Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

Balancing Service and Education in Residency Training: A Logical Fallacy

Balancing Service and Education in Residency Training: A Logical Fallacy The system of residency training in the United States has at its core a perpetual tension between service and education. Graduate medical education (GME) is financed through prospective payments to teaching hospitals, where house officers compose a significant portion of the health care workforce. Numerous changes have occurred during the past 20 years that have put increasing pressure on this delicate balance. Radical transformation in the structure and process of GME training, most notably duty hour limitations, has led to compression of work, coupled with increasing emphasis on patient safety and quality. Hospitals have simultaneously undergone equally radical changes resulting from economic forces that have intensified pressure on faculty to increase clinical productivity to generate revenue. As a result, less time is available for faculty to teach and for trainees to learn. Creating a Shared Mental Model of Service and Education In 2014, Kesselheim et al1 surveyed program directors and trainees to measure their respective perceptions of the balance of service and education during training, noting significant differences. In contrast to their program directors, trainees consistently perceived an excess of service over education. In another study,2 surgical residents and attending faculty were asked to rate 27 common activities on a Likert-type scale, ranging from “pure service” to “pure education.” Considerable overlap existed among ratings in the middle of the continuum, and substantial variability occurred in estimates of time spent in service vs education across resident levels and rotations. Some residents considered fundamental tasks, such as speaking with families and other health care professionals, as extra work that does not contribute to their overall education.3 Educators have argued that service is an essential component of GME.4 These authors reason that medicine is a service profession and that a commitment to service is a hallmark of a humanistic physician. Therefore, they view service as education. As an explicit aim of GME, educators should clearly define the components of service and education with trainees and openly reaffirm the relevance of patient care service to future clinical positions.4 Determining What the Costs Are of Education-Oriented Teaching Services (and Whether We Can Afford Them) Consider the following statement by Ludmerer in The New England Journal of Medicine: “Every measure that might be taken to improve the learning environment carries a cost—whether it be paying for teaching time, hiring other physicians to see patients that the resident staff once saw or relieving residents from mundane chores by employing more phlebotomists and ward clerks. The critical issues become what value teaching hospitals will place on their educational missions and whether the requisite funds can be obtained.”5(p1338) Evidence suggests that residents spend up to 35% of their time in activities having marginal or no educational value, including paperwork beyond patient progress notes, transport of patients, and acquisition of laboratory results.6 Can these activities be eliminated from the resident workload? Would the use of medical scribes, laboratory czars, and couriers to offset that workload be a cost-effective strategy? To our knowledge, few studies have been conducted that measure the costs of teaching and weigh them against patient outcomes and learner satisfaction. McMahon et al7 studied the effect of an education-oriented teaching service vs a traditional hospital ward team. Trainees who participated in the education-oriented service reported higher satisfaction, spent more time in learning activities, and demonstrated no differences in patient quality measures. Participants reported significantly decreased workloads (3.5 vs 6.6 patients per intern), and their patients had shorter lengths of stay (4.1 vs 4.6 days) compared with the traditional team. Unfortunately, the researchers did not report the costs of the teaching service but suggested the “potential for financial savings as a result of the efficiencies gained.”7(p1310) One reviewer estimated the costs at an extra $1 million per year.8 Studies are needed that assess patient care outcomes, sustainability, and return on investment of such residency redesigns, focusing on which educational components have the greatest effect on transfer of learning to the bedside using an evidence-based approach. Without data, we have no evidence to support arguments that education-oriented activities (and dollars) will improve patient care. Optimizing Education in the Context of Service It is time to stop debating what has been called the logical fallacy of balancing these two equally important and undeniably intertwined activities of service and education and to begin to rethink, reimagine, and redesign our current apprenticeship model to optimize education in the context of service.9 The Institute of Medicine and others have called for changes in GME financing to best meet the nation’s health care needs.10,11 We believe that these changes alone are insufficient to make education more explicit in the training environment. We also realize that one size does not fit all. Therefore, our solutions focus on education-based guiding principles for transformation that we as educational leaders can influence. Adam Urbanski, PhD, president of the Rochester Teachers Association in New York, said: “Anybody who believes that all you have to do to be a good teacher is to love to teach also has to believe that all you have to do to be a good surgeon is to love to cut.”12 The first step in changing the training environment is to develop a standard for faculty on the front lines with learners. Based on our experience, the most junior physicians and inexperienced educators often provide the bulk of patient care and teaching. We contend that physicians who teach should demonstrate competency in the educational skills needed to enhance learning in the clinical setting. In 2009, a Council of Emergency Medicine Residency Directors working group issued a consensus statement of specific recommendations aimed at physician educators.3 Suggestions included having faculty (1) identify and capitalize on the “teachable moment” in every clinical encounter, (2) spend additional face time during seemingly mundane or rote activities and provide feedback on these tasks, and (3) teach best practices with regard to the electronic medical record. Physicians who are less skilled in teaching should be shifted to nonteaching services or should participate in professional development courses to improve their skills. Faculty on the education-oriented teaching service in the pilot study by McMahon et al7 were superior teachers and participated in ongoing faculty development meetings with the service director to optimize bedside teaching quality and learner feedback. Along with the suggestions above, programs should identify a core group of experienced faculty educators to serve as learning facilitators and clinical coaches using observation, feedback, and reflective learning throughout residency training. Models similar to that described by McMahon et al7 could be used for selected rotations with higher service demands or during high-acuity times of the year. In addition, master physician educators and residents should conduct peer reviews of clinical learning environments to uncover redundancies and inefficiencies and to identify the best teaching opportunities. Evidence-based teaching strategies, including spaced education,13 deliberate practice,14 and team-based learning, should be implemented to increase retention of material and application to practice. New technologies and principles of self-regulated learning (eg, the flipped classroom,15 just-in-time teaching, and virtual learning communities) should be leveraged to optimize educational opportunities. In tandem with these efforts, faculty should be rewarded and promoted for the quality and outcomes of their teaching. There is no easy answer to this dilemma, but without transparent discussions and evidence to support our decisions, we will keep treating the symptoms without curing the disease. By focusing on what each of us can do, we can optimize education in the context of service. This Viewpoint is being published to coincide with the publication of JAMA’s annual theme issue on medical education. Back to top Article Information Corresponding Author: Teri L. Turner, MD, MPH, MEd, Department of Pediatrics, Baylor College of Medicine, 6621 Fannin St, Ste 1540, Houston, TX 77030 (Teri.Turner@bcm.edu). Published Online: December 7, 2015. doi:10.1001/jamapediatrics.2015.3816. Conflict of Interest Disclosures: None reported. Additional Contributions: B. Lee Ligon, PhD (Center for Research, Innovation, and Scholarship in Medical Education, Texas Children’s Hospital), provided editorial support. Gordon E. Schutze, MD (Department of Pediatrics, Baylor College of Medicine), critically reviewed the article. No compensation was provided. References 1. Kesselheim JC, Sun P, Woolf AD, London WB, Boyer D. Balancing education and service in graduate medical education: data from pediatric trainees and program directors. Acad Med. 2014;89(4):652-657.PubMedGoogle ScholarCrossref 2. Reines HD, Robinson L, Nitzchke S, Rizzo A. Defining service and education: the first step to developing the correct balance. Surgery. 2007;142(2):303-310.PubMedGoogle ScholarCrossref 3. Quinn A, Brunett P. Service versus education: finding the right balance: a consensus statement from the Council of Emergency Medicine Residency Directors 2009 Academic Assembly “Question 19” working group. Acad Emerg Med. 2009;16(suppl 2):S15-S18.PubMedGoogle ScholarCrossref 4. Kesselheim JC, Cassel CK. Service: an essential component of graduate medical education. N Engl J Med. 2013;368(6):500-501.PubMedGoogle ScholarCrossref 5. Ludmerer KM. Redesigning residency education: moving beyond work hours. N Engl J Med. 2010;362(14):1337-1338.PubMedGoogle ScholarCrossref 6. Boex JR, Leahy PJ. Understanding residents’ work: moving beyond counting hours to assessing educational value. Acad Med. 2003;78(9):939-944.PubMedGoogle ScholarCrossref 7. McMahon GT, Katz JT, Thorndike ME, Levy BD, Loscalzo J. Evaluation of a redesign initiative in an internal-medicine residency. N Engl J Med. 2010;362(14):1304-1311.PubMedGoogle ScholarCrossref 8. Wachter B. Show me the money: can we afford education-oriented residency programs?http://community.the-hospitalist.org/2010/04/08/show-me-the-money-can-we-afford-education-oriented-residency-programs/. Accessed September 29, 2015. 9. Cochran A. Asking (and answering) the wrong questions? comment on “Service or Education.” Arch Surg. 2011;146(12):1395-1396.PubMedGoogle ScholarCrossref 10. Committee on the Governance and Financing of Graduate Medical Education, Institute of Medicine. Graduate Medical Education That Meets the Nation’s Health Needs. Washington, DC: National Academies Press; 2014. 11. Ludmerer KM, Johns MM. Reforming graduate medical education. JAMA. 2005;294(9):1083-1087.PubMedGoogle ScholarCrossref 12. Mansnerus L. A promotion for Mr. Chips. The New York Times. http://www.nytimes.com/1993/11/07/education/a-promotion-for-mr-chips.html?module=Search&mabReward=relbias%3Aw. Published November 7, 1993. Accessed October 29, 2015. 13. Kerfoot BP, Baker HE, Koch MO, Connelly D, Joseph DB, Ritchey ML. Randomized, controlled trial of spaced education to urology residents in the United States and Canada. J Urol. 2007;177(4):1481-1487.PubMedGoogle ScholarCrossref 14. Ericsson KA. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med. 2004;79(10)(suppl):S70-S81.PubMedGoogle ScholarCrossref 15. Moffett J. Twelve tips for “flipping” the classroom. Med Teach. 2015;37(4):331-336.PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Pediatrics American Medical Association

Balancing Service and Education in Residency Training: A Logical Fallacy

JAMA Pediatrics , Volume 170 (2) – Feb 1, 2016

Loading next page...
 
/lp/american-medical-association/balancing-service-and-education-in-residency-training-a-logical-790Z1WPcY9
Publisher
American Medical Association
Copyright
Copyright © 2016 American Medical Association. All Rights Reserved.
ISSN
2168-6203
eISSN
2168-6211
DOI
10.1001/jamapediatrics.2015.3816
Publisher site
See Article on Publisher Site

Abstract

The system of residency training in the United States has at its core a perpetual tension between service and education. Graduate medical education (GME) is financed through prospective payments to teaching hospitals, where house officers compose a significant portion of the health care workforce. Numerous changes have occurred during the past 20 years that have put increasing pressure on this delicate balance. Radical transformation in the structure and process of GME training, most notably duty hour limitations, has led to compression of work, coupled with increasing emphasis on patient safety and quality. Hospitals have simultaneously undergone equally radical changes resulting from economic forces that have intensified pressure on faculty to increase clinical productivity to generate revenue. As a result, less time is available for faculty to teach and for trainees to learn. Creating a Shared Mental Model of Service and Education In 2014, Kesselheim et al1 surveyed program directors and trainees to measure their respective perceptions of the balance of service and education during training, noting significant differences. In contrast to their program directors, trainees consistently perceived an excess of service over education. In another study,2 surgical residents and attending faculty were asked to rate 27 common activities on a Likert-type scale, ranging from “pure service” to “pure education.” Considerable overlap existed among ratings in the middle of the continuum, and substantial variability occurred in estimates of time spent in service vs education across resident levels and rotations. Some residents considered fundamental tasks, such as speaking with families and other health care professionals, as extra work that does not contribute to their overall education.3 Educators have argued that service is an essential component of GME.4 These authors reason that medicine is a service profession and that a commitment to service is a hallmark of a humanistic physician. Therefore, they view service as education. As an explicit aim of GME, educators should clearly define the components of service and education with trainees and openly reaffirm the relevance of patient care service to future clinical positions.4 Determining What the Costs Are of Education-Oriented Teaching Services (and Whether We Can Afford Them) Consider the following statement by Ludmerer in The New England Journal of Medicine: “Every measure that might be taken to improve the learning environment carries a cost—whether it be paying for teaching time, hiring other physicians to see patients that the resident staff once saw or relieving residents from mundane chores by employing more phlebotomists and ward clerks. The critical issues become what value teaching hospitals will place on their educational missions and whether the requisite funds can be obtained.”5(p1338) Evidence suggests that residents spend up to 35% of their time in activities having marginal or no educational value, including paperwork beyond patient progress notes, transport of patients, and acquisition of laboratory results.6 Can these activities be eliminated from the resident workload? Would the use of medical scribes, laboratory czars, and couriers to offset that workload be a cost-effective strategy? To our knowledge, few studies have been conducted that measure the costs of teaching and weigh them against patient outcomes and learner satisfaction. McMahon et al7 studied the effect of an education-oriented teaching service vs a traditional hospital ward team. Trainees who participated in the education-oriented service reported higher satisfaction, spent more time in learning activities, and demonstrated no differences in patient quality measures. Participants reported significantly decreased workloads (3.5 vs 6.6 patients per intern), and their patients had shorter lengths of stay (4.1 vs 4.6 days) compared with the traditional team. Unfortunately, the researchers did not report the costs of the teaching service but suggested the “potential for financial savings as a result of the efficiencies gained.”7(p1310) One reviewer estimated the costs at an extra $1 million per year.8 Studies are needed that assess patient care outcomes, sustainability, and return on investment of such residency redesigns, focusing on which educational components have the greatest effect on transfer of learning to the bedside using an evidence-based approach. Without data, we have no evidence to support arguments that education-oriented activities (and dollars) will improve patient care. Optimizing Education in the Context of Service It is time to stop debating what has been called the logical fallacy of balancing these two equally important and undeniably intertwined activities of service and education and to begin to rethink, reimagine, and redesign our current apprenticeship model to optimize education in the context of service.9 The Institute of Medicine and others have called for changes in GME financing to best meet the nation’s health care needs.10,11 We believe that these changes alone are insufficient to make education more explicit in the training environment. We also realize that one size does not fit all. Therefore, our solutions focus on education-based guiding principles for transformation that we as educational leaders can influence. Adam Urbanski, PhD, president of the Rochester Teachers Association in New York, said: “Anybody who believes that all you have to do to be a good teacher is to love to teach also has to believe that all you have to do to be a good surgeon is to love to cut.”12 The first step in changing the training environment is to develop a standard for faculty on the front lines with learners. Based on our experience, the most junior physicians and inexperienced educators often provide the bulk of patient care and teaching. We contend that physicians who teach should demonstrate competency in the educational skills needed to enhance learning in the clinical setting. In 2009, a Council of Emergency Medicine Residency Directors working group issued a consensus statement of specific recommendations aimed at physician educators.3 Suggestions included having faculty (1) identify and capitalize on the “teachable moment” in every clinical encounter, (2) spend additional face time during seemingly mundane or rote activities and provide feedback on these tasks, and (3) teach best practices with regard to the electronic medical record. Physicians who are less skilled in teaching should be shifted to nonteaching services or should participate in professional development courses to improve their skills. Faculty on the education-oriented teaching service in the pilot study by McMahon et al7 were superior teachers and participated in ongoing faculty development meetings with the service director to optimize bedside teaching quality and learner feedback. Along with the suggestions above, programs should identify a core group of experienced faculty educators to serve as learning facilitators and clinical coaches using observation, feedback, and reflective learning throughout residency training. Models similar to that described by McMahon et al7 could be used for selected rotations with higher service demands or during high-acuity times of the year. In addition, master physician educators and residents should conduct peer reviews of clinical learning environments to uncover redundancies and inefficiencies and to identify the best teaching opportunities. Evidence-based teaching strategies, including spaced education,13 deliberate practice,14 and team-based learning, should be implemented to increase retention of material and application to practice. New technologies and principles of self-regulated learning (eg, the flipped classroom,15 just-in-time teaching, and virtual learning communities) should be leveraged to optimize educational opportunities. In tandem with these efforts, faculty should be rewarded and promoted for the quality and outcomes of their teaching. There is no easy answer to this dilemma, but without transparent discussions and evidence to support our decisions, we will keep treating the symptoms without curing the disease. By focusing on what each of us can do, we can optimize education in the context of service. This Viewpoint is being published to coincide with the publication of JAMA’s annual theme issue on medical education. Back to top Article Information Corresponding Author: Teri L. Turner, MD, MPH, MEd, Department of Pediatrics, Baylor College of Medicine, 6621 Fannin St, Ste 1540, Houston, TX 77030 (Teri.Turner@bcm.edu). Published Online: December 7, 2015. doi:10.1001/jamapediatrics.2015.3816. Conflict of Interest Disclosures: None reported. Additional Contributions: B. Lee Ligon, PhD (Center for Research, Innovation, and Scholarship in Medical Education, Texas Children’s Hospital), provided editorial support. Gordon E. Schutze, MD (Department of Pediatrics, Baylor College of Medicine), critically reviewed the article. No compensation was provided. References 1. Kesselheim JC, Sun P, Woolf AD, London WB, Boyer D. Balancing education and service in graduate medical education: data from pediatric trainees and program directors. Acad Med. 2014;89(4):652-657.PubMedGoogle ScholarCrossref 2. Reines HD, Robinson L, Nitzchke S, Rizzo A. Defining service and education: the first step to developing the correct balance. Surgery. 2007;142(2):303-310.PubMedGoogle ScholarCrossref 3. Quinn A, Brunett P. Service versus education: finding the right balance: a consensus statement from the Council of Emergency Medicine Residency Directors 2009 Academic Assembly “Question 19” working group. Acad Emerg Med. 2009;16(suppl 2):S15-S18.PubMedGoogle ScholarCrossref 4. Kesselheim JC, Cassel CK. Service: an essential component of graduate medical education. N Engl J Med. 2013;368(6):500-501.PubMedGoogle ScholarCrossref 5. Ludmerer KM. Redesigning residency education: moving beyond work hours. N Engl J Med. 2010;362(14):1337-1338.PubMedGoogle ScholarCrossref 6. Boex JR, Leahy PJ. Understanding residents’ work: moving beyond counting hours to assessing educational value. Acad Med. 2003;78(9):939-944.PubMedGoogle ScholarCrossref 7. McMahon GT, Katz JT, Thorndike ME, Levy BD, Loscalzo J. Evaluation of a redesign initiative in an internal-medicine residency. N Engl J Med. 2010;362(14):1304-1311.PubMedGoogle ScholarCrossref 8. Wachter B. Show me the money: can we afford education-oriented residency programs?http://community.the-hospitalist.org/2010/04/08/show-me-the-money-can-we-afford-education-oriented-residency-programs/. Accessed September 29, 2015. 9. Cochran A. Asking (and answering) the wrong questions? comment on “Service or Education.” Arch Surg. 2011;146(12):1395-1396.PubMedGoogle ScholarCrossref 10. Committee on the Governance and Financing of Graduate Medical Education, Institute of Medicine. Graduate Medical Education That Meets the Nation’s Health Needs. Washington, DC: National Academies Press; 2014. 11. Ludmerer KM, Johns MM. Reforming graduate medical education. JAMA. 2005;294(9):1083-1087.PubMedGoogle ScholarCrossref 12. Mansnerus L. A promotion for Mr. Chips. The New York Times. http://www.nytimes.com/1993/11/07/education/a-promotion-for-mr-chips.html?module=Search&mabReward=relbias%3Aw. Published November 7, 1993. Accessed October 29, 2015. 13. Kerfoot BP, Baker HE, Koch MO, Connelly D, Joseph DB, Ritchey ML. Randomized, controlled trial of spaced education to urology residents in the United States and Canada. J Urol. 2007;177(4):1481-1487.PubMedGoogle ScholarCrossref 14. Ericsson KA. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med. 2004;79(10)(suppl):S70-S81.PubMedGoogle ScholarCrossref 15. Moffett J. Twelve tips for “flipping” the classroom. Med Teach. 2015;37(4):331-336.PubMedGoogle ScholarCrossref

Journal

JAMA PediatricsAmerican Medical Association

Published: Feb 1, 2016

Keywords: quality of care,costs,academic medical centers,education, medical, graduate,medical faculty,financial support,teaching hospitals,internship and residency,learning,pediatrics,training support,teaching,electronic medical records,patient safety,service-learning,work schedules

References