is useful in their clinical practice. In clinical medicine, 56% of patients’ problems diagnosed after taking a comprehensive history and 73% by the end of a physical examination [6, 7]. In BST, a clinician takes a group of learners to the bedside of a patient, listens to the history, elicits the physical signs, makes a provisional diagnosis and decides on the best diagnostic and therapeutic options [8].

There are studies focused on the benefits of BST patient’s perspective and student’s perspective, its barriers and possible causes for its decline; however, prospective randomized studies are not abundant in the literature. The previous studies evaluated the majority of patients appear to appreciate bedside teaching because of the extra time and insight given to their medical situation. The physicians seem to less favor of this teaching method, especially younger physicians they are afraid of demeaning and burdening to patients [4]. There is no much written on bedside teaching after 2008.

The students are the beneficiary group get best out of BST, there are very few studies made an effort to explore student trainees´ regarding the benefits of BST. Previously BST is used as an instrument for student evaluation, but no literature found over feedback for the satisfaction of the learners. Feedback in medical education is an integral part of teaching; which encourages better teaching method and enhances the learners' knowledge, skills, and professionalism. Therefore, assessing the benefits of bedside teaching method on medical students’ perspective is beneficial. The finding of research in this area limelight’s on the values of bedside teaching method which has benefited students by this module of clinical teaching since Osler time. Currently, educators’ focus to reflect on BST method to make BST is an effective teaching method.

OBJECTIVES:

1. To investigate the perceived educational status of bedside teaching by the first year clinical students.

2. To improve the teaching method in the UNIMAS by assessing the attitude of consumers (medical students) in the university towards BST.

METHODOLOGY:

The study is basing contextual design. Among the clinical modules, the Obstetrics and Gynaecology are one of the core clinical modules of teaching in Year 3 clinical period of the medical program. The module was undertaken combining three modules such as medicine, surgery, and community and public health for the whole academic year. All students in the first clinical year divided into four groups. Further, the group rotated to all modules in the whole year before they promoted to Year 4. Each posting period lasted for eight weeks. During this period, students were assigned to the maternity, labour and gynaecology wards and operation theatre. They were required to attend scheduled teaching sessions with professors, consultants and lecturers. The topics covered were taken from the curriculum and SIO from the guide book.

Study design

This study was on student perception towards clinical training on BST carried out at the Faculty of Medicine and Health Sciences, UNIMAS. The students recruited were posted for clinical training in Obstetrics and Gynaecology in Sarawak General Hospital. It was a cross-sectional, questionnaire-based study using a sample of one hundred and two year-three medical students. It was cross-sectional questionnaire based study using a sample of one hundred and two year-three medical students. Students for the study were selected during the first clinical year. The study period current research was from September 2017 to June 2018.

Researchers emphasized the students that it was not mandatory for them to take part in the study, and their anonymity was maintained. A well-structured and well-designed questionnaire for perception and their satisfaction regarding bedside teaching was developed and used as a research instrument for this study.

Previous literature, feedback from previous teaching session, and personal experience were taken to formulate BST module. Further, students’ soft skills during BST, perception, and satisfaction of the students were taken as feedback.

A pilot study conducted on 30 voluntary participants from the previous year; further checked with Cronbach’s alpha, which found to be as good as 0.711. The students were asked to fill up the questionnaires at the end of the teaching sessions. Before collecting the data, a description of the study and confidentiality were explained. Then, the written consent was taken from each respondent. Data entry with analysis was carried out by using SPSS v 22. Descriptive analysis was done for each of the items.

RESULTS:

The total participants were hundred and two (102) year-three medical students participated in the study. Result of the current study revealed participant’s perceived educational value towards the effectiveness of BST appreciated as useful in improving clinical skill. All the participants of the current study revealed BST was beneficial for them; which enabled them to manage their patients better. They also stated knowledge gained in the BST mend them as better professionals. Among the participants, a few of them (29%) had not expressed a positive attitude on the clinical BST sessions in gaining well enough knowledge. Another, similar study by Nair et al revealed half of their learners (48%) reported they had good enough BST during the clinical years [8]. It was a favourable result (29% vs. 52%) for our curriculum; which may be due to UNIMAS curriculum already involved with the BST sessions for the students in their clinical postings.

The contents of BST

Out of all respondents, 91.1% expected that bedside teaching should provide with all necessary information in the well-organized, well-structured plan. Furthermore, 51% refused to accept that BST covered the most topics from the syllabus. These feedback responses were a surprising result for us, and it is totally in contrast to our positive expectation. The reasons may be the participants just started their clinical year, and their exposure to the clinical field was still new. Therefore, there was a possibility to get confused on BST learning; which is patient-centered or patient- orientated. Indeed, multiple modes of teaching associated with clinical domains need to consider during the learning process. Among the total participants, 51% of them responded with discouraging feedback; uncertain about the knowledge retention after BST; but 83.3% of respondents positive about take-home messages after BST. Positive feedback received from the respondents proved on the effective educational outcome. Like 76.5 % of respondents appreciated getting hands-on practice after BST.

Realized fact is that significance of the participant’s positive expectation of getting prepared for BST.

Among these participants, 94.1% of them admitted studying in advance on the related topic before the learning session is beneficial. Further, 86.6% of them expected topic given to beforehand, would help them to focus more on the subject by questioning on relevant areas, reasoning and evaluating the causes and effects. Indeed, this may pave up productive in the discussion. This feedback proved helpful to the authors to conceptualize on the students’ learning experience and educational value on bedside teaching.

Facilitator

Few of the participants (18%) revealed that teaching with higher rankers like professors and consultants were useful to them. The similar result was rated (19.6%) to a small lecturer teaching session. Among them, 53.9 % expressed were uncertain about the knowledge sharing from BST in terms of the rank of the clinicians, whether resident/consultant or professor. However, they expressed a preference for professionals; who are enthusiastic, motivated, and share a positive relationship with them. From the student participants’ perspectives, as long as the facilitator or teacher was interactive and well-engaged; it drives them benefiting educationally.

Participants also revealed the physicians interact with patients in a proper way of professional’s conduct during BST and performing the surgery in operation theatre; observation of which paves up students desire and motivation to pursue this professional conduct.

The students were satisfied, 55.9% them showed a positive response for overall aspects of BST. Majority of the participants (80.4 %), revealed that it was more productive in terms of knowledge and skill. Further, 66.6% of them believed, BST create a dynamic group, preference for interactive discussion given by majority; which is 92.1%. Among the total participants, 70.6% of them said, the cases already taught to them if repeated in BST by different teachers, in different teaching style, and with variable strengths which upgrade their learning. It was probably related to presenter´s ability (Active and attractive style), and creativity of team engagement agreed by 65.7% of respondents.

Soft skills

Interestingly, 77.8% of feedbacks disagreed that language used during the BST was not a barrier. The reason may be that most medical students had good command in the English language. Out of the total participants, 55.8% agreed that BST eliminates the classroom diversity. Further, 86.2 % said BST helps to improve communication skills among the students and with the patients.

Perception and Satisfaction

Among the total participants, 74.5% said it is interesting, and 89.3% of them thought it is more practical. All the participants agreed bedside teaching is an effective teaching method. This fact is supported by Nair et al. study; which showed 90% of the study group believed BST is effective in improving skills of communication, history-taking, and physical examination [8].

Most of the participants (80.4 %) revealed that it was more productive in terms of knowledge and skill. They agreed it helped them to grow in professionalism and ethical consideration by observing from their peers. Response on stress during the bedside teaching 34.5 %, improved teamwork activity 73.5%, 69% revealed no focus distraction during discussions in the session.

Table 1: Student’s feedback on bedside teaching (n = 102)

No.	Questionnaires	%
1	It is an effective teaching method.	100.0
2	It gives useful knowledge.	97.0
3	It is more productive.	80.4
4	It is interesting.	74.5
5	It is practical and useful.	89.3
6	To be interactive is important	92.1
7	Group dynamic can be created	66.6
8	Learning from high ranker is better	17.6
9	It covers most of the topics.	49.0
10	It is beneficial.	100.0
11	It provides more information.	91.1
12	same topic taught by different lecturers	70.6
13	Retains much of the content after BST	20.6
14	Take- home message	83.3
15	Role of the presenter is important	65.7
16	Language is a barrier	16.7
17	It is stressful	34.3
18	hands-on practice	76.5
19	It improved team work activity	73.5
20	It can improve communication skill with patients	86.2
21	It can eliminate classroom diversity	55.8
22	It needs study in advance	94.1
23	It is better if the topics is given beforehand	86.2
24	It is boring.	0.0
25	Able to focus	69.6

The description of the students’ perception and satisfaction regarding bedside teaching are discussed in percentages. Moreover the feedback given by students depicted in percentages in table one. Table two represents bar diagram of these results. Moreover, the feedback was given by students depicted in percentages in table one. Table two represents a bar diagram of these results.

Figure 1: Student’s feedback on bedside teaching

DISCUSSION:

Bedside teaching academicians in the medical field need to provide clinical experience. Academicians should provide hands-on experiences to their students by seeing the patients, learning practical skills, finding out useful physical signs in patients’ physical examination, reasoning, and evaluation of possible diagnoses. It provides the students with a unique opportunity to meet and interact with patients together with their peers and experienced professionals. Previously studied literature on bedside teaching has been proven improvement in certain clinical skills of the students and residents [13].

It will pave up the students to attain their educational benefits by hierarchical learning; which motivate them to work with the best of themselves. It provides the snowballing effect in terms of growth and expansion of their knowledge boundary. Several other skills essential in patient contact can, for a great part, best be learned at the bedside. One of the previous research work in the literature revealed skills essential to be with patient contact, are best learned at the bedside [14]. Studies have also revealed communicating effectively with real patients ingrains the medical ethics and adequately obtaining a structured history not going extensively with medical terminology [14]. Apart from student satisfaction, bedside teaching extends patient satisfaction; Simons et al. revealed patients generally satisfied with bedside teaching [15].

Medical education aims to produce skilled medical professionals in the health care system. To achieve this education system need to be focused on curriculum design and teaching strategy. Literature reveals, to improve undergraduate medical curriculum changes in medical programs is made inconsistent with the current societal needs, emphasis on a medical education based on the healthcare system is essential [16].

We need to accept the fact that in Medicine, the educational focus has shifted away from knowledge acquisition and duration of training towards the achievement of learning outcomes. By conducting the bedside teaching, the students can thrive to their utmost by asking relevant questions from the patients, practicing the hands-on examination skills, reasoning through the theory-backed approach to correlate with the findings and build up the rationale for clinical decisions. The literature on bedside teaching supports the fact; that bedside teaching is still to hold the respect patients, students, residents, and clinical teachers; which they appreciate as a useful teaching method [13].

The current study did not look into the time constraints as UNIMAS curriculum had already set the standard time for the BST. It is rightly spelled in one study, teaching in an integrative way allows doctors to practice, the curriculum support on learning outcomes; which aim at teaching for understanding [17]. Compared to other universities, the lecturers from UNIMAS generally cover three-quarters of the bedside teaching sessions. The remaining sessions of their curriculum were thought by the adjunct lecturers from hospitals. As a result, the standard BST session times in our university are adequate for the learners. There are some barriers as patient’s refusal to participate in hands-on practice, rapid turn-over time in hospital stay, the rarity of some cases due to better understanding in pathology resulting in less extinction and more reliable diagnostic technology.

This study will help to assess the satisfaction of our students regarding their learning process as well as evaluate their different attitude and expectations in building up of their career. Indeed, it helps the students to gain better control over their clinical skill. In one previous study it is stated, the uncertain profession is one where the professional has no direct control over the outcome of their work [18].

Getting responses to their ideas and expectations from the students will support our effort to improve in teaching method for the best interest of consumers in our university. At the same time, it will support the importance of bedside teaching; which rooted and expanded since Oslerian time until now. One past literature state bedside teaching is one of the modes in medical education. The current study found to be beneficial and reliable in terms of perspectives in developing a better outcome -based teaching method [19, 20]. Researchers in this study hope that it will help to contribute some information to modify the teaching strategies to improve the efficacy and quality of clinical learning exercises.

CONCLUSION:

Bedside teaching is a learning method which is significant for clinical learning in medical education. The current study evaluated the medical students’ feedback and their satisfaction bedside teaching. The aim of medical education to produce better skilled and compassionate physicians with effective teaching and training methods; which enhance students skill in their clinical practice. Students’ feedback on bedside teaching and learning method useful in guiding to improve on teaching methods those are beneficial in medical education. The current study conceptualizes various pros and cons of the bedside teaching method that paves a way, for further advancement. The current study conceptualizes the fruitful context of BST, its significance in enhancing the soft skills and professionalism among budding doctors; which is and groundwork for their future career. The mannerism and conduct of ethical issues will directly be learned from their peers during the BST through the hierarchy. This study results insights to look into the strategies to improve the quality of BST, in the future by providing opportunities to get more hands-on practice. Additionally, budding medical practitioners broaden their problem-solving skills incorporation with the teaching process, which integrate the learners’ autonomy and confidence in decision making. Researchers in this study have realized BST should be structured well before; during and after the encounter, so it will be enfolded into learners, teachers, and patients.

The weaknesses of this study are its, ignorance of other areas; like patient’s perspectives, teachers or clinicians’ response in this dynamic, complex, and clinical ward. The barriers that impede the momentum of bedside teaching; and productivity or efficacy score from this teaching method. The results of this study based on participants’ feedback studying in year 3; the year 4 and year 5 medical students were not part of the study though they are of majority.

The past literature had given less emphasis on student satisfaction. The current study actualizes the favourable acceptance of the teaching method and its perceived value that contribute to the quality of medical education. The study also realizes the need for emphasizing on the patient-centered teaching that indicates the priority for the patient- based learning process in medical education as Flexner said “The facts are locked up in the patient” [9].

DISCLOSURE:

The authors report no conflicts of interest in this work.

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Received on 16.03.2019 Modified on 28.04.2019

Research J. Pharm. and Tech. 2019; 12(6): 2724-2729.

DOI: 10.5958/0974-360X.2019.00456.6