Technique matters – if you don’t have the right technique, you won’t get the results you want.
Abraham Verghese says “I don’t know” at the bedside!
Respect for the learner: avoid “pimping,” saying “you should know this,” “here’s an easy one,” etc.
– Residents are trying to build up a rapport with their patients, and we should avoid undermining that rapport.
– Start instead with “let me show you a new technique,” or “you may not have seen this yet…”
Respect for the patient: Be empathetic and aware of the patient’s feelings, but also understand that physical exam will inconvenience the patient in a minor way. Two rules: 1. The patient has to be willing – has to know it is purely educational rounds and not for medical care. 2. Patient should be able to understand what is being said.
- What is your chief complaint / what brought you to the hospital?
- What physical signs should we look for to diagnose that complaint?
Recipe for successful teaching rounds at the bedside:
- Set the agenda: pre-brief with learners and, when possible, with the patient.
- Learning climate: make sure everyone knows their role and the reason for the visit. Introduce and re-introduce.
- Ask the patient what has been done well and poorly in their care before, how they like to be treated…
- Role model: pay attention to body language and position, show patients the respect they deserve.
- Basic stuff: ask how the patient would like to be addressed, get at eye level, ask permission prior to exam
- Ask permission and explain to the patient what everyone is doing when examining the patient.
- Make sure learners practice.
- Have an understanding of how learners often mess it up.
– carotid comes out at you, whereas IJV is more of a depression
– IJV moves with inspiration and frequently disappears
We are not only teaching observation and technique with physical exam, but also JUDGMENT – different physicians interpret things differently, whether it’s a JVP or a CXR or a CT scan.