Returning to the Bedside

Every teaching attending is familiar with the daily decisions about how to conduct rounds. What is the correct balance between teaching and patient care? Between the purely technical and the more human dimensions of medicine? Who should be included in rounds to encourage care integration across an interprofessional team? What strategies promote patient-centered care while also providing necessary access to computers and the electronic medical record? Where should new cases be presented: in a conference room, in the hallway, or at the patient's bedside? These decisions express, often unconsciously, the culture and values of the care team—what educators refer to as “the hidden curriculum” [1]. They impact patients, clinicians, and the professional development of tomorrow's physicians. By intentionally re-envisioning rounds, care teams can choose processes that actualize patient and family engagement and that value the patient as a person with unique goals and perspectives on his or her illness and care.

Over the last 30 years, bedside rounding has all but disappeared from most teaching hospitals. On the typical medical service, newly admitted patients are presented in a conference room or hallway where computers are readily accessible, and visits to the bedside tend to be brief—mainly for the attending physician to meet the patient and confirm important findings [2]. Discussion of the remaining patients is relegated to “card flip” around a table, without the team actually laying eyes or hands on the patient. Nurses see their patients separately and rarely round with the medical team. An unintended consequence of regulations restricting resident duty hours is that efficiency has become the highest priority, thus reducing the amount of time trainees have to talk with and listen to patients and families, let alone reflect and discuss the experiences of the clinical day. In fact, an intern's schedule allows, on average, only 8 minutes per day with each of his or her patients [3]. Teaching physicians also admit to discomfort discussing complex issues in front of patients and feel unprepared to round efficiently while addressing both the technical and human dimensions of care. They prefer the relative privacy and informality of the conference room to the unpredictability of the bedside, where new patient concerns or strong emotions may emerge.

Patients and families overwhelmingly prefer to have their case presented at the bedside so long as there is reasonable privacy, medical jargon is limited (or interpreted), and their concerns are heard and questions answered [4]. Fundamentally, patients simply want their doctors to spend more time with them, and they view bedside rounds as a welcome step in that direction. If cases are presented in the hallway or conference room, patients are not privy to and cannot contribute to the presentation of their case or the discussion of their management. During bedside conversations, if clinicians listen closely, patients nearly always provide important insights into their disease and how best to manage it. This is not rocket science or magic. These fundamental human relationship and communication approaches come more naturally to some than others, but they can be successfully acquired with practice and coaching [5].

Abraham Verghese eloquently describes how rounds conducted in a workroom are dominated by care of the “iPatient,” the surrogate patient housed in the computerized medical record, rather than the actual sick person in the bed [6]. Consider how trainees may be impacted by the discrepancy between what they hear about patient-centered care and what they see in actual practice. Compared with hallway rounds, bedside rounds place the actual patient, rather than the “iPatient,” at the center, literally, of the team's attention, concern, and study (see Figures 1 and 2). As Hafferty noted over 2 decades ago, “many of the ‘messages’ transmitted via the hidden curriculum may be in direct conflict with what is touted in formal courses” [1]. Verghese, among others, also notes that, without bedside instruction, clinical skills atrophy, with a resultant over-reliance on costly tests [7].

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FIGURE 1.

Hallway Rounds

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FIGURE 2.

Bedside Rounds

There is clear evidence that time spent listening closely to patients and families, engaging them in conversations about decision making, and responding empathically to their concerns improves medical outcomes, promotes patient self-management, and enhances patients' experience of being cared for and prepared for their transition home [8]. Unfortunately, hospitalized patients often complain that doctors do not spend enough time with them, do not listen carefully, do not provide information in a clear and understandable fashion, and sometimes are downright rude and condescending [9, 10]. In Crossing the Quality Chasm, the National Academy of Medicine defines patient-centered care as “respecting and responding to patients' wants, needs, and preferences, so that they can make choices in their care that best fit their individual circumstances” [11]. Levinson notes that while attention to infrastructure can facilitate these goals, the real key is skilled interpersonal communication with patients and families, which cannot be accomplished in the conference room or hallway [8].

In 2013, Wake Forest Baptist Health received a 2-year grant from the Institute on Medicine as a Profession and the Josiah Macy Jr. Foundation to train attending physicians, residents, and students to conduct daily rounds at the patient's bedside, rather than in a conference room or hallway. We felt this would provide a venue to role model, teach, and assess patient-centered communication during actual patient encounters, and we preferred this approach to relegating instruction on professionalism to conferences or lectures separate from clinical care. The Macy Foundation asked that all grantees use a behavioral definition of professionalism that states that it is “not simply a set of text-based ideals for practice, rather it is an approach to the practice of medicine that is expressed in observable behaviors” [12]. We aimed to transform the bedside into a venue where the entire team can embody whole-person care and “walk the talk” of professionalism. We realized that in order to be successful, attention to the patient's needs must be balanced with efficiency in rounding, and there must be high-fidelity communication among members of the interprofessional team to enhance quality and safety.

Culture change was surprisingly rapid. Within 6 months of the project's inception, most patients on 4 general internal medicine floors and 1 geriatric floor were being presented at the bedside. It appeared that the grant tapped into a strong desire for change; students, residents, and attending physicians seemed hungry to return to the bedside to learn and provide care. The Macy curriculum, as it came to be known, emphasizes relationship-centered communication skills across the educational continuum, beginning in the first weeks of medical school and extending through interactive seminars for internal medicine residents and faculty development workshops. The communication model PEARLS (Partnership, Empathy, Apology, Respect, Legitimization, and Support) was chosen from among many possible models to provide a common language to facilitate teaching, feedback, and assessment (see Table 1) [13]. The curriculum emphasizes reflective listening, empathic responses to patient distress, clear and understandable explanations using minimal medical jargon, inquiry about the patient's perspective, shared decision making, and teach-back techniques. During rounds, one team member is tasked with noting which PEARLS are employed and what opportunities may have been missed. After the encounter, the team pauses for a moment to receive feedback and discuss how they communicated. With this approach, teaching and assessing professional communication are seamlessly linked to other dimensions of the clinical encounter.

Medical students at Wake Forest are introduced to bedside patient presentations (BSPPs) early in their first year as part of the introductory course on the doctor-patient relationship. By their third year, they are fully prepared for bedside presentations. The clerkship director noted, “The students enjoy being able to tell the patient's story to the team, at the bedside, in a patient-centered fashion. The more bedside presentations they do, the more comfortable they become and the more effective and patient-centered the process feels to them.” Student feedback was also positive. One third-year student reported, “I felt that with BSPPs patients were more directly involved in their own care. They were more aware of their medical plan and more likely to ask questions.” Another third-year student said, “I was reminded of why I entered into medicine to begin with—to interact with patients and provide comprehensive care … [BSPPs] renewed my interest in medicine.”

Each year, about 115 internal medicine residents at Wake Forest Baptist Health are exposed to the Macy approach to rounding. The residency program director reported, “They definitely appreciate how it connects the team to the patient and how it showcases to the patient the thought processes going into their care … Bedside rounds allow residents to learn from each other, our students to learn from residents, and our faculty to observe both.” Similarly, an internal medicine resident said, “It is a very efficient and useful way to learn clinical skills … decisions can be made and orders placed at the same time. It is also very useful for residents and students to have physical exam maneuvers explained and demonstrated.”

To date, 39 teaching physicians at Wake Forest Baptist Health, including general internists, hospitalists, geriatricians, and subspecialists, have been trained to conduct effective bedside rounds and intentionally emphasize professional communication and patient-centered values [14, 15]. The PEARLS communication model was new to most of the faculty and was practiced during each of 3 development workshops. Faculty learned to manage challenging bedside interactions and debrief after rounds to reinforce teaching points. They explored how to balance purposeful rounding strategies with flexibility and responsiveness to what emerges at the bedside: the unexpected twist in a patient's history, a new physical finding, or a strong emotion. They were encouraged to always set aside brief intentional pauses during and after rounds to engage in thoughtful reflection about the team's observations and responses to patient encounters [16].

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