Although bedside teaching is often employed in clinical medical education in the form of rounds, there has been little study on the impact of these rounds on the patient perception of care. Lehmann, et al, 1 demonstrated a trend toward greater patient satisfaction with care when rounds were conducted at the bedside on a medical floor. There is no published data regarding patient perception of bedside rounds in the emergency department (ED).
A resident or research assistant administered a survey to patients present at morning change-of-shift in the ED. Rounds were either conducted at the bedside, or at a remote location based on a preset schedule, alternating by day and by week.
During the study period 344 patients were present at morning change-of- shift. 212 patients completed the survey (62%). The others refused (19), had an altered mental status (30), or had left the ED prior to completion of the study (83). 113 patients completing the study experienced bedside teaching rounds. 99 patients did not have bedside teaching rounds. The groups did not vary significantly by sex, understanding of English, time spent in the ED, or level of education. There was a difference in age between the two groups, but multivariate analysis found this to be noncontributory. The group that had rounds at the bedside felt that their doctor was more interested in their care and had more concern about their privacy. There was a trend toward higher rating of their general care among those who had rounds at the bedside, but this did not reach statistical significance. There was no significant difference in the patients rating of level of knowledge of the physician, or likelihood that they would return to the ED for another problem.
Bedside teaching rounds have long been a mainstay of clinical medical education. William Osler in 1903 called for “radical reform” in medical education and extolled medical educators to move from the classroom to the bedside. 3 Over the years numerous physician-teachers have repeated that call.
Some study has been done evaluating the utility of bedside teaching for student and resident education, 2 3 but patient perception of these rounds has rarely been investigated. Often on rounds at the bedside, we discuss personal and sensitive information, in a venue that is not private. Does this offend patients, or do they appreciate hearing what we think of their problem? Bedside teaching rounds could be misinterpreted by the layperson as a breech of doctor-patient confidentiality.
Lehman, et al 1 addressed the topic of patient perception of bedside rounds in a study conducted on the medical ward. However, his findings might not apply to the emergency department, where the physician may not have been able to establish a relationship with his doctor, where the patient may be gravely ill or injured, and may be under great stress. We determined to look as the patient’s perception of bedside teaching rounds in the ED, particularly how patients feel about privacy, and the discussion of personal information.
At our urban teaching hospital morning rounds have traditionally been “teaching” rounds. Typically, four attending physicians, six to eight residents and several interns and students are present as we move from bed to bed and discuss the details of a patient’s case. Patients are in private or semiprivate cubicles, separated by cloth drapes. Visitors are routinely asked to leave the department before rounds take place. Usually physicians inform patients of the purpose of our bedside rounding.
An eight-item survey was administered to patients present at the time of morning rounds, by a physician or assistant, dressed in street clothes. The patient was informed that the questionnaire could be read to them in English or Spanish, or they could read it themselves in either language. They were also informed, both verbally and in writing that their completion of the questionnaire would have no impact on the treatment they received in the emergency department or during a hospital stay. The patient was asked to evaluate their physician and their care in the emergency department on a scale of 1 (excellent) to 5 (poor). Demographic data was recorded on the back of the questionnaire before being given to the patient.
Rounds were conducted either at the patients’ besides (“bedside rounds”), or at a remote location out of the patients’ sight and hearing (“non-bedside rounds’). The location of the rounds alternated, based on a predetermined, random schedule.
During the study period 344 patients were present at morning change of shift. 212 patients completed the survey (62%). The others refused (19), had an altered mental status (30), or had left the ED prior to completion of the study (83). There was no significant difference between bedside rounds, and no bedside rounds, in the number of patients who had refused, or failed to complete the study because of alteration in mentation, or because they left the department.
113 patients completing the study experienced bedside teaching rounds. 99 patients did not have bedside teaching rounds. The groups did not vary significantly by sex, understanding of English, time spent in the ED, or level of education. There was a difference in age between the two groups, but multivariate analysis found this to be noncontributory.
The group that had rounds at the bedside felt that their doctor was more interested in their care (1.75 vs. 2.05; p=0.04 95%CI .008, .584) and had more concern about their privacy (1.77 vs. 2.09; p=0.04 95%CI .018, .606). There was a trend toward higher rating of their general care among those who had rounds at the bedside, but this did not reach statistical significance (1.83 vs. 2.1; p=0.08). There was no significant difference in the patients rating of level of knowledge of the physician, discussion of test results with the patient or likelihood that they would return to the ED for another problem.
In the ED, there is little time to establish a relationship with patients, there is little privacy, and there may be an increased level of anxiety in patients due to the acuity of their problem and lack of knowledge about their diagnoses. And, because there is often little opportunity for private discussion, patients might feel that their privacy is not respected when their cases are discussed during bedside rounds. At our urban teaching hospital, as in many others, there is a high proportion of patients with particularly sensitive medical conditions. Would our patient population perceive rounds as an infringement on their privacy, or affect their impression of the physicians caring for them?
Patients’ perception of bedside teaching rounds has been evaluated in the past, but only on ward services. A recent article by Lehmann et al, assessed patient reaction to rounds conducted at the bedside, and found a favorable response. Romano 6 assessed the attitude and behavior of 100 patients during and after weekly bedside ward rounds. Patients were evaluated on their behavior during the presentation of their case and were interviewed following their presentation. Romano concluded that ward round teaching was not a traumatic emotional experience, but rather educates and reassures patients. Rounds in a ward setting may not be comparable to the open forum of a busy urban emergency department.
Our survey included six questions relating to the patients’ perception of their care while in the emergency department. To our surprise, the patients who had rounds conducted at the bedside were more likely to feel that their physicians respected their privacy. Patients who had rounds conducted at the bedside also felt that their physicians were more concerned and interested in their medical care. There was no difference found in whether patients would again return to the emergency department, whether the physician discussed results with them, or educational level of the patients.
We had theorized that patients who had experienced bedside rounds might feel that their physicians were more knowledgeable, but less interested in their privacy. Visitors are routinely asked to leave the department, and physicians’ attempt to be discrete while discussing patients’ history. This may have been observed and appreciated by patients. Physicians usually explain the point of rounds, and this may also reassure patients. A follow-up survey of our attending and resident physician staff assessed how they felt about rounds at and away from the bedside. They uniformly preferred rounds at the bedside: They felt that not seeing, and having the opportunity to examine, the patient under discussion might compromise patient care.
Limitations and Future Questions
The populations at our hospital is derived from an inner city area, which is medically under-served, poor and largely made up of immigrants. Our findings might not be generalizable to other populations. There is concern in any survey that patients will answer as they think we want to hear. Our overall rating was positive, but variability within patient response was adequate.
The majority of patients are not present at change of shift, when formal rounds take place. We would like to look at patient response to the ongoing, informal rounds and bedside teaching that occurs throughout the clinical shift.
Patients felt that their doctor was more interested in their care when rounds were conducted at the bedside. Contrary to our expectations, they also felt that there was more consideration for their privacy when rounds were done at the bedside.
Lehmann LS, Brancati FL, Chen MC, Roter D, Dobs AS. The effect of bedside case presentation on patients’ perception of their medical care. N Engl J Med 1997; 336:1150-5
Osler W. On the need of a radical reform in our methods of teaching senior students. The Medical News 1903: 82: 49-53.
LaCombe MA. On bedside teaching. Ann Intern Med 1997; 126:217-20.
Linfors EW, Neelon FA. The case for bedside rounds. The New England Journal of Medicine 1980; 303:1230-3.
Romano J. Patients’ attitudes and behavior in ward round teaching. Journal of the American Medical Association 1941; 117:664-7.