Guidelines for Teaching Rounds

Many barriers have been cited in reference to why bedside teaching rounds have decreased in frequency during graduate medical education. One perceived barrier to the use of bedside teaching rounds is a fear of it causing patient discomfort or dissatisfaction. The objective of this study was to compare patient perception of bedside versus nonbedside teaching rounds. Study participants were adults admitted to a family medicine inpatient team at a large university teaching hospital. Upon admission, participants were randomized to receive bedside or nonbedside teaching rounds conducted by a team consisting of medical students, family medicine residents, and one attending physician. Each participant completed a questionnaire administered on the day of discharge assessing patients' perception of their involvement in medical decision making, trust in the medical team, satisfaction with care, and provider compassion. Statistical analysis was performed to examine any differences between the two groups. The vast majority of the sample indicated that they knew what they were being treated for in the hospital (n = 105, 98%), reported the medical team spent an adequate amount of time with them (n = 100, 94%), and reported the medical team explained the diagnosis and care in easy-to-understand terms (n = 101, 94%). On 1- to 5-point scales, participants reported that the medical team involved them in making decisions (4.62, standard deviation [SD] 0.72), they trusted the medical team (4.91, SD 0.32), they were satisfied with their care (4.85, SD 0.38), and their medical team was compassionate toward them (4.84, SD 0.44). Overall levels of satisfaction were positive on all of the measures, with no statistical significance between the two groups regarding measures of involvement in medical decision making, trust in the medical team, and satisfaction with care. Interestingly, subjects perceived level of compassion of their medical team to be significantly higher with a bedside teaching approach compared with a nonbedside approach. Despite concerns that bedside teaching rounds may lead to patient discomfort, this study found no evidence supporting this perception. In fact, patients may perceive a medical team that engages in bedside teaching rounds as being more compassionate providers, supporting a patient-centered argument that teaching rounds should return to the bedside.

To the editors: We applaud the effort by Gonzalo et al. to increase bedside rounding by internal medicine residents1. However, we do wish to comment on their study’s expressed motive, a perceived downward trend in the fraction of medical education taking place at the bedside. Among the many physician-educators lamenting this trend since the 1960s, LaCombe’s 1997 commentary in the Annals of Internal Medicine has been particularly influential2. His statement that, “In the old days, 30 years ago, 75% of teaching was at the bedside. … By 1978, that figure had decreased to 16%” has been widely repeated in the literature on bedside teaching, including in the article by Gonzalo et al. The 1964 study from which LaCombe derived his 75% “baseline,” however, actually reported that 75% of dedicated teaching sessions for ward-based medical students included time at the bedside3. Forty-five years later, in 2009, the frequency of trips to the bedside during teaching rounds remained fairly stable at 61%4. The percentage of time on teaching rounds spent at the bedside has also stayed similar over time compared to the 16% cited by LaCombe, ranging from 19.2%5 in 1965 to 17%4 in 2009. This is not to say that bedside teaching—critical for training in humanism, physical exam, and other clinical skills poorly amenable to either classroom instruction or written assessment—is not under pressure from technology, work hour limitations, rapid patient turnover and the ever-expanding canon of raw medical knowledge. Work to study and promote bedside teaching should be motivated by the technique’s intrinsic value rather than by a misconception that bedside instruction is on the decline.

Background: Spontaneous coronary artery dissection (SCAD) contributes to a significant number of acute coronary syndrome (ACS) in middle-aged female. SCAD data are accumulating to understand its epidemiology, etiology, presentation, and diagnosis. Despite the rising incidence, there is limited data regarding the number of diagnosed cases based on hospital location. We hypothesized that more cases of SCAD are diagnosed at teaching urban hospitals than urban non-teaching or rural hospitals. Methods: In this retrospective study, the discharge data were extracted from the National Inpatient Sample (NIS), and Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality from 2010 to 2017. We used the 9th and the 10th revisions of International Classification Disease (ICD-9-CM code 414.12, ICD-10-CM Code I25. 42) for SCAD. SCAD cases per year (weighted to represent nation sample) were collected and stratified by hospital location (urban teaching, urban non-teaching, and rural). p - value was calculated by Cochran-Armitage test. A p -value of <0.05 was considered significant and all p-values were two-sided. Results: We found a total of 490 patients with a primary diagnosis of SCAD. The numbers were weighted to present a national total of 2432 discharges. Demographic characteristics are shown in table-1. Year-year SCAD cases quantified by rural, urban teaching, urban non-teaching status are shown in table-1. Of these 2432 discharges, 72.34% were at the urban teaching hospitals, followed by 25.05% at urban non-teaching hospitals, and only 2.6% were at rural hospitals. This difference was statistically significant (p -value <0.001). Conclusions: A higher number of SCAD cases at urban teaching hospitals may indicate the diagnosis bias due to better availability of expertise and advanced modalities to diagnose this entity at urban teaching hospitals.

Aim The aim of this study is to evaluate the impact of changes made to third-year students’ Surgical bedside teaching with the inclusion of surgical teaching fellows, as compared to the initial survey results. Method Post-event, retrospective, optional questionnaire formed of 5 Questions evaluated by a Likert scale and 2 open-ended Questions. First Cycle: 2022-2024 Year 3 BSMS Student, 40 responses Second cycle: September – December 2024 Year 3 BSMS students, 11 responses Results Changes: Smaller teaching groups, improved communication between the Fellows and surgical teams, improved teaching material. Most students agreed that Surgical Ward Round Bedside Teaching sessions with dedicated fellows effectively enhanced clinical knowledge and skills. Compared to an initial 48%, 60% strongly agreed that teaching fellows were engaging and approachable during Surgical Ward Round Teaching. Also, the majority agreed that they felt comfortable asking questions and seeking clarification during the Teaching sessions. However, 55% agreed that Bedside Teaching sessions were well-organized and focused on relevant surgical/clinical cases compared to an initial 35%. When asked, ‘How could the bedside/Ward Round teaching sessions be improved?’ – Responses revolved around suggesting including more teaching fellows on ward rounds, a de-brief session of the patients on the ward, and having clearer learning objectives, more structured as well as spending more time on history taking and examinations. Conclusions The introduction of surgical teaching fellows has had a positive impact on the students’ Surgical Teaching experience. However, there is still room for future refinement, and further enhancement strategies are in progress.

Limitations of chest pain follow-up from an urban teaching hospital emergency department

Background/AimsTo analyze the incidence of post-endoscopic retrograde cholangiopancreatography (ERCP) sepsis in the early (July to September) and later (October to June) academic months to assess the “July effect”.MethodsThe National Inpatient Sample (2010–2014) was used to identify ERCP-related adult hospitalizations at urban teaching hospitals by applying relevant procedure codes from the International Classification of Diseases, 9th revision, Clinical Modification. Post-ERCP outcomes were compared between the early and later academic months. A multivariate analysis was performed to evaluate the odds of post-ERCP sepsis and its predictors.ResultsOf 481,193 ERCP procedures carried out at urban teaching hospitals, 124,934 were performed during the early academic months. The demographics were comparable for ERCP procedures performed during the early and later academic months. A higher incidence (9.4% vs. 8.8%, p<0.001) and odds (odds ratio [OR], 1.07) of post-ERCP sepsis were observed in ERCP performed during the early academic months. The in-hospital mortality rate (7% vs. 7.5%, p=0.072), length of stay, and total hospital charges in patients with post-ERCP sepsis were also equivalent between the 2 time points. Pre-ERCP cholangitis (OR, 3.20) and post-ERCP complications such as cholangitis (OR, 6.27), perforation (OR, 3.93), and hemorrhage (OR, 1.42) were significant predictors of higher post-ERCP sepsis in procedures performed during the early academic months.ConclusionsThe July effect was present in the incidence of post-ERCP sepsis, and academic programs should take into consideration the predictors of post-ERCP sepsis to lower health-care burden.

Rural South Australia contains a higher share of electronic gaming machines and gambling expenditure per capita than metropolitan areas, raising concerns about the risk of problem gambling in these communities. This paper describes the implementation and outcomes of an outreach behavioural psychotherapy (exposure therapy) program for problem gambling in rural South Australia. A retrospective cohort study design was used for 551 adult treatment-seeking problem gamblers who presented to the Statewide Gambling Therapy Service in South Australia. Fifty-one gamblers were from rural areas and participated in the outreach program. Outcomes were compared between gamblers who participated in either the metropolitan-based or rural outreach program. Outcome measures used: South Oaks Gambling Screen, Kessler Psychological Distress Scale, Work and Social Adjustment Scale, and hours gambled the previous month. Sixty-one per cent of clients (n = 551) completed treatment. There was no significant association between service location and number of treatment completers. Significant improvements were recorded across all outcome measures for both groups with small to large effect sizes, and there were no significant differences in outcomes at post-treatment between the groups while controlling for baseline scores. Both metropolitan and rural clients reported significant clinical improvement. Given the risk of problem gambling in rural communities, these early outcomes are encouraging. These findings will inform future treatment planning and service delivery for rural clients, and guide further research into the effectiveness of exposure therapy for problem gambling.

Our objective was to compare the rate of native tissue repair (NTR) versus sacrocolpopexy (SCP) and reconstructive (RECON) versus obliterative repair (OBR) for the treatment of pelvic organ prolapse (POP), evaluating for health care disparities based on race, socioeconomic, and geographic factors. The National Inpatient Sample database was queried for patients older than 18 years undergoing POP surgery from 2008 to 2018. Baseline demographics, comorbidity index, socioeconomic, and hospital variables were extracted. The weighted t test, Wilcoxon test, and χ2 test were used to compare the rate of (1) NTR versus SCP and (2) RECON vs OBR. Multivariate weighted logistic regression was used to compare while controlling for confounders. Reference groups were White race, Medicare patients, northeast region, small hospital size, and rural location. Of 71,262 patients, 67,382 (94.6%) underwent RECON. Patients undergoing OBR were older and had a higher comorbidity score. Multivariate analysis showed the following: (1) Black, Hispanic, and other races; (2) Medicaid patients; (3) patients at urban teaching hospitals are less likely to receive RECON. Patients in the midwest were more likely to receive RECON. Among 68,401 patients, 23,808 (34.8%), and 44,593 (65.19%) underwent SCP and NTR, respectively. Hysterectomy was more common in the NTR group. Multivariate analysis showed the following:(1) Black, Hispanic, and "other" races; (2) uninsured and Medicaid patients; (3) patients in the midwest, south, and west were at higher odds of receiving NTR. Patients in large and urban hospitals were less likely to undergo NTR. Racial, socioeconomic, and geographic disparities exist in surgical management for POP warranting further study to seek to eliminate these disparities.

OUTCOMES FROM CATHETER-DIRECTED EMBOLECTOMY VERSUS SURGICAL PULMONARY EMBOLECTOMY FOR PATIENTS WITH ACUTE PE

Physicians in training in our medical center were found to have a higher risk of tuberculous infection than other hospital employees. Their annual tuberculin conversion rate was 3.96%; in two of the 15 recent converters, active disease developed. There is a significant linear relationship between the acquisition of tuberculous infection and the duration of training in an urban teaching hospital. Their compliance rate to annual tuberculin testing and chemoprophylaxis is less than 50%.

A rural, community-dwelling group of elders referred to a psychogeriatric outreach program were examined for presence of aggressive behaviors. Aggressive patients were compared to non-aggressive patients on the following variables: age, sex, presence of hallucinations and delusions, alcohol use, cognition score, score on Hamilton Depression Scale, physical and instrumental activity of daily living (ADL) scores, general health and quality of life. Of one hundred and fifty-eight patients, 19 (12%) exhibited aggressive behavior. Aggression was significantly associated with presence of hallucinations (p < 0.0001), delusions (p = 0.004), lower physical (p = 0.004), instrumental activity of daily living scores (p < 0.0001) and diagnosis of dementia versus other psychiatric diagnoses. However, lower cognitive score, depressive symptoms, age, gender, alcohol use, quality of life and general health did not differ between aggressive and non-aggressive patients. Aggression is not uncommon in community-dwelling elders in a rural psychogeriatric program. Careful evaluation for treatment of psychotic symptoms should be done in aggressive elders.

Bedside teaching remains a cornerstone of clinical education, yet concerns persist about its impact on patients’ comfort and confidence in the care they receive. Contemporary literature suggests that, when done well, bedside rounds can enhance patient understanding, satisfaction, and engagement without compromising privacy or dignity. However, little is known about the specific effect of short, structured bedside teaching sessions on patients’ confidence in hospital wards. This prospective research evaluates whether brief (10-15 minute) bedside teaching encounters, integrated into routine ward rounds, influence patients’ confidence in their treating team. Adult inpatients in medical wards were allocated to either standard ward rounds or ward rounds incorporating short bedside teaching sessions led by senior residents with medical students present. Patient confidence was measured within 24 hours of the round using a validated patient-confidence questionnaire adapted from instruments assessing trust and confidence in physicians, alongside secondary outcomes of perceived communication quality and willingness to ask questions. We hypothesised that patients exposed to short bedside teaching would report higher confidence scores than those receiving usual care. Preliminary analyses indicate that patients generally welcome bedside teaching, particularly when they are introduced to students, consent is explicitly obtained, and the teaching emphasises clear explanations and shared decision-making. Patients in the intervention group showed higher mean confidence scores and reported better understanding of their diagnosis and management plan, without increases in reported discomfort or concerns about privacy. These findings suggest that carefully structured short bedside teaching sessions can strengthen patient confidence while preserving the educational value of bedside rounds. Embedding patient-centred principles into such encounters may help reconcile educational needs with patient expectations in busy hospital wards.

Medical schools in Australia are being funded by the Commonwealth Government Department of Health and Aging to move a considerable amount of undergraduate clinical education into rural and remote settings. There are concerns that these students may be disadvantaged in terms of exposure to appropriate clinical learning opportunities. This study compared learning opportunities for students undertaking an entire clinical year based in a rural primary care setting, a remote secondary hospital, or a traditional urban tertiary teaching hospital. Twenty-nine students, six from rural primary care, eight from the remote secondary hospital, and 15 from the urban tertiary teaching hospital, completed a retrospective survey of their experience and perceived competence to manage 78 common procedural skills and 62 common conditions. Students in rural primary care reported a pattern of increased clinical exposure to common clinical conditions and procedures in comparison with their hospital-based peers. In comparing the two hospital-based programs, the students in the remote secondary care hospital reported increased exposure to common conditions and no significant difference in the opportunity to undertake common procedures. The data also demonstrated that there was a positive correlation between reported experience and self-perceived competence, and that this was greater for procedural skills than competence in managing common conditions. This study provides further evidence that rural primary care is an excellent setting for high quality clinical and educational experiences. These findings should serve to encourage students and staff involved with the new Rural Clinical School programs.

100 Background: Dysphagia is associated with significant morbidity in patients (pts) with EC. Our study is the first report of national trends in hospitalizations due to EC and dysphagia, with special emphasis on nutritional interventions and related outcomes. Methods: The analysis included all adult inpatients with EC and dysphagia in the Nationwide Inpatient Sample from 2002-2012. We examined temporal trends and performed multivariate analysis for key outcomes; controlling for demographics, hospital factors, comorbidities, and interventions. Results: Among 509,593 hospitalizations involving pts with EC, 12,205 were related to dysphagia. The percentage of all hospitalizations for EC (1.52 vs. 3.28%; p &lt; 0.001) and EC with dysphagia (0.0025 vs. 0.0059%, p &lt; 0.001) doubled over the study period. Among all pts with EC, inpatient mortality for EC with dysphagia was 4.39%. Mean length of stay (LOS) and cost of hospitalization were 8.1 days and $15,171, respectively. Feeding tube (FT) placement was performed in 27 % of pts, esophageal stenting in 13% and peripheral nutrition (TPN) was used in 11%. The incidence of stent placement was higher in urban teaching hospitals (33%) vs. urban non-teaching (21%) or rural nonteaching hospitals (17%). On multivariate analysis, placement of FT and stents was associated with comparable inpatient mortality and LOS, but TPN was associated with higher mortality (OR 2.25; 95% CI 1.93, 2.62) and prolonged LOS (+3.4 days, CI 2.79, 3.97). Compared to FT, stents (+ $3,042, CI 432, 5,652) and TPN (+ $10,573, CI 8,766, 12,380) resulted in higher cost of hospitalization. More pts developed sepsis on TPN (6.1%) compared to FT (2.5%) or stents (1.8%). Inpatient mortality associated with any nutritional intervention was lower in urban teaching compared to rural nonteaching hospitals (0.71; CI 0.65, 0.79). Conclusions: Hospitalizations for EC and dysphagia are increasing and mortality in such pts is high and multifactorial. TPN is associated with sepsis and mortality in this setting. Nutritional intervention practices and possibly outcomes vary significantly based on hospital type. This finding should be further explored to better define the most appropriate interventions and treatment setting for this patient population.

Background: To determine the impact of a dedicated trauma service on cost and quality of care in an urban teaching hospital, a before-and-after study was designed. The key elements of the trauma service were dedicated in-house trauma attending surgeons and residents, and continuity and integration of trauma care. Methods: Injury Severity Scores and probabilities of survival for each patient were calculated from the hospital International Classification of Diseases, Ninth Revision, codes, and individual patient costs were estimated from charges using the Medicare Cost Report. Results: The trauma service resulted in a significant increase in the severity of injuries. There was a highly significant (p < 0.001) increase in the mean probability of death (from 0.16 to 0.21). There was no change in actual mortality. Although the mean cost of care increased by 16.6%, there were small reductions in the cost of care of the most severely injured patients. Conclusion: A dedicated trauma service has a positive impact on the quality of care.