Medicine
Bedside teaching
John Roman Wilson
One of the more constructive aims of the 'consumer movement' in recent years has been to defend the interests of patients in hospitals. The Patients Association has been active in uncovering instances of offhand and inconsiderate treatment, and there is no doubt that the existence of such a watchdog has a valuable cautionary effect. It has also raised the question of how necessary certain of our customary hospital traditions are. One of these is the practice of bedside teaching of students.
The opponents of bedside teaching claim that it is embarrassing, and often distressing, to patients. They also point out that, since it is not done on private patients, it is a form of class discrimination and against the principles of the Health Service. According to this view, it should be a question of 'opting in' rather than opting out '; but this raises the question of whether we could, at a pinch, manage without bedside teaching.
I'm afraid the answer is that we couldn't. ,Medicine has to be learnt, not only on the patient, but to a large extent from the patient. To learn medicine from lectures is rather like trying to learn tennis from hitting a ball against a wall. This is impossible in tennis because an essential element is the reaction to what somebody else is doing. Precisely the same applies to the diagnosis and treatment of disease.
In fact, learning at the bedside is not ohly desirable, it is in the last resort unavoidable. If you deny it to students, you simply delay their medical education to a later stage, when they are supposedly qualified and are given patients to treat. In Africa, some of the new independent countries have sent their students to be trained at medical schools behind the Iron Curtain, where teaching is much more theoretical than it is in our own schools. The result is that it takes them a year or so after graduation to acquire the degree of practical skill which is taken for granted in a qualified doctOr from Western Europe.
The area where practical experience is most essential for a student is diagnosis. This is a very inexact science, and one in which personal observation plays a great part. It cannot be easily explained in the lecture theatre and the construction of non-human models is usually impracticable. Patients are very variable, both physically and psychologically. The student has to learn how to ask questions and how to interpret the answers. He has to learn the great variations in normal physical characteristics, so that he does not, for example, mistake an unusually bony ribcage for a malignant tumour. He has to acquire the kind of confidence which can only come from doing the same thing over and over again, in familiar circumstances.
There is the same necessity for practice in learning simple physical manipulations such as drawing blood, making an injection, or incising an abscess. The student has to do these for the first time, and it is better that he should do them, and do them pretty often so as to develop skill, in the controlled environment of a teaching hospital.
Having said this, one must also say that there is no excuse whatever for using patients as 'teaching material' without their bonsent or without due regard for their feelings. It is difficult to prevent this happening occasionally, since it is not so much an actual policy but a manifestation of boorishness on the part of the individual teacher. There is no system yet devised which can prevent people in authority from behaving badly now and then. What is most important is that doctors should be constantly aware that patients have feelings of dignity and privacy which must be respected, and that patients should have a channel of complaint if things go wrong.
As for teaching on private patients — why not? Some American hospitals have recently started doing it, without any trouble at all. Indeed, they have found to their surprise that most of the private patients actually enjoy it.
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