Teaching Prescription Pad: Teaching in the Presence of the Patient
Session recorded July 27, 2021

Welcome to this session of the teaching prescription pad, where we learn the prescription for effective teaching from the best clinical teachers. This session is on teaching in the presence of the patient. Our expert is Dr. Ken Cheyne. Dr. Cheyne practices Adolescent Medicine at Blank Children's Hospital in Des Moines, where he teaches medical students and pediatric internal medicine and family medicine residents. I am Jeff Pettit your moderator for this session. Welcome, Dr Cheyne. Thank you.

My first question is why is this topic important or of interest to you?

So, I think the biggest reason is, and Buffy inpatient and outpatient setting. It's a huge time saver. Scholars have done research on it and shows that it doesn't take any longer to teach in front of the patient, than it does if you teach outside of the patient's presence. Also, the families and the patients feel that you spend more time with them. By being in the room instead of doing the staffing outside of the room. And lastly, and maybe the most important thing is it really helps the family understand that the learners an important part of the team. So, oftentimes, whether it's a student or resident, the patient will want to just get to see the quote unquote real doctor. And so, this is a way that the learner can be an integral part of the team, and family can recognize that.

From the learner’s perspective, how do you create an environment that they feel safe and comfortable to be taught in the presence of the patient?

Well, everybody has a little anxiety at first. So, I just try to acknowledge that they're going to have some anxiety. In the beginning, I also always tell them that it's okay if there's some information or something they want to discuss outside of the room before we enter the room.  That rarely ever happens.

I also, especially in the beginning of the academic year, will tell the resident or student if they get stuck, or they get really anxious, it's okay, just to stop and kind of give me the nod, and I'll take over and again that's rare that that happens.

And I think that by knowing that there's an out that the learner feels more comfortable in those situations.

All right let's switch over to the patient's perspective. How do you create the environment so that they're comfortable having the teaching going on at the same time while you're diagnosing them, you know as we walk into the room together?

After the introductions, I always ask the patient. Are you willing to help me teach the student or the resident today and, again, nobody ever says no. I also tell the patient that occasionally we may use words that they don't understand, and it's okay to stop us and ask us to explain what we were talking about.

I also will try to explain different parts of the teaching so after the student has presented the history and physical and we're going to start talking about assessment or differential diagnosis, I'll tell the patient that this is the purpose of that, and that we're going to talk about things that there's no chance that they have but it's important for this learner to think about.

So, in this method of teaching in the presence of the patient, what are some of the challenges that you've seen or come across and what have you been able to do to overcome some of the challenges?

I think you know number one is patient selection. There are going to be some loquacious patient, some patients who are really anxious or their family members are really anxious. And that's probably not the best patient to have the student or learner teach in front of. I also think that sometimes when the learner is presenting, they're not sure “am I supposed to look at the patient or am I supposed to look at the preceptor?” So I always try to position myself right next to the patient, so that the learner doesn't have to choose who to look at.

If I recognize that we use terms that the patient might not understand or might cause anxiety to them, I will often stop and ask the student to explain that.

And sometimes the patient just gets to be quite talkative and you just kind of have to ask them to let the students or learner finish, and that they'll get their chance after the student is done with their presentation.

So as a pediatrician, do you focus your attention more on the parents or the child? How did you pay attention and how does the learner deal with those?

So, for me personally I see adolescents. Often the adolescent is in the room alone and I have the learning learner present, often in front of the adolescent and myself, if the parents are in the room. I'll sometimes work to try to position myself so they can look at all three of us at the same time, but the patient, I think is the most important. If it's a young toddler who's on the parents lap, that makes it easy, and I can now listen to the presentation, look at the learner intermittently, and kind of focus on the parent and on the adolescent to see if they have any signs that they're not understanding or becoming concerned about what we're talking about.

When you get a new learner for the very first time, do you demonstrate your presentation? Do you demonstrate how you interact with patients so that learners know how you like to interact with patients since they just came from another instructor and learn that person’s style? How do you set it up in the very beginning, so that the learner knows what you prefer and the way you like things done?

I think that that really depends a little bit on the learner. And the very first part of the academic year with a brand new medical student, I might say, “do you want to do this one together?” so that they can see how I do it. And what's important to me. I'll also try to just prime the learner. “This patient is coming back for recheck on their depression. What kind of things would you ask about?” I try to prime them for those things, you know, what are they, what are their symptoms of depression? Are they having any side effects? Were they able to take the medication? So, I think that with that early learner, I do much more priming, and I always give the learner the option if they want to watch once, and I think it again depends on the learners. I see lots of adolescents with psychosocial problems. Sometimes the first patient that we teach in front of may be a simple sore throat or simple your egg, something that they probably feel more comfortable with. And sometimes they will have forgotten an important part of the history or the physical so sometimes I'll just prompt them, you know, it's probably important that we ask about this. Why don't you ask about that? So for me, it's also a good way to observe the student taking a history because almost every clerkship requires some type of observation, or if the patient brings up a new concern.

It's an easy way to say to this, why don't you ask about that or I forgot to say my ankle hurts, well why don't you examine the ankle so then you can watch them do part of that physical exam so it often helps me do observation that the students are supposed to have completed this course gives me the opportunity to get better feedback to them about their skills. I also think that as we pause, and the student is done with their presentation I ask the patient if they have anything else. Then, I'll often ask a couple of other questions to clarify things and that helps reinforce to the student that those would be other things that they could ask and seeing myself and the patient talk about that is probably better than just telling them later on outside of the room.

I know one of the concerns for physicians that want to do this is that it takes so much more time to teach in the presence of the patient. Have you found that it does add more time or is it more effective and efficient to do it in the presence of the patient?

If you do the proper patient selection, I think it's much more efficient. Because, you know, a student takes the history, does the physical comes out and gets me and then we go back in and presents the history to me. I look at the patient and say, “is there anything else you want to add?” Then, really, you have met that supervision requirement. And the students note can be used for part of your note. And so I think it's a huge time saver.

And I think that's one of the important things for me personally, in the outpatient setting, I like to help students learn the difference between the inpatient and outpatient setting and how we may be a little more focused in the outpatient setting. And this amount of time, that's a lot it and so we do have to kind of focus our history, focus our exams to stay within that allotted time. I think that's something we're not very good about teaching learners.

You've given us a lot of really good and interesting points, are there any other aspects to teaching in the presence of patients that you feel should be addressed or important for other learners to know to use this technique?

I think that for the learners, just realize that it will probably be a very positive experience. I always ask the adolescent or their parents, “is there anything you want to add? How did they do?” And it's uniformly very positive. I think there's nothing better than having the patient or family, say that the student did a good job. I also think that sometimes it's helpful for the students to hear from the patient or the family, a little bit about their disease, so it may be that Johnny came in and he's no longer depressed and doing really, really well. But oftentimes, if time allows, I'll say, “can you just tell the student a little bit about what it felt like to be depressed?” I think that that sticks with students. We all learn better from our patients. And so that's another great opportunity for the patient to, in their own words, tell a little bit about their disease.

With regard to feedback, do you give this learner feedback in the presence of the patient or do you wait to leave and exit the room before you do that?

I do both and depends on the type of feedback that I'm going to give. Early in the year when people are more sensitive to feedback, I probably give it outside the presence of the patient. If it is later in the year, it’s been six months into the year, I often try to give feedback. An example would be students may have asked about cutting and will have talked to the patient about that and often I'll say, you know, it's important to look at the arms but it's also important to look at cuts in other areas because sometimes adolescents will do it in areas that are less visible. Another example might be, “it was really great that you asked about cutting, but I think we should ask them to they get relief from it.” If they didn't get relief from it, that's not a very positive sign. 

So, there's some things you can teach in front of the patient, especially if the student said something that might have worried the patient, like if in the differential, what I've heard was a brain tumor, I might teach in front of the patient and say, “it was a good that you considered that but the patient, in my mind, doesn't have that because of these five things. So I'm reassuring the patient, but I'm also teaching the learner at the same time.

Just out of curiosity, have you gotten any feedback from the learners about their views of teaching in the patient’s presence? Do they like being taught in front of the patient or do they prefer being outside? Any kind of comments or suggestions from their learners.

I think, in general, if the feedback is provided in a constructive way, they will like to be taught in front of the patient because it's kind of a learning experience and I'll look at the patient and say, “I'm going to talk to the student now. Will you help me teach them?” I think if you frame it in the right way, there are some things like early on in the year I really focus on to help students on their presentations. Everybody writes down every single fact and wants to make sure you get every single fact. So, some teaching like that I'll do I'll say to them, “after we walk out of the room, I want you to not look at your notes and give me that same presentation,” and it's, in my opinion, always better—more succinct and they don't forget anything that's important.

So, there's some teaching I would like that I might do outside of the room. But often, I'll teach them in front of the patient.

We want to thank Dr. Ken Cheyne for his information and sharing teaching in the presence of the patients.

If you have further questions related to the topic, you are able to contact us through this email: OCRME-PrescriptPad@uiowa.edu.

These sessions will be recorded and maintained on the Teaching Prescription Pad page of OCRME’s website at the University of Iowa.