Bringing Patient Care Back to the Bedside:
Collaborative Clinical and Academic Leadership
Mohamed Panju MD, Leslie Martin BMSc, MD, FRCPC, Marianne Talman MD, Juan Guzman MD, MSc, FRCPC,
Khalid Azzam MD, MBBS, DABIM, FACP, FRCPC, CPE
About the Authors:
Mohamed Panju is Associate Professor, Division of General Internal Medicine, Department of Medicine, McMaster University. Leslie
Martin is Assistant Professor, Division of General Internal Medicine, Department of Medicine, McMaster University. Marianne
Talman is Associate Professor, Department of Medicine, McMaster University. Juan Guzman is Associate Professor, Division of
General Internal Medicine, Department of Medicine. McMaster University. Khalid Azzam is Associate Professor of Medicine, Division
of General Internal Medicine, McMaster University.
Correspondence to Mohamed Panju: mohamed.panju@medportal.ca
Submitted: January 12, 2018. Accepted: February 20, 2018. Published: November 9, 2018. DOI: 10.22374/cjgim.v13i4.269
Academic tertiary care centres face several challenges in
providing excellent patient care and medical education. These
centres provide service to high volumes of medically complex
patients with multiple needs. In addition, there is demand for an
efficient patient flow to accommodate newly admitted patients
and discharge stable patients to their homes with appropriate
care plans. A large portion of the medical care for patients in
academic hospitals is provided by medical learners (medical
students, residents, and fellows). Accommodating learners
has its own set of challenges. This includes providing a safe
learning environment, exposure to a variety of medical cases,
and appropriate supervision. The Royal College of Physicians
and Surgeons of Canada is moving towards Competency Based
Medical Education (CBME) which is an educational paradigm
gaining attention and uptake international.
1,2
CBME requires
direct observation of learners by supervising faculty. To ensure
excellence in both clinical care and medical education, there
needs to be strong collaboration between both hospital and
educational leadership.
The internal medicine (IM) service at the Hamilton General
Hospital has taken a collaborative approach to help integrate
achieving the educational objectives with the provision of
excellent patient care and efficient patient flow. In order to
achieve this, a novel model for reviewing new patients each
morning was established.
As an academic IM training site, our inpatient medicine
service has at least six medical teams on service at any time
with six different attending physicians. Four of the teams have
medical learners while the other teams are staffed by a physician
and nurse practitioner. One of the teaching teams provides
IM consultation and admission when necessary for patients
referred from the Emergency Department between 8 am and
4 pm during weekdays. The other teams accept patients in the
morning, who have been admitted overnight by the medical
house-staff on call. Overnight medical admissions are completed
by a minimum of four residents (junior and senior) plus one
to two medical students. The patients are reviewed with the
senior resident overnight. To ensure that morning handover,
including reviewing patients with the attending physicians and
the teams, is effective and efficient and to improve patient flow
with timely patient management decision, several interventions
were introduced.
A Novel Model of Bedside Patient Presentations
Each evening the junior residents and medical students are
assigned to a specific team to admit patients. The junior
learner assigned, whenever possible, is a member of that
teaching team. The overnight resident and/or student are
able to handover (8–10 am) to a single dedicated attending
physician and their team of learners. Each morning there
are, on average, between 2–6 patients admitted to each of the
teaching teams. The junior learner presents the patients to
the attending physician and the medical team at the bedside
in the presence of the patient, family, and when possible the
bedside nurse. These changes have the potential for several
clinical and educational benefits.
Canadian Journal of General Internal Medicine
Volume 13, Issue 4, 2018 23
Commentary
facilitate workplace-based assessment and decisions regarding
entrustment in the era of CBME.
3
Setting the Stage
To ensure there was appropriate infrastructure for morning
bedside handover, the clinical and educational leadership in
our hospital took a collaborative approach. The clinical and
educational leaders needed to ensure support and buy-in from
the supervising physician group. The benefits of this approach
were explained to involved physicians. In addition, informal
presentations on how to conduct morning bedside rounding
were delivered. The on-call schedule for learners was updated to
ensure that there were specific learners dedicated to the teaching
teams each evening. The clinical physician leadership also had to
rally support for the Emergency Department and ward nursing
leadership and staff. The large group of learners spending time
at the bedside of newly admitted patients could appear to be
disruptive to nursing workflow. To avoid this undesired outcome,
the potential positive patient-care outcomes were explained in
advance to secure support at all levels. The method of team
rounding on newly admitted patients has become part of the
hospital culture for the IM service.
Next Steps
Moving forward, we will need to assess our model of assessing
new patients as a team at the bedside. From a clinical point of
view, we will need to assess if we are able to shorten hospital
stays, ensure that new admissions are safer and evaluate if we
are improving the patient experience and satisfaction. From an
educational aspect, we will be able to evaluate if we are able to
provide better evaluations and feedback for our learners. This may
help as we transition to CBME. Overall it has been an exciting
process to bring patient care back to the bedside.
References
1. 1. Carraccio C, Englander R, Van Melle E, et al. Advancing Competency-
Based Medical Education: A Charter for Clinician-Educators. Acad Med
2016;91(5):645–49. doi:10.1097/acm.0000000000001048
2. 2. Frank JR, Mungroo R, Ahmad Y, et al. Toward a definition of competency-
based education in medicine: a systematic review of published definitions.
Med Teach 2010;32. doi:10.3109/0142159x.2010.500898
3. 3. Ten Cate O, Hart D, Ankel F, et al. Entrustment Decision Making
in Clinical Training. Acad Med 2016;91(2):191–98. doi:10.1097/
acm.0000000000001044
Optimizing Clinical Care
Clinically, patients are seen earlier with the case presentation
at the bedside with the entire team. Patient care and treatment
decisions are made with the team of residents who are able to
provide assistance in executing the plan of care. This includes
performing tasks such as calling to expedite a diagnostic test,
communication with a pharmacy or a consultant, etc. The entire
house-staff also becomes familiar with the new patients admitted
to the team. This helps with providing care throughout the day as
the residents are able to deal with issues arising. This also helps
with safe handover at the end of the day. When the bedside nurse
is involved in this process, there is a shared mental model that
also includes the nursing staff. The ability to provide efficient
and timely decisions on day one of admission has the potential to
shorten hospital length of stay. With regards to patient experience,
the patients and their families become aware of the structure
of a medical teaching team. They are introduced to the team
members including junior resident who will manage day-to-day
issues, the senior resident and the supervising physician. Patients
are also involved in their care from first day of admission and
are updated with the next step in their care.
Educational Benefits of Bedside Patient
Presentations
“He who studies medicine without books sails an
uncharted sea, but he who studies medicine without
patients does not go to sea at all
William Osler
Team rounding on newly admitted patients has several
educational benefits. The medical trainees are able to learn new
concepts in context of an acute medical case. Each new patient
presentation at the bedside functions like a miniature morning
report. This allows for learning to be moved from the classroom
back to the bedside. In addition, the supervising physician is able
to provide immediate feedback to the resident who admitted the
patient. By presenting the patient at the bedside the supervising
physician is able to comment directly on the management plan.
The supervising physician is also able to directly observe physical
exam skills and explore the learner’s cognitive thought process
regarding investigations and the workup of the patient. This
level of direct observation and immediate feedback will help to
Canadian Journal of General Internal Medicine
24 Volume 13, Issue 4, 2018
Bringing Patient Care Back to the Bedside: Collaborative Clinical and Academic Leadership