Saturday, August 27, 2011

Teaching in the New Duty Hour Environment

I have been a teaching doctor for over 10 years.  It has been an incredibly rewarding experience, helping shape the physicians of tomorrow.  “Back in the day” we used to teach in the hospital inpatient setting several months a year, in addition to having a “clinic” or “office”, where we saw outpatients and developed long-lasting healing relationships as primary care physicians.
Now  those days are few and far between.  The opportunities for those to teach in both inpatient and outpatient venues have diminished.  Mostly, the frenetic pace of the inpatient environment is simply taxing (physically and emotionally), and that in and of itself makes it difficult to “be on wards” so much (for the non-hopsitalists) and also maintain a cohesive, outpatient practice.
I always get jazzed up when I start a new inpatient tour of duty, and I usually do so earlier in the year, when new interns and medical students are still early in the training period.  It is great to see the interest learners have in performing certain components of the physical exam, to mentor them through tougher situations, such as telling patients a difficult diagnosis, and to observe learners improve literally in front of one’s eyes.
With the new duty hours, however, the time for teaching has clearly gone down.  Documentation requirements have become more stringent throughout the years, necessitating more time in front of a computer and less time with patients and learners.  Nevertheless, I do feel that today’s learners are just as dedicated as those of previous generations to the provision of high-quality, excellent patient care.  In addition, the duty hour restrictions were thrust upon them, not the other way around.
The teaching docs of the future need to figure out how to integrate “snippets of learning” into a busy day.  Handoffs will become one of the most important skills of today’s trainees (they probably already are).  Learners need to remember that “teaching moments” will probably not occur as a “60-minute chalkboard lecture on abnormal liver tests” as much as in the past, but rather integrated into the care of the patients (and isn’t that the best way to learn anyway?).  Communication skills will need to be stressed, and bedside rounding (in pediatrics, known as “Family-Centered Rounds”, with nurses, pharmacists, other health care professionals and families all together at the same time) will be critical to evaluate how learners interact directly with patients.
I have confidence that today’s learners will learn the necessary skills to continue to provide the best care for patients, and also maintain a semblance of a life outside of medicine.  Something tells me that they already know how to figure out the “work-life balance” better than my generation.


  1. Glad to be the first to comment...

    Maybe it will TEACH us how to be better at bedside teaching?

  2. Alex,
    Enjoyed reading this post. I would agree that trainees will learn to become better at handoffs, and will have to learn from taking care of patients (rather than from chalk talks) which is not a bad thing.
    I am not convinced that we have a good handle on the best way to train our residents while providing good patient care. Lets hope we will get closer to this utopia soon!

  3. Welcome to the world of blogging! I would also like to add that one other important skill for the future is critical thinking. It was probably always a fallacy that you "saw everything once" as a resident, but now it definitely is. Residents will have to become experts at handling novel situations even more than in the past.

  4. You have written well about some of the challenges faced in hospital 'bedside' teaching.

    General practice/Family medicine teaching (in UK) need not be so stressful for the Teacher nor the student.

    In my practice, protected time for teaching permits no more than 4-5 patients in a 3 hour period. No more than four students are taken per session. The focus is on the clinical examination with an emphasis on correlating symptoms and signs with known physiology and Creating a differential diagnosis and management plan is a secondary objective to assess student's clinical reasoning skills.

    The students seem to enjoy the sessions and often comment that they learn more in my practice than in a week in hospital bedside teaching!

  5. Dear Dr.Djuricich,
    I totally agree with your assessment. Talking from residents perspective, I believe as an intern I am more well rested compared to previous generations of interns! However, I think the program needs to develop a better schedule to protect educational time. Especially, at our program- I am not a big fan of short calls. They represent a big challenge for everyone involved and not at all ideal for teaching activity. So, as an intern I am learning good executional skills but feel deprived of learning the thought process involved in patient management.
    And, I agree that it is very difficult on everyone's part to get more teaching done within the confines of our tight schedules. And, hence, there is an increased need than ever for active learning process.

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