Rescuing Bedside Medicine: The Fundamental Unit of Care Isn't High Tech
Bedside Medicine is under siege from a glut of new technology and limited patient interaction time. While medical practice has changed remarkably during the lifetime of most of today's physicians, the fundamental unit of care has not. It is bedside medicine, specifically the clinical transaction - the interaction between doctor and patient that results in the accumulation of the basic facts needed for diagnosis, evaluation of responses to therapy and understanding of the physical, psychologic, and social impacts of the illness on the patient.
The basic facts needed have traditionally been gathered through a set of fundamental bedside skills, i.e. a detailed medical history and physical examination, followed by an initial formulation of the nature of the disease responsible for the patient's illness and plans for further investigation through laboratory and other ancillary procedures.
These basic skills have proven so effective that medical education and residency training programs have emphasized them for more than a century.
The Allure and Traps of Technology
In recent years a panoply of new technologies and demands have displaced these fundamental bedside skills.
Imaging techniques such as computed tomography and magnetic resonance imaging give us information that goes well beyond what can be gleaned at the bedside. The electronic medical record has replaced notes generated from the words of the patient.
Today, computer use occupies 40% of the day of physicians in training; in part a reflection of the amount of data that must be processed for complex patients. Face to face time between residents and hospitalized patients has fallen to as little as 8 to 9 minutes per patient per day.
Demands for increased throughput of patients further diverts trainees from the bedside where the fundamental skills are learned and honed. But these skills remain the basis of good clinical care and cannot be substituted for by technologies.
Indeed, diagnostic error as the result of faulty data gathering has been shown to contribute to the deaths of as many as 40,000 to 80,000 patients each year in the United States.
Furthering the problem is the prevalence of burnout among physicians in training and continuing into the practice years. At least 50% of resident physicians show one or more signs of burnout (depression, depersonalization, loss of interest in medicine, substance abuse and the like).
The negative impact of burnout on information gathering at the bedside compounds the problem of faulty diagnosis.
While medical practice has changed remarkably during the lifetime of most of today's physicians, the fundamental unit of care has not. It is the clinical transaction - the interaction between doctor and patient that results in the accumulation of the basic facts needed for diagnosis, evaluation of responses to therapy and understanding of the physical, psychologic, and social impacts of the illness on the patient.
A renewed, energetic and focused effort to restore the primacy of training in these basic clinical skills is needed, and will require concerted action by medical educators, clinical societies and other key players such as accrediting organizations.
These actions must include attention to the physical and mental health of people in training if trainees (medical students, residents, fellows) are to retain their enthusiasm for medicine.
Residents must be relieved of the burden of caring for more patients than they have time to devote to them, an agenda for payment reform.
Training programs must be given more flexibility to tailor work limits so that residents can experience greater continuity of care.
Both patient and trainee will benefit from the added knowledge that comes with it.
There are promising signs of a broader recognition that something important is being lost; in resuscitative efforts in some schools and training programs throughout the country, in the formation, often by junior faculty, of new societies dedicated to the problem (e.g.The Society for Bedside Medicine).
Commentary by Dr. Paul Griner in collaboration with Dr. Jeremiah Barondess
How to Keep Your Bedside Diagnostic Skills Sharp
The Med-Challenger medical education blog provides a series called "Bedside Diagnostic Challenges." Each month, clinical experts provide case-based bedside diagnostic scenarios aimed at recognizing and processing diagnostic clues and decisions that can help clinicians arrive at the a proper diagnosis at beside. Each case provides a detailed summary and key points to help you keep your bedside medicine skills sharp.
The blog and diagnostic challenges are 100% free. To get the challenges, subscribe here.
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