I recognize that I am older and that medical training has changed quite a bit. I did not realize how much until I ran across this article titled, “Patient bedside important for medical student learning.” [Full disclosure - I spent an hour trying to get at the actual article, but could not so what I am about to say represent my reading of the press release. I apologize in advance]. The article reports on a “web-based tool” called Learning Moment that allows a student to record their learning experiences. In a pilot study, conducted in the emergency department, the logs reveal that the majority of ‘learning’ recorded by students was, get ready for it, in patient rooms. The authors also noted some ‘learning’ at computer workstations and in rooms specifically for resuscitation of critically ill patients.
Bedside training involves bedside care – a history, physical examination – the laying on of hands both physically and mentally, under the supervision of a trained physician. The development of Learning Moment was predicated upon the belief that bedside education had diminished from an estimated 75% of training in the 60’s to an estimated 20% now. Advancing technology, where images replace examinations and administrative demands “on providers” (the article's choice of words) is felt to reduce the opportunity for bedside learning. The study’s lead author, Alexander Sheng, MD comments that Learning Moment "… has the potential to help educators better understand the intricacies of local learning microenvironments as well as the broader clinical learning ecosystem."
In medical school, you first learn the vocabulary of medicine and then the underlying physiologic processes that contribute to health and disease. You learn the interventions in that physiology that we consider as best practice treatment. As you end your medical school training, you start to apply all of that educational material to patients. You begin supervised practice. Practice is the keyword with a dual meaning. Practice, of course, means repeating a skill until it is learned. Medicine is a skill, bolstered by a sizeable didactic background, but it is impossible to practice medicine without patients. It would be like asking a carpenter to learn how to make a cabinet without wood. Practice also refers to the entirety of a physician’s efforts, my practice consisted of patient care, both directly in the office or operating room and indirectly at the workstation or talking with consultants.
I become concerned when I hear phrases like ‘learning microenvironments’ not because they are jargon meant to suggest importance, highly specialize thought and reflection, but because we use jargon in the first place. There has been for as long I have been a physician a tug of war at our academic centers between research, teaching, and care. Care bolsters revenue and research strengthen revenue and status. But teaching the practice of care is increasingly an afterthought. A good teacher of medicine must of necessity be a good clinician, but teaching takes both time and one-on-one relationships. I am afraid that unless we protect our clinician-teachers and recognize that they are an endangered species, we will see more tools and toolkits and simulators. If clinical bedside teaching, in all of its forms, is lost we will lose the ability to transfer the subtlety and nuance of care, the knowledge not codified in books. We will impoverish our physicians and in turn, impoverish our care.