Should Case Presentations Occur at the Patient’s Bedside?

Performing case presentations at the patient’s bedside was shorter and did not impact patients’ knowledge of their medical care—however, patients reported higher confusion, and sensitive topics were less likely to be discussed, according to a Swiss study published in Annals of Internal Medicine.

Clinical discussion of a patient’s illness at the bedside provides “a unique opportunity for healthcare professionals to ensure direct participation of patients in medical discussions and decision-making,” Sabina Hunziker, MD, Of University Hospital Basel in Basel, Switzerland, and colleagues from the BEDSIDE-OUTSIDE Study Group explained. What’s more, some medical students and trainees prefer being taught at patients’ bedsides to teaching without the patient present, Michael A. LaCombe, MD, associate editor of Annals of Internal Medicine, noted in an accompanying editorial. The concern, they noted, is that the complexity and magnitude of medical information, including personal information and medical jargon, may lead to misunderstandings, make patients less comfortable, and potentially reduce patients’ understanding of their own condition.

For their analysis, Hunziker and colleagues compared the efficacy of bedside versus outside the room patient case presentation on patient’s knowledge of their medical care.

The Study Group found that, “compared with bedside case presentation, outside the room case presentation during ward rounds does not result in patients having less knowledge of their medical care. Bedside presentation resulted in overall shorter durations of the ward round with still more patient-physician interaction time, but sensitive topics were less frequently addressed, and there was more confusion associated with medical jargon. Physicians presenting at the bedside need to be skilled in the use of medical language to avoid confusion and misunderstandings.”

“For me, these findings suggest that bedside teaching is efficient and that we should teach at the bedside, but doing so requires skilled communication to avoid patient confusion,” LaCombe argued. “Yet, we stick to the classroom, or at best, the hallway outside the patient’s room. How might we bring teaching back to the bedside?”

LaCombe wrote that bedside teaching could be implemented effectively if medical staff are properly educated on the subject and the proper rules are put in place—asking the patient’s permission; encouraging the patient to speak up if something the team says is confusing or concerning; if a topic is too sensitive to discuss in front of the patient, make sure the discussion happens once the team leaves the room rather than being neglected; respect the house staff’s time constraints; and clean hands before and after entering the room.

“The most important lessons I have learned have been taught to me by patients at the bedside,” he added. “Watching a skilled clinician extract a history from a patient can inspire learners’ curiosity in ways that are infeasible without the patient present. The youth and energy in our students can reassure patients that the future of medicine is bright. The opportunity to contribute to medical education means a great deal to many patients. No classroom or hallway rounds can illustrate ways to embrace sensitive interactions with our patients.”

Hunziker and colleagues conducted their randomized, controlled, parallel-group trial in the general medical divisions of three Swiss teaching hospitals—University Hospital Basel, Kantonsspital Aarau, and Kantonsspital Basellan—from July 2017-October 2019.

Hospitalized patients were randomly assigned to either bedside or outside the room care presentation—in the bedside group, case presentations and discussions only occurred at the bedside in front of the patient, “including examination as appropriate, with no discussions beforehand,” they explained; in the outside the room group, case presentation and discussions were held in the hallway outside the room without the patient present, after which the team entered the room and gave the patient a short summary of the medical situation, completed the gathering of medical information, examined the patient as needed, and discussed next steps.

The study’s primary endpoint was patients’ average knowledge of three dimensions of their medical care—understanding the disease, the therapeutic approach being used, and further plans for care—each rated on a visual analogue scale from 0 to 100.

“Compared with patients in the outside the room group (n= 443), those in the bedside presentation group (n= 476) reported similar knowledge about their medical care (mean, 79.5 points [SD, 21.6] versus 79.4 points [SD, 19.8]; adjusted difference, 0.09 points [95% CI, −2.58 to 2.76 points]; P=0.95),” they found. “Also, an objective rating of patient knowledge by the study team was similar for the 2 groups, but the bedside presentation group had higher ratings of confusion about medical jargon and uncertainty caused by team discussions. Bedside ward rounds were more efficient (mean, 11.89 minutes per patient [SD, 4.92] vs 14.14 minutes per patient [SD, 5.65]; adjusted difference, −2.31 minutes [CI −2.98 to −1.63 minutes]; P<0.001).”

The study authors concluded that the issues of confusion regarding medical jargon and lack of discussion of more sensitive topics could be improved by educating physicians on the best practices and strategies for initiating case presentations at the bedside.

Study limitations included limited generalizability due to confining the analysis to three Swiss hospitals; participating physicians tended to have less experience with bedside patient case presentation and did not receive specific coaching beforehand; blinding was only possible for outcome assessors; the survey used to assess patient knowledge and perception of their care was created for this analysis and not externally validated; discussions during ward rounds were not standardized; and, while randomization took place at the patient level, application of the intervention was at the group level (the medical ward round team), which could possibly introduce bias and variance.

1. Performing case presentations at the patient’s bedside was shorter and did not impact patients’ knowledge of their medical care—however, patients reported higher confusion, and sensitive topics were less likely to be discussed, according to a Swiss study.

2. The study authors concluded that the issues of confusion regarding medical jargon and lack of discussion of more sensitive topics could be improved by educating physicians on the best practices and strategies for initiating case presentations at the bedside.

John McKenna, Associate Editor, BreakingMED™

Cat ID: 791

Topic ID: 498,791,791,730,192,925