Bed side clinical encounters

The new england journal of medicine

Brian T. Garibaldi, M.D., M.E.H.P.,1 and Stephen W. Russell, M.D.2

Medical trainees today spend as little as 13% of their time in direct contact with patients.1 As physicians spend less time with patients,

fundamental bedside skills decline. This decline contributes to diagnostic

error, poor clinical outcomes, and increased health care costs.3 More than half of outpatient diagnostic errors have been attributed to poor history taking and mis- takes in the physical examination.4 An overreliance on technology, due in part to declining clinical skills, leads to overinvestigation and rising costs.5 The drift away from direct contact with patients contributes to a decrease in empathy on the part of medical students and residents and an increase in stress and burnout among practicing physicians. It also leads to a weakening of the doctor–patient relation- ship.6,7 Lack of time at the bedside disproportionally affects marginalized groups and propagates health care disparities.8 As bedside skills have declined, so too has the number of faculty members who are comfortable teaching those skills, which further contributes to their decay.9 To help reverse these trends, we provide practi- cal suggestions for clinical educators to reinvigorate the teaching and practice of bedside clinical skills in the modern health care environment.

How Did We Get Here?

Early American medical education relied on a tiered system, from individual precep- torships in the beginning of the 19th century to didactic, degree-granting medical schools by midcentury. Few physicians could afford the education provided in Europe, where trainees learned at the bedside with clinical masters and then correlated clinical signs and symptoms observed in live patients with findings from autopsies and pathological examinations. This situation began to change around the begin- ning of the 20th century, as an increasing number of American medical schools fol- lowed the example set by master clinical educators such as Sir William Osler at The Johns Hopkins Hospital, whose students “examined patients, made diagnoses, heard the crepitant rales of a diseased lung, felt the alien and inhuman marble tex- ture of a tumor.”10

This scientifically based method of combining bedside observation with patho- logical study reflected an endeavor to prepare doctors for teaching and learning at the bedside. But those aspirations have not endured for modern learners. Technology- based tests have moved the diagnostic process toward the laboratory and radiology suite, creating a false impression that what physicians see, feel, hear, and smell is no longer accurate or reliable.11 The electronic health record (EHR) creates work- flows that force physicians to spend more time with the digital representation of a patient (the “iPatient”) than with the actual person.12 With changes in duty hours and economic pressures, throughput is prioritized over bedside evaluation and education.13 The limited time that physicians do spend with patients is increasingly fragmented.14

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Author affiliations are listed at the end of the article. Brian T. Garibaldi can be con- tacted at brian.garibaldi@northwestern .edu or at the Center for Bedside Medicine, Northwestern University Feinberg School of Medicine, 240 E. Huron St., Suite 1-200, Chicago, IL 60611.

This article was published on November 12, 2025, at NEJM.org.

DOI: 10.1056/NEJMra2500226

The New England Journal of Medicine is produced by NEJM Group, a division of the Massachusetts Medical Society.

Downloaded from nejm.org at Sun Pharmaceuticals Pvt. Ltd. on November 15, 2025.

The new england journal of medicine

Key Points

Strategies to Reinvigorate the Bedside Clinical Encounter

• Medical learners in the 21st century spend less time with patients during training than their counterparts did in the 20th century, which decreases the knowledge and practice of bedside clinical skills.

• Decreased bedside clinical skills lead to diagnostic error, poor clinical outcomes, increased health care costs, and physician burnout.

• Taking learners to the bedside facilitates clinical observation skills, creates opportunities to practice skills, and allows for evidence-based demonstrations of examination skills.

• Integration of point-of-care technology and artificial intelligence in the clinical encounter complements human observation, human clinical decision making, and human communication.

• Seeking opportunities to provide feedback on clinical skills in a context-specific way improves the technique at the bedside, as well as the interpretation of information obtained from the encounter.

• Beyond the diagnostic data obtained in the bedside clinical encounter, the physical examination helps learners navigate clinical uncertainty, helps teachers model interactions with patients, improves physician–patient communication, increases professional fulfillment, and helps address health care disparities.

An interactive graphic is available at NEJM.org

Some physicians and trainees falsely believe that going to the bedside is inefficient.15 Some worry that discussing the complexities of care in the presence of patients leads to discomfort or confusion on their part.16 The uncertainty that comes with going to the bedside can be intimidat- ing for educators and learners alike.17 Although personal protective equipment protects physi- cians and patients from the spread of infectious diseases (René Laënnec, the inventor of the stetho- scope, died from tuberculosis18), physical barriers can prolong rounds; decrease the accuracy of activities such as communication, palpation, and auscultation; and limit overall time spent in con- tact with patients.17 As a result of these barriers, morning rounds, traditionally a bastion of bed- side teaching, have migrated to the hallway, with less than 20% of rounding time spent with ac- tual patients.1 This creates a cycle in which bedside clinical skills are undervalued, undertaught, and underused, which further contributes to their ero- sion among practicing physicians and trainees.

Recent data support the enduring value of the bedside encounter. In a study of emergency room visits that resulted in hospital admission, history taking and physical examination led to the diag- nosis in almost 40% of cases, with another 33% of diagnoses made by adding simple investiga- tions.19 An appropriate physical examination can obviate the need for additional diagnostic test- ing, yet the most commonly reported error with respect to the physical examination is simply not performing it.20 One study showed that among patients who were admitted overnight, an attend-

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ing physician uncovered a pivotal diagnosis in 26% of cases after performing a physical exami- nation the following morning.21 When teams go to the bedside after a handoff of care, the differ- ential diagnosis changes substantially 20% of the time.22 In addition to the diagnostic importance of bedside rounds, patients often prefer them and feel that their teams care more about them as individuals when rounds are conducted at the bedside.15,23,24

The interactive graphic describes a common sce- nario encountered by clinical educators. Using this scenario as a starting point, we offer six strategies to help reinvigorate a culture of bedside medicine and respond to the needs of patients, physicians, and learners (Table 1).

Go to the Bedside and Observe

The notorious criminal Willie Sutton supposedly once said, “I rob banks because that’s where the money is.”25 Applied to medicine, Sutton’s law has traditionally meant “proceeding immediately to the diagnostic test most likely to provide a diagnosis.”26 A revised Sutton’s law might state that in order to improve bedside clinical skills, you need to go where the patients are: the bed- side.27 The modern-day “bedside” includes not only a hospital room or outpatient office but also a telemedicine encounter or home health visit.

No matter where the encounter takes place,

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How to Reinvigorate a Culture of Bedside Medicine

Reinvigorating the Bedside Clinical Encounter

Table 1. Strategies to Reinvigorate the Bedside Encounter. Strategy

Justification

Go to the bedside and observe (both patient and trainee)

Observation forms the basis of much of the physical examination and can provide valuable clues to the diagnosis of many diseases, as well as the prognosis.

Direct observation of the trainee’s clinical skills is critical for providing actionable and specific feed- back.

Observational skills can be improved through practice in nonmedical contexts.

Practice and teach an evidence- based approach to the physical examination

The physical examination should be used in a hypothesis-driven approach, just like any other diag- nostic test.

In many cases, the physical examination remains the reference-standard diagnostic test.

In other cases, likelihood ratios can help in selecting the appropriate physical examination maneu-

ver, by comparison of that maneuver with a technology-based test.

Create opportunities for intentional practice

Time at the bedside is limited, so educators need to create opportunities for intentional practice of bedside skills.

Traditional morning rounds remain the best opportunity for teaching bedside clinical skills.

Other teaching sessions, such as morning report, noon conference, or dedicated physical examina-

tion sessions, can provide opportunities for practice.

Use technology to teach and rein- force clinical examination skills

Point-of-care technology (e.g., use of digital stethoscopes and ultrasonography) is part of the bed- side examination. It enhances diagnosis, allows learners to calibrate physical examination skills, and brings educators, learners, and patients together.

Telemedicine improves access to care and allows clinicians to visit with patients in their home envi- ronment.

Artificial intelligence can reduce the administrative burden, assist in the clinical reasoning process, and help in the acquisition of data.

Awareness of the possibility of bias is important when existing or new technologies are used at the bedside.

Seek and provide feedback on clini- cal skills

Direct observation and feedback on clinical skills with real patients are rare in the United States. Assessment can drive learning.

Formative assessments with real patients can inform individual learning plans.

Acknowledge the power of the bed- side encounter beyond diagnosis

Approaching each encounter with curiosity can help physicians navigate uncertainty.

Performing an appropriate history taking and physical examination helps patients feel cared for and

can have a healing effect.

Using evidence-based approaches to being fully present with patients improves the patient–physi-

cian relationship and increases professional fulfillment.

Spending time at the bedside can help address health care inequities.

observation is one of the most important and underused clinical skills that can aid in estab- lishment of a diagnosis, as well as in clinical teaching. James Parkinson’s description of the “shaking palsy” relied almost exclusively on his direct observation of patients.28 Observing a pa- tient from the foot of the bed, or even from the hallway, reveals clues that are critical for under- standing the diagnosis, the prognosis, and the patient’s personal circumstances.29 Intentional practice can improve observational skills. In the preclinical years, practicing observation in a nonmedical context (e.g., by looking at art) im- proves observation in the clinical realm.30 Ob- serving learners engaging in a clinical encounter provides rich opportunities for assessment of and feedback on their clinical skills. Faculty members’ competence and confidence in di- rectly observing clinical skills can be improved with practice.31

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Practice and Teach an Evidence-Based Approach to the Physical Examination

In medical school, the physical examination is of- ten taught in a head-to-toe fashion rather than as part of a threshold-based approach to clinical de- cision making.32 This strategy could lead some physicians to prioritize technology-based tests above the physical examination. One way to over- come this tendency is to teach and practice a hy- pothesis-driven physical examination,33 in which a physical examination maneuver is considered in the same way that other diagnostic tests are con- sidered.

The first step in this approach is to estimate a pretest probability of diagnostic hypotheses, with the use of clues derived from the patient’s history and knowledge of the prevalence of dis- ease in a particular context. Sometimes the diag- nosis is apparent from the history alone, but if additional data gathering is warranted, the clini-

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cian can select an appropriate physical examina- tion maneuver targeted toward a suspected diag- nosis. Some physical examination findings are pathognomonic of the disease in question (e.g., the rash of herpes zoster or the appearance and warmth of cellulitis). However, in many cases, the accuracy and reliability of findings from the physical examination are established by compar- ing the findings with those from a technology- based test (e.g., a laterally displaced apical im- pulse and a third heart sound are compared with an echocardiogram in diagnosing heart failure with reduced ejection fraction).

Using the information derived from the history and a hypothesis-driven physical examination, cli- nicians can decide whether additional testing is warranted or enough information is available to make a diagnosis and offer a treatment recom- mendation.11 But this approach requires seeking out opportunities to demonstrate and practice such an examination. The interactive graphic shows a hypothesis-driven physical examination of a pa- tient with exertional dyspnea.

Create Opportunities for Intentional Practice

Intentional practice as part of a dedicated clini- cal skills curriculum improves physical examina- tion skills.34 Being with patients teaches the value of bedside skills and how data acquisition (i.e., history taking and physical examination) imme- diately affects patient care.17 But intentional prac- tice starts with empowering teachers and learners to overcome barriers and get back to the bedside.

Patient-centered medical education conducted with learners and teachers at the bedside during rounds can increase efficiency and enhance phy- sician satisfaction.35 Rounding in the patient’s room identifies immediate issues to be addressed, helps to frame a shared medical agenda, and expe- dites the ordering of tests, treatments, and consul- tations. Teachers should prepare both patients and learners for what to expect during bedside rounds. One way to do this is to choreograph the bedside interaction by assigning tasks to members of the medical team, such as order entry or data retrieval from the EHR. Assigning roles to the participants helps to focus clinical presentations, carve out time to clarify important historical data, and inte- grate details of the physical examination into the case presentation. Structuring time with the pa- tient also provides opportunities for teaching.36

Several tools are available to aid in efficient

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bedside teaching, such as the One-Minute Pre- ceptor37 and the Five-Minute Moment.38 The Five- Minute Moment combines a memorable vignette related to a finding from a physical examination with information on how to properly perform a maneuver during the examination and data on the relevance of the finding (see Fig. S1 in the Supplementary Appendix, available with the full text of this article at NEJM.org). If time allows, multiple scripted teaching tools can be combined to create a more comprehensive approach to a pa- tient’s chief concern.

Seeing every patient with the entire team dur- ing morning rounds is often not possible. Clini- cal educators can prioritize which patients to see with learners by selecting circumstances in which the history or physical examination is likely to be helpful in elucidating a diagnosis. For example, a focused cardiopulmonary examination can help distinguish chronic obstructive pulmonary dis- ease from heart failure in a patient with chronic dyspnea.39 Since a substantial proportion of in- patient admissions are due to cardiopulmonary disease,40 learning how to perform a targeted cardiopulmonary examination is useful for most clinicians. Educators can also select patients to see on the basis of particular presentations that would provide an opportunity for both the educa- tors and their learners to improve their clinical skills. Given that “neurophobia” is a commonly described phenomenon in medical training,41 see- ing patients with neurologic symptoms is often a high-yield endeavor for both diagnosis and teaching.

Taking learners to the bedside apart from tra- ditional rounds can also be valuable. For example, examining a patient with a new or worsening clinical condition can demonstrate in real time the value of the bedside encounter in diagnosis and clinical decision making. This type of “reac- tive learning” is an important part of informal learning in the workplace.42

Dedicated physical examination and observa- tion sessions outside of routine patient care can also build clinical skills. One of the authors leads regular sessions in which trainees provide the chief concern or symptom they would like to ex- plore for a patient unknown to the faculty and other learners. The team goes to the bedside to conduct a physical examination (including ultra- sonography, if appropriate), agrees on the findings that are present, discusses the potential clinical

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Reinvigorating the Bedside Clinical Encounter

significance of the findings, and compares them with available results from imaging studies and other diagnostic tests. These educational sessions demonstrate the value of bedside clinical findings and calibrate examination technique with imag- ing results. The sessions also provide an opportu- nity to celebrate discoveries made by trainees and acknowledge the limitations of the bedside ex- amination (e.g., when the findings from the ex- amination and ultrasonography do not uncover the diagnosis).

Teachers can take advantage of traditional ed- ucational sessions to teach and practice clinical skills. For example, after a morning report pre- sentation, the team goes to the bedside to con- duct a focused history taking and physical ex- amination. When this strategy is used, bedside findings can lead to substantial changes in the differential diagnosis (e.g., a patient with renal failure from suspected dehydration is discovered to have decompensated heart failure).43 Traditional morning report or other conferences can also be used to demonstrate and practice specific physi- cal examination maneuvers with the use of stan- dardized patients (persons trained to simulate the symptoms of a condition) or healthy volunteers.44

Bedside sessions should start early on in medical school, since habits form early and in- f luence clinical practice throughout physicians’ careers. Preclinical students who participate in observed bedside clinical encounters with both real and standardized patients have better clini- cal skills at the end of their third-year clerkships than preclinical students who have not partici- pated in such sessions.45 However, when preclini- cal students move on to their clinical rotations and do not see physicians using the history and physical examination in the everyday care of pa- tients, they quickly shift their focus toward the EHR and technology-based tests.12

Use Technology to Teach and Reinforce Clinical Examination Skills

Laënnec’s invention of the stethoscope two cen- turies ago remains one of the most important technological advances in medicine.18 New tech- nology has broadened the diagnostic capabilities of the stethoscope. Digital stethoscopes allow simultaneous auscultation with real-time visual- ization of spectrophonographs and electrocardio- grams (see the interactive graphic). Artificial in- telligence (AI) algorithms aid in the diagnosis

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of arrhythmias and valvular heart disease.46,47 Point-of-care ultrasonography (POCUS) can es- tablish diagnoses that elude the traditional physi- cal examination. POCUS allows learners to cali- brate their physical examination skills by linking examination findings with real-time visualization of pathophysiological features.48 AI algorithms can assist learners with image acquisition and interpretation.49 But perhaps the true power of POCUS is that it brings patients, physicians, and trainees together at the bedside. To become pro- ficient at POCUS, physicians need to be present with patients, strike up a conversation, and ap- propriately uncover the part of the body to be examined. In the process, important historical clues and physical examination findings become apparent (e.g., a sternotomy scar or a pacemak- er).50 Physicians can also build a connection with patients and engage them in shared decision making by showing real-time images of patho- physiological features.51

Technology can help overcome physical barri- ers to the clinical examination (e.g., personal protective equipment, which limits touch and hearing) and provide real-time diagnostics when transporting a patient to a scanner is not feasi- ble (e.g., because of clinical instability or the need for infection prevention).52 Technology has also reframed the concept of the bedside to include telehealth, which allows the patient to engage in a physician-assisted, patient-led physical exami- nation while offering the physician insight into the patient’s home environment.53

Emerging technologies have the potential to further modify the bedside clinical encounter. For example, multimodal AI systems might one day be able to assist with observation and visual inspection of patients.54 Large language models have shown promise in clinical reasoning tasks.55 Perhaps the more immediate and useful impact of AI will be to offload the administrative bur- den imposed by the EHR, freeing up time for direct contact with patients.56 No matter how the role of AI at the bedside takes shape, the results from AI interactions should always inform rather than replace human observation, human clinical decision making, and human communication at the bedside.57 Bedside clinical skills will be even more important in an AI-enabled clinical work- place, which highlights the need for a stronger emphasis on direct observation and feedback on those skills.

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Seek and Provide Feedback on Clinical Skills

Delivering feedback to learners in the presence of patients is a complex skill, particularly if the feedback involves correcting a mistake in physical examination technique or modifying the differen- tial diagnosis or treatment plan. Poorly delivered feedback could undermine the relationship be- tween trainees and patients. If delivered in a context-specific and thoughtful way, however, bedside feedback can reassure patients that the entire team is invested in their care (see the inter- active graphic). It is critical to set expectations with patients and learners before delivering bed- side feedback; this process may involve alerting both the patient and the team beforehand that feedback is going to be provided and seeking specific areas of need for the learner. Avoiding medical jargon, when possible, can improve com- munication and education. A short debriefing with the learner after the bedside encounter can rein- force key points and identify ways to improve future experiences.36,58

Despite the importance of bedside feedback, direct observation and assessment of clinical skills with real patients are rare in the United States.59 U.S. medical education instead relies on summative assessments of medical knowledge with the use of multiple-choice examinations to determine learners’ developing competence. In many other countries, graduating residents in internal medicine are required to pass examina- tions in which they encounter real patients with real findings while being assessed by faculty ob- servers. A high-stakes assessment can drive learn- ing.60 Non–U.S.-trained physicians who have gone through this experience are usually more fluent in their clinical examination skills and have a broader appreciation for the value of the bedside encounter in patient care than U.S.-trained phy- sicians.61 This experience may translate into better outcomes for patients.62

Although there is no appetite for a high-stakes, summative clinical skills examination in the Unit- ed States, there is a need to incorporate more direct observation into training. The Assessment of Physical Examination and Communication Skills (APECS) is a formative experience for in- ternal medicine residents that includes integrat- ed, physical examination–only, telemedicine, and POCUS encounters with real patients. Residents are assessed across seven clinical domains and

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receive individualized, hands-on feedback from experienced faculty.63

The APECS underscores the enduring value of the physical examination. A study that used the APECS to assess the physical examination skills of interns showed that good technique is signifi- cantly associated with identification of the cor- rect physical findings, and both good technique and identification of physical findings are sig- nificantly associated with formulation of a correct differential diagnosis.63 Direct observation of train- ees also provides an opportunity for feedback. In another study that incorporated the APECS, only half the interns who participated in the exami- nation of a patient with severe aortic regurgita- tion (the scenario in the interactive graphic) ap- preciated the characteristic diastolic murmur.64 Two commonly observed errors (which the learn- er in the scenario in the interactive graphic also made) are auscultating through the gown or clothing and listening to the heart while feeling the radial pulse (instead of the apical impulse or carotid pulse).64 These are simple errors in tech- nique that can be easily corrected. The APECS also provides an opportunity for faculty develop- ment, since physicians from different specialties and with varying degrees of experience are paired as preceptors with learners.63

The APECS is resource-intensive and happens outside the delivery of routine care. Recognizing this limitation, the Society of Bedside Medicine created the Ten-Minute Moment for use in the daily workflow,65 in which faculty observe a learner performing a focused physical examination and provide real-time feedback with the help of a skills- based worksheet. The Mini–Clinical Evaluation Exercise (Mini-CEX) is another commonly used tool to guide workplace-based observations and subsequent feedback.66

Acknowledge the Power of the Bedside Encounter beyond Diagnosis

Clinical medicine is practiced against a back- ground of uncertainty. Whether the task at hand is establishing a diagnosis, making treatment decisions, or providing clinical follow-up, uncer- tainty is a part of bedside patient care. Acknowl- edging this fact allows patients, clinicians, and trainees to negotiate the uncertainty together, which can strengthen the patient–physician rela- tionship.67 One attribute educators can demon-

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Reinvigorating the Bedside Clinical Encounter

strate to mitigate uncertainty is curiosity. Curi- osity, as defined in a 1999 essay by Fitzgerald, “is the urge to investigate, to discover,” and when applied to clinical medicine, curiosity allows the patient to be viewed as a person, with signs and symptoms as set pieces in a story.68 Approaching the bedside encounter with curiosity allows cli- nicians to effectively partner with patients and learners.

Using evidence-based practices to be fully present during interactions with patients, such as preparing with intention, listening intently, and agreeing on what matters, allows time spent at the bedside to yield more than just clinical clues. It allows for connection with a patient’s story and engenders trust.69 Time spent being fully present helps clinicians find meaning in their work, which can be a powerful buttress against stress and burnout.7,27 A physical exami- nation done well conveys caring and can have a placebo effect beyond diagnostic findings.7 Cel- ebrating moments when time spent with a pa- tient yields important clinical information builds excitement in the clinical encounter and is an antidote to “eurekapenia” (i.e., the paucity of “eureka” moments when the learner recognizes the link between a clinical finding and the pathobiologic basis of a disease). Many learners and practicing physicians experience eurekape- nia, since they spend little time at the bedside.70

The bedside encounter can also address health care disparities. Among teenagers who are mem- bers of underrepresented racial and ethnic groups, the percentage who report having never had a physical examination during routine checkups is higher than that among their White peers.71 Even when those examinations occur, systemic ineq- uities (e.g., the paucity of dermatologic textbooks

that include darker skin tones72 or bias in devices such as pulse oximeters73) can worsen outcomes for patients of color. Patients with low English language proficiency can also receive inadequate care.74 When educators take teams to the bedside, they are able to acknowledge and address these inequities in a context-specific way.

Conclusions

Against a backdrop of technological advances, limited time with patients, and clinical uncertain- ty, there is an urgent need to reinvigorate the bedside encounter in order to meet the needs of patients, trainees, and clinical educators in the 21st century. By using six strategies, clinical edu- cators can help trainees appreciate the value of the bedside encounter in diagnostic reasoning, strengthen the patient–physician relationship, combat health care inequities, improve profes- sional fulfillment, and avoid burnout. The words of Osler ring true more than a century later: “Medicine is learned by the bedside and not in the classroom. Let not your conceptions of the manifestations of disease come from words heard in the lecture room or read from the book. See, and then reason and compare and control. But see f irst.”75

Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.

We thank Dr. Andrew Elder, Royal College of Physicians of Edinburgh, for his thoughtful comments on an earlier version of the manuscript and for his mentorship in bedside medicine.

Jeffrey M. Drazen, M.D., Raja-Elie Abdulnour, M.D., and Ju- dith L. Bowen, M.D., Ph.D., are the editors of the Medical Edu- cation series.

Author Information

1 Center for Bedside Medicine, Northwestern University Fein- berg School of Medicine, Chicago; 2 Department of Medicine, University of Alabama at Birmingham, Birmingham.

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