David Power, MD, MPH, Program in Medical Student Education and Department of Family Medicine and Community Health, University of Minnesota Medical School

Teaching ward rounds that occurred at the patient's hospital bedside had been the traditional world-wide method of educating medical trainees for much of the early part of the 20th century and continues to this day in many countries. However, in recent decades in the United States, probably for many varied reasons, inpatient medical education moved away from patient-centered teaching at the bedside to conference room discussions by doctors in settings where the patient was not present.¹ This has now become the norm in US inpatient settings. With the movement to more outpatient-based care, this conference room precepting has also become the most common method of outpatient clinical precepting with trainees. As we all know, preceptor and trainee interactions in the outpatient setting are particularly limited by busy patient schedules, brief clinical encounters, limited clinic space, and a host of other variables. This means that any inefficiency caused by precepting learners can be sufficient cause for a preceptor to abandon student teaching entirely "because they don't have the time."

A method has been described, titled "Teaching in the Presence of the Patient" (TIPP). This is a simple concept that describes the clinical precepting interaction occurring entirely in the exam room in the patient's presence (the clinic equivalent of the "bedside") instead of in a removed, preceptor area. There is good evidence that patients prefer this method and report higher satisfaction with their care over conference room staffing.^2-5 In addition, one recent innovative, educational randomized controlled trial (RCT), coauthored by a family medicine educator, found that the attendings and learners, as well as the patients, preferred TIPP.⁶ In this well-performed study, the total time spent in precepting was equal whether it occurred in the clinic exam room or preceptor area. However, the actual contact time between physician and patient was significantly increased by almost double when the preceptor and learner communicated in the exam room (TIPP). Patients indicated that they preferred to be involved in the communication that occurred between preceptor and student, rather than be excluded.

In addition to improved patient satisfaction and no increase in precepting time, TIPP may have an added benefit in being favored by compliance officers as a less vulnerable strategy to maximize student involvement in clinical care. That all the participants in clinical care, including the patient, can attest to the accuracy of the student's history taking may support the legitimacy of any student role in documentation as a true reflection of what the preceptor actually heard and performed.⁷ Further studies are underway to test the utility of TIPP in a psychiatric outpatient clinic—sensitive issues, such as mental health symptoms, have been considered taboo by physicians for discussion in front of the patient. However, thus far, there appears to be no evidence to support that concern. Additionally, the use of TIPP with interpreted visits in family medicine is to be studied, and, anecdotally, TIPP performs well in such settings.

With the emphasis on outpatient-based medical care likely only to increase in the coming years, we need our own method of clinical precepting that works well in family medicine. TIPP seems to be that method. If you haven't used TIPP, I encourage you to give it a try. You, your patients, and your trainees will probably like it.

References
1. La Combe M. On bedside teaching. Ann Intern Med 1997;126(3):217-20.

2. Lehmann L, Brancati FL, Chen M, Roter D, Dobs AS. The effect of bedside case presentations on patients' perceptions of their medical care. N Engl J Med 1997;336:1150-5.

3. Anderson R, Cyran E, Schilling L, et al. Outpatient case presentations in the conference room versus examination room: results from two randomized controlled trials. Am J Med 2002;113:657-62.

4. Smith AG, Bromberg MB, Singleton JR, Forshew DA. The use of "clinic room" presentation as an educational tool in the ambulatory care setting. Neurology 1999; 52:317-20.

5. Rogers HD, Carline JD, Paauw DS. Examination room presentations in general internal medicine clinic: patients' and students' perceptions. Acad Med 2003;78:945-9.

6. Petersen K, Rosenbaum ME, Kreiter CD, Thomas A, Vogelgesang SA, Lawry GV. A randomized controlled study comparing educational outcomes of examination room versus conference room staffing. Teach Learn Med 2008;20(3):218-24.

7. Department of Health and Human Services. Guidelines for teaching physicians, interns, and residents: fact sheet, ICN 006347. Washington, DC: Department of Health and Human Services, December 2011.