International Journal of Medical Education.

2015;6:201-207
ISSN: 2042-6372
DOI: 10.5116/ijme.5669.ea24

Patients’ attitude towards bedside teaching in

Tunisia
Arwa Ben Salah, Sana El Mhamdi, Ines Bouanene, Asma Sriha, Mohamed Soltani

Department of Epidemiology and preventive medicine, University Hospital of Monastir, Tunisia

Correspondence: Arwa Ben Salah, Department of Epidemiology and preventive medicine, University Hospital of Monastir,
First June Street 5000 Monastir, Tunisia. E-mail: bensalah.arwa@yahoo.fr

Accepted: December 10, 2015

Abstract
Objectives: To assess patients’ reaction towards bedside attending ward rounds and observing doctor examining
teaching at the University Hospital of Monastir (Tunisia) them). As the degree of students’ involvement increased, the
and to identify the factors that may influence it.
refusal rate increased. Gender, age, educational level,
Methods: A cross-sectional study was conducted during
marital status and the extent of students’ involvement in
December 2012 at the University Hospital of Monastir.
Each department, except the psychiatric department and the patient’s care were identified as the main factors affecting
intensive care units, was visited in one day. All inpatients patients’ attitude.
present on the day of the study were interviewed by four Conclusion: Taking advantage of this attitude, valorizing
trained female nurses using a structured questionnaire. patient role as educator and using further learning methods
Results: Of the 401 patients approached, 356 (88.8%) in situations where patient’s consent for student involve-
agreed to participate. In general, the results demonstrate ment was not obtained should be considered to guarantee
that patients were positive toward medical students’ partici- optimal care and safety to patients and good medical
pation. The highest acceptance rates were found in situa- education to future physicians.
tions where there is no direct contact between the patient Keywords: Bedside teaching, medical education, medical
and the student (e.g. when reading their medical file, students, patient acceptance of health care, Tunisia

Introduction
Bedside teaching is seen as one of the most important medical students presence, which may hinder bedside
component of medical education. It provides students and teaching and even affect the quality of medical education,
trainees with an opportunity to learn several clinical skills especially in countries, like Tunisia, where alternative
such as history taking, physical examination, clinical learning approaches are not developed yet.
reasoning, decision making, communication and profes- In fact, medical education in Tunisia is characterised by
sionalism.1 It requires considerable enthusiasm and com- being very traditional, with large number of students and
mitment on the part of both teacher and learner and will- hospital based education. Clinical teaching takes place in
ingness to cooperate on the part of patient who plays a the third to fifth years of medical training. During these
crucial role in this educational method. three years, medical students rotate through different
Several studies have shown that the majority of patients medical and surgical departments where they spend about
had positive attitudes towards the involvement of medical four hours a day experiencing patient-based clinical teach-
students,2-5 they even enjoyed their contribution in ing; some of them perform clinical examination on their
improving the training of the medical workforce, resulting own, later they report their findings to the supervising
in improved healthcare for the whole population.3,4,6,7 clinician who corrects or confirms these findings and
However, these attitudes vary across regions and countries demonstrates the correct examination.
and seem to be determined by various socio-demographic Playing a passive role in this approach, patients simply
factors and cultural issues.3Many of these factors, as female act as “teaching material”. However, since the transition,
gender,8-10 male student’s gender,11 and Islam religion11, 12 patient’s rights and informed consent have gained greater
have shown to be associated with greater refusal rates of visibility, and patients now have the right to choose whether

201
© 2015 Arwa Ben Salah et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution License which permits unrestricted use of
work provided the original work is properly cited. http://creativecommons.org/licenses/by/3.0
Ben Salah et al.  Patients’ perspective on bedside teaching, Tunisia

to have medical students involved in their care or not. These participant had to choose between “permitting male stu-
facts have prompted us to conduct this study to assess dents only”, “permitting female students only”, “permitting
Tunisian patients’ attitude towards bedside teaching at the both genders of students” or “not to permit either gender of
University Hospital of Monastir and to identify factors that students”. The third section included three questions; a
may potentially influence their decision to allow or refuse question about who did the patients think was involved in
medical students’ participation in their care, so that aca- their care (student, doctors or both of them), a question
demic institutions would be adequately prepared to address about the manner that the presence of medical students in
different scenarios in order to guarantee high quality Teaching Hospitals did affect the quality of health care (it
medical education. The aims of this study were twofold. The improves, doesn’t affect or worsens the quality of care) and
first was to assess patients’ attitude towards the presence of a question about the level of patients’ satisfaction with the
medical students at the Teaching Hospital of Monastir. The care given by students (very satisfied, satisfied, not satisfied
second was to identify factors that may affect this attitude in or not satisfied at all).
order to act upon them for better bedside teaching.
Statistical analysis
Methods Data entry and analysis were performed using the Statistical
Package for Social Sciences software (SPSS) version 18.0.
Study design We used Chi square test and fisher exact test to study the
We carried out a cross-sectional study in December 2012 at association between each item evaluating “patients’ reaction
Fattouma Bourguiba University hospital of Monastir which toward students” and socio-demographic variables (age,
is an 866 bed tertiary-level teaching hospital with 22 depart- gender, marital status, educational level and occupation).
ments. Each department, except the psychiatric department For this analytical part, participants ‘answers were pooled in
and the intensive care units, was visited in one day to collect two modalities “to permit medical students regardless of
data. their gender” and “not to permit medical students regard-
less of their gender” which corresponds to the answers “to
Study participants
permit male students only, to permit female students only
All inpatients present, on the day of each department’s visit,
and not to permit either genders”. Pediatric patients were
were enrolled. For pediatrics participants (patients under 15
excluded from univariate analysis. A p-value less than 0.05
years old), we surveyed parents in order to determine their
was considered statistically significant.
comfort with medical student involvement in the care of
their children. Results
The consent of all patients was obtained after an expla-
Study participants
nation of the nature and the purpose of the study. Also, the
Of the 401 interviewed patients, 356 agreed to participate
participants were assured the anonymity and the confiden-
(response rate of 88.8%). The mean age of all patients
tiality of the collected information and that their
surveyed was 42.7 years (SD=21) and 59.8% of them
participation would not affect the quality of care provided.
(n=213) were female. The majority of the participants were
For pediatrics participants (patients under 15 years old), the
medical patients (36.8%, 131) and surgical patients (31.7%,
consent was obtained from their parents. All patients have
113) while the rest were either obstetrics/gynecology patie-
the choice to whether or not they want to take part in this
nts (20.5%, 73) or pediatrics patients (11%, 39) (Table 1).
study. The study protocol and data collection instrument
were reviewed and approved by the University Hospital of Table 1. Socio-demographic characteristics of patients in the
teaching hospital of Monastir (Tunisia), December 2012 (n= 356)
Monastir Ethics Board.
Characteristics N (%)
Data collection method and procedure
Age (years)
Data were collected over a period of one month, December ≤40 162(45.5)
2012, using a questionnaire designed on the basis of litera- >40 194 (54.5)
Gender
ture8 and piloted on a sample of 20 patients to ensure face Male 143(40.2)
Female 213 (59.8)
validity and clarity. In view of the anticipated variance in Marital status
participant literacy, the questionnaire was administered by Married 281(78.9)
Not Married 75 (21.1)
four trained female nurses who were not part of the health Educational level*
care team. ≤ Primary 196 (60.1)
≥ Secondary 130 (39.9)
The questionnaire contained 38 items under 3 main sec- Occupation
Not employed 177 (44.8)
tions. Section I included demographic and socio-economic Employed 179 (55.2)
data (age, gender, nationality, marital status, educational Specialty/ Department
Medicine 131 (36.8)
level and occupation). Section II included 26 questions Surgery 113 (31.7)
Pediatrics 39 (11)
about patients’ acceptance regarding the involvement of Obstetrics/Gynecology 73 (20.5)
medical students in care process. To each question, the *Question for patients aged more than 6 years (n= 326)

202
Table 2. Patients’ acceptance to medical student in teaching hospital of Monastir, December 2012

Permit male Permit female Permit both genders Not to permit either
Items students only students only of students gender of students
n(%) n(%) n(%) n(%)
To read their medical file 7(2) 2(0.5) 331(93) 16(4.5)
To be present in outpatient 7(2) 3(0.8) 333(93.5) 13(3.7)
clinic
To attend the ward rounds 7(2) 2(0.6) 334(93.8) 13(3.7)
To be present in the 7(2) 5(1.4) 321(90.2) 23(6.4)
operation theatre
To be present in the 0(0) 37(18.7) 140(70.7) 21(10.6)
*
delivery room
To take medical history In the presence of a SD 7(2) 3(0.8) 332(93.3) 14(3.9)
Without the presence of a SD 6(1.7) 3(0.8) 314(88.2) 33(9.3)

To perform chest In the presence of a SD 1(0.3) 15(4.2) 322(90.4) 18(5.1)

auscultation Without the presence of a SD 0(0) 19(5.3) 284(79.8) 53(14.9)
To perform breast exam* In the presence of a SD 0(0) 38(19.2) 141(71.2) 19(9.6)
Without the presence of a SD 0(0) 31(15.7) 125(63.1) 42(21.2)
To perform abdominal In the presence of a SD 2(0.6) 23(6.4) 320(89.9) 11(3.1)
exam Without the presence of a SD 4(1.1) 25(7) 283(79.5) 44(12.4)
Vaginal examination* To perform 0(0) 50(25.3) 65(32.8) 83(41.9)
To observe doctor performing it 1(0.5) 64(32.3) 92(46.5) 41(20.7)
†
Digital rectal examination To perform 6(1.8) 52(14.5) 143(40.1) 155 (43.6)
To observe doctor performing it 6(1.8) 49(15.6) 126(39.7) 136 (42.9)
Repair of Episiotomy* To perform 0(0) 42(21.2) 66(33.3) 90(45.5)
To observe doctor performing it 0(0) 60(30.3) 96(48.5) 42(21.2)
Urinary catheterization To perform 18(5.1) 47(13.2) 138(38.7) 153(43)
To observe doctor performing it 15(4.2) 57(16) 214(60.1) 70(19.7)
To prescribe drugs 0(0) 1(0.3) 228(64) 127 (35.7)
To give drugs 0(0) 1(0.3) 284(79.8) 71(19.9)
To ensure follow-up visit 0(0) 2(0.6) 189(53.1) 165 (46.3)
in outpatient clinics
*Questions for non pediatric female patients (n=198); †Question for non pediatric patients (n= 317); SD= Supervisor Doctor

Table 3. Patients' acceptance of medical students reading their medical files, being present in outpatient clinic, attending ward rounds
and surgical intervention and taking medical history, in the teaching hospital of Monastir, December 2012 ( n= 317)

Be present in Attend ward Attend surgical Take medical history

Variables Read file
outpatient clinic round intervention With SD Without SD
n(%) p n(%) p n(%) p n(%) p n(%) p n(%) p
Gender 0.03 0.02 0.02 0.02 0.03 0.02
Male 105(88.2) 105(88.2) 105(88.2) 100(84) 105(88.2) 99(83.2)
Female 188(94.9) 189(95.5) 189(95.5) 183(92.4) 188(94.9) 182(91.9)
Age (years) 0.89 0.93 0.66 0.5 0.57 0.71
≤ 40 114(92.7) 114(92.7) 113(91.9) 108(87.8) 115(93.5) 108(87.8)
>40 179(92.3) 180(92.8) 181(93.3) 175(90.2) 178(91.8) 173(89.2)
Marital status 0.33 0.31 0.31 0.02 0.74 0.27
Married 261(92.9) 262(93.2) 262(93.2) 255(90.7) 260(92.5) 251(89.3)
Single 32(88.9) 32(88.9) 32(88.9) 28(77.8) 33(91.7) 30(83.3)
Educational level 0.92 0.78 0.87 0.67 0.74 0.9
≤ Primary 174(92.6) 175(93.1) 174(92.6) 169(89.9) 173(92) 167(88.8)
≥ Secondary 119(92.2) 119(92.2) 120(93) 114(88.4) 120(93) 114(88.4)
Professional status 0.53 0.66 0.66 0.66 0.14 0.91
Unemployed 129(93.5) 129(93.5) 129(93.5) 122(88.4) 131(94.9) 122(88.4)
Employed 164(91.6) 165(92.2) 165(92.2) 161(89.9) 162(90.5) 159(88.8)

Table 4. Patients' acceptance of medical students performing digital rectal examination, urethral catheterization and observing these
procedures done on them, in the teaching hospital of Monastir, December 2012 (n=317)
Digital rectal examination Urinary catheterization To perform abdominal exam
Variables To perform To observe To perform To observe With SD Without SD
n(%) p n(%) p n(%) p n(%) p n(%) p n(%) p
Gender 0.003 <10-3 0.004 <10-3 0.01 0.03
Male 60(50.4) 86(72.3) 61(51.3) 89(74.8) 113(95) 102(85.7)
Female 66(33.3) 92(46.5) 69(34.8) 94(47.5) 169(85.4) 150(75.8)
-3 -3
Age (years) 0.002 <10 0.001 <10 0.10 0.43
≤ 40 36(29.3) 54(43.9) 36(29.3) 56(45.5) 105(85.4) 95(77.2)
>40 90(46.4) 124(63.9) 94(48.5) 127(65.5) 177(91.2) 157(80.9)
Marital status 0.12 0.14 0.18 0.52 0.009 0.48
Married 116(41.3) 162(57.7) 119(42.3) 164(58.4) 255(90.7) 225(80.1)
Single 10(27.8) 16(44.4) 11(30.6) 19(52.8) 27(75) 27(75)
Educational level 0.02 0.14 0.006 0.13 0.52 0.87
≤ Primary 85(45.2) 112(59.6) 89(47.3) 115(61.2) 169(89.9) 150(79.8)
≥Secondary 41(31.8) 66(51.2) 41(31.8) 68(52.7) 113(87.6) 102(79.1)
Professional status 0.012 0.02 0.015 0.007 0.93 0.45
Unemployed 44(31.9) 67(48.6) 46(33.3) 68(49.3) 123(89.1) 107(77.5)
Employed 82(45.8) 111(62) 84(46.9) 115(64.2) 159(88.8) 145(81)

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Ben Salah et al.  Patients’ perspective on bedside teaching, Tunisia

Table 5. Patients' acceptance of medical students prescribing drugs, giving them drugs and ensuring follow up visit in outpatient clinics,
in the teaching hospital of Monastir, December 2012 ( n= 317)
To ensure follow-up visit in
To prescribe drugs To give drugs
Variables outpatient clinics
n(%) p n(%) p n(%) p
Gender 0.13 0.07 0.21
Male 73(61.3) 88(73.9) 74(62.2)
Female 138(69.7) 163(82.3) 109(55.1)
-3
Age (years) 0.09 0.86 < 10
≤ 40 75(61) 98(79.7) 51(41.5)
>40 136(70.1) 153(78.9) 132(68)
Marital status 0.99 0.82 0.52
Married 187(66.5) 223(79.4) 164(58.4)
Single 24(66.7) 28(77.8) 19(52.8)
Educational level 0.15 0.37 0.008
≤ Primary 131(69.7) 152(80.9) 120(63.8)
≥ Secondary 80 (62) 99(76.7) 63(48.8)
Professional status 0.66 0.30 0.19
Unemployed 90(65.2) 113(81.9) 74(53.6)
Employed 121(67.6) 138(77.1) 109(60.9)

Table 6. Female patients' acceptance of medical students being present in the delivery room, performing breast exam and observing
and performing vaginal exam and repair of episiotomy in the teaching hospital of Monastir, December 2012 (n=198)
being present in the Vaginal examination Repair of episiotomy performing breast exam
delivery room To perform To observe To perform To observe With SD Without SD
Variables
n(%) p n(%) p n(%) p n(%) p n(%) p n(%) p n(%) p

Age (years) 0.002 0.02 0.009 0.03 0.01 0.001 0.03

≤ 40 56(60.2) 23(24.7) 34(36.6) 24(25.8) 36(38.7) 56(60.2) 52(55.9)
>40 84(80) 42(40) 58(55.2) 42(40) 60(57.1) 85(81) 74(70.5)
Marital status 0.002 0.006 0.001 0.005 <10-3 0.002 0.01
Married 136(73.5) 65(35.1) 92(49.7) 66(35.7) 96(51.9) 137(74.1) 122(65.9)
Single 4(30.8) 0(0) 0(0) 0(0) 0(0) 4(30.8) 4(30.8)
Educational level 0.17 0.27 0.44 0.12 0.34 0.006 0.17
≤ Primary 87(74.4) 42(35.9) 57(48.7) 44(37.6) 60(51.3) 92(78.6) 79(67.5)
≥ Secondary 53(65.4) 23(28.4) 35(43.2) 22(27.2) 36(44.4) 49(60.5) 47(58)
Professional status 0.69 0.46 0.33 0.76 0.43 0.59 0.89
Unemployed 84(71.8) 36(30.8) 51(43.6) 38(32.5) 54(46.2) 85(72.6) 74(63.2)
Employed 56(69.1) 29(35.8) 41(50.6) 28(34.6) 42(51.9) 56(69.1) 52(64.2)

Patients’ reactions towards medical students examination and repairing episiotomy, while only about
Table 2 summarizes the patients’ reactions towards the 33% of them would accept that student perform these
presence of medical students in Teaching Hospitals. Of the procedures (Table 2).
patients interviewed, 93% (n= 331) permit both male and Several factors may explain patients’ reactions toward
female students to read their medical file. Also, the majority medical students. In fact, the patient’s gender was statisti-
of the participants agreed to allow them to be present in the cally associated to the acceptance of patients in allowing
outpatient clinic during consultation (93.5%, 333), in the medical students to read their medical files (p-value 0.03),
ward during ward rounds (93.8%, 334) and in the operation to be present in the outpatient clinic during consultation (p-
theatre during their surgical intervention (90.2%, 321). value 0.02) and in the ward during ward rounds (p-value
When female patients were asked about their acceptance 0.02), to attend their surgical intervention (p-value 0.02)
regarding the presence of medical students in the delivery and to take their medical history with or without the
room during childbirth, 10.6% of them (n= 21) refused male presence of the doctor (p-value 0.03 and 0.02 respectively).
and female students, 18.7% (n=37) agreed only about female Female patients were more likely to accept medical stu-
students while 70.7% (n=140) agreed about both genders of dents, regardless of their gender, than male patients
students to be present. Regarding clinical breast exam, (Table 3).
71.2% (n=141) approved to be examined by a medical The acceptance by patients to allow students to perform
student in the presence of a supervising doctor, while or observe some procedures being performed on them (as
63.1 % (n=125) approved the examination in the absence of digital rectal examination and urinary catheterization) was
a supervisor. The same applied to observing and performing found to be statically associated to patients’ gender, age and
procedures; more than 45% of women would permit both occupation (Table 4). Male patients, patients aged more
genders of students to observe doctor performing vaginal than 40 years and employed person revealed higher ac-
204
ceptance to students compared to women, patient aged toward medical students and particularly the attitude of
under 40 and unemployed patients. female patients toward male students5,13,14,23 which may lead
Regarding the question of patient acceptance that stu- to a poorer clinical experience for male students.24
dents ensure follow-up visit in outpatient clinics, age and As the degree of student involvement increased (from
educational level were significantly associated to it (Table observation to history taking to examination and proce-
5). Among female patients, a higher refusal rate was found dures), the refusal rate increased; especially when the parts
among women aged under 40 years old and single women examined were obviously sensitive (such as vaginal exami-
about accepting medical students to be present in the nation and digital rectal examination). This may be due to
delivery room during childbirth (p-value 0.02), to perform privacy-related concerns. Another common reason for
clinical breast exam with or without the presence of the objecting towards students’ involvement in physical exami-
supervisor and to observe or perform vaginal exam and nation, reported in the literature, was low confidence in
repair of episiotomy (Table 6). Table 6 shows also that medical students ‘skills to do a proper examination that
educational level was statically associated to the allowance detects findings8,24 which may explain the fact that the
of trainees to perform breast exam in the presence of a refusal rate was lower when an exam was performed by the
supervising doctor. student in the clinician’s supervision. This finding is con-
When asked about who is involved in their care process, sistent with other studies8,15,24,25 and matches with the
78.1% (n=278) answered that only doctors were treating results of Sayed-Hassan RM et al,5 who concluded that the
them, while 21.9% (n=78) thought that students were patient’s feeling of safety and comfort is correlated to the
involved too. In the question about the level of satisfaction presence of a supervisor.
by the care provided by medical students, 39% (n=139) of The study also revealed that patients ‘reaction towards
the patients answered that they were very satisfied, 54.2% medical students depends on certain characteristics of
(n=193) reported that they were satisfied and 6.8 % (n= 24) patients themselves (such as gender, age, marital status,
were either not satisfied or not satisfied at all. Most re- education level and occupation). Female patients showed
spondents (79.5%, 283) thought that the involvement of higher acceptance of both genders of medical students when
medical students improves the quality of health care, only asked about situations where there was a minimal direct
2% (n=7) thought that their presence worsens it and 18.8% contact with students. However, when significant disrobing
(n=67) believed that there is no relationship between quality and embarrassing examinations were performed (for
of care and students. example during digital rectal examination or urinary
catheterization), they were less likely than male patients to
Discussion accept students of either gender. This finding is in agree-
This study contributed to the understanding of Tunisian ment with that previously obtained by Shah-Khan M et al,10
patients ‘attitude towards the involvement of medical and by Shann S et al 9 and may be explained by the higher
students in their care. It showed a high level of patients’ sensitivity of women compared to men. On the other hand,
acceptability of the presence of medical students in Teach- patients with positive reaction towards the involvement of
ing Hospitals. This finding coincides with the results of students in pelvic examination and intimate procedures
other studies in the Arab World8,13-16 and in developed were likely to be older (≥ 40 years old) and to have lower
countries.3,17,18 Many possible reasons for this high allow- educational level. This could be because older patients are
ance were discussed in the literature, as the patients’ desire less likely to get embarrassed when exposed in front of
to contribute to medical education, the extra time that others, and patients who had lower educational level
physicians may spend with them, and the opportunity to believed that they had not the right to refuse medical
talk about their problem and to learn more about their students. However, in the study of Anfinan et al,14 and that
condition.5, 17, 19-22 of Shah-Khan et al,10 no significant association was observed
This positive reaction varied with the extent of involve- between patients‘ attitudes and their age or their educa-
ment of medical students in the care process. The highest tional level. The influence of marital status had been shown
levels of acceptability were found in situations where there only among women patients when asked about their reac-
is a minimal direct contact between patients and students; tion towards students’ involvement in breast and pelvic
such as reading medical files (93%, 331), being present in examination and procedures, and may be explained by the
outpatient clinic (93.5%, 333) and attending ward rounds fact that married women have an experience with gyneco-
(93.8%, 334).There was however, some reluctance to stu- logical examination.
dents’ presence during childbirth (70.7%, 140), pelvic Other studies have indicated that religion,11 economic
examination and procedures (such as digital rectal examina- level,5,26 severity of diagnoses10 and previous experiences
tion, urethral catheterization, vaginal examination etc.). with medical trainees2,3,27,28 may affect patients’ reaction
This finding has been documented in several studies espe- toward medical students. Besides, Saeed F et al26 has docu-
cially those conducted in Muslim countries where cultural mented that informing patients about the presence of
and religious issues might affect the attitude of patients student and obtaining their consent was associated with a

Int J Med Educ. 2015;6:201-207 205

Ben Salah et al.  Patients’ perspective on bedside teaching, Tunisia

positive attitude to be involved in teaching. In this study, multimedia programs (live demonstrations, slide shows,
only 21.9% of participants (n=78) thought that students computerized animations and videotapes), should be
were involved in their care which means that the majority of explored as possible tools to improve physical diagnosis
patients were not informed about the presence of medical skills.1,33 Although effective and safe, all these methods
students and therefore their consent was not obtained. This should be considered to address scenarios that most pa-
finding is in agreement with the result of O’Flynn N et al29 tients are unwilling to allow students to participate but not
who found that 28% of patients believed that they did not to replace bedside teaching.
have a choice about students presence and participation.
Limitations and strengths
Moreover, Sayad-Hassan RM et al,5 reported that more than
two thirds of patients were unaware of their right to refuse The important strength of this study is its originality. This
or accept the involvement of medical student, which repre- study is the first one in Tunisia that aims to assess the
sents an ethical issue given the mandatory nature of pa- patients’ acceptability of medical students in a Teaching
Hospital, in a country where medical education is based on
tients’ consent and its crucial role in establishing a positive
bedside teaching .Social desirability bias may be a limitation
patient and medical student relationship.13 Indeed, the
to our study. In fact, patients were surveyed while still
acceptance and willingness of patients to be involved in
hospitalized which could have influenced response rate and
clinical teaching should not be taken for granted. Instead,
answers. However, the questionnaire was administrated by
we should seek methods to promote patients’ cooperation.
nurses, who were not part of health care team members and
Communication is one of the strategic pillars on which we
who have informed patients that their answers would not
have to focus; by informing patients of the presence of the
affect the quality of care provided.
student and explaining to them his role and the degree of
We must also emphasize that the number of patients
his involvement, we can reduce their fear and convince
involved in bedside teaching the day of the interview was
them to accept to be involved in the teaching process.
unknown; nevertheless, we do not think that this can
Targeted messages should be delivered especially to single
influence the results since all patients had experienced
young women, people under 40 years old and well educated
bedside teaching during their hospital stay. In fact, every
patients who showed some reluctance to students’ involve-
day, all newly admitted patients undergo real case based
ment in physical examination and procedures. On the other
teaching.
hand, we should valorize patients’ role as educators; as they
have unique expertise derived from their experience of Conclusions
illness, disability or the effects of the social determinants of
In conclusion, Tunisian patients showed overall positive
health, important messages that cannot be taught to stu-
attitude towards bedside teaching. This attitude appeared to
dents from a textbook.30 In this context, an active involve-
be affected by patients’ characteristics (gender, age, educa-
ment of patients as educators is increasingly being recog-
tional level and marital status) and the extent of students’
nized as a powerful educational strategy for both patients
involvement in their care. Taking advantage of this attitude,
and learners. Bleakley and Bligh31 build on these concepts to
valorizing patients’ role as educators and using further
propose a radical overhaul of conventional doctor-led
learning methods in situations where patients’ consent for
medical education leading to an authentic patient-centred
student involvement was not obtained should be considered
model that shifts the locus of learning from the
to guarantee optimal care and safety to patients and good
relationship between doctor (as teacher) and student (as
medical education to future physicians.
learner) with patients playing a supportive role, to the
relationship between patient (as educator) and student Acknowledgements
(both as learner and co-educator) with the doctor-educator Authors would like to thank all teams in the University
playing a supportive role. Hospital of Monastir for their commitment and help.
However, in situations where patients’ consent for stu-
Conflict of Interest
dents involvement may not always be obtained, alternative
strategies should be sought to ensure that students develop The authors declare that they have no conflict of interest.
the required competencies; simulation using manikins and
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