NEJM commentary on service in medical education – They got it wrong.

Last week there was a very interesting perspective/editorial published in the NEJM. But one that I thought deserves some comment because I strongly disagreed with the authors. In fact, I thought it was unfortunate to see this commentary in such a widely read journal.

The title was “Service: An Essential Component of Graduate Medical Education“. It was authored by two Boston physicians (both appear to be oncologists). The authors outline their concern that service should be seen as an educational objective that shouldn’t be minimized, instead “resident duties that confer a high degree of service may still provide high educational value, in the form of genuine experience with patient care”. In essence they argue that seeing any/all patients is a learning opportunity! We will often joke about this on a shift when there’s a patient that likely won’t be a valuable learning experience for the trainee. I would agree that learning probably can gained from most patient interactions however, the quality and the yield may very often be low. Plus rather than subscribe to these authors’ belief  any patient presents learning opportunities and service should be viewed as learning, we should recognize that different learners have different needs. I would argue that in the emergency department, a surgery intern may gain very little from seeing a patient with chronic back pain that is seeking opiates and has considerable behavior issues. Patients like this can be challenging and often provide little learning especially when there are other patients to see. For instance, it’s very possible there’s a patient that needs to be seen that will better fulfill the pre-defined objectives of the surgery intern. However, this patient may be useful for the senior emergency medicine resident to manage as such patients will be their responsibility once they’re staff.

The authors then provide several examples of “service” which I found quite interesting.  One which particularly caught my attention…”A family practice resident misses a teaching conference in order to see her last clinic patient, who arrives late because of transportation problems“. They argue that a “didactic” teaching session is not nearly as valuable as seeing that final patient in clinic! I think this sets a dangerous precedent. Residents/trainees should not be made to miss preestablished learning opportunities for service. Whatever this “teaching session” is, it’s been integrated into the curriculum such that the resident can work towards achieving competence in their field. There may be exceptions but as a rule I would advocate against this mindset.

We have begun to move towards a competency-based approach to medical education with a set of competencies laid out for residents to achieve by the end of their training. As they work towards these competencies, there’s no doubt that they’ll be doing “service” and “less valuable” tasks but to think that simply seeing patients and doing scut work is valuable because you never know when that little piece of learning may occur is wrong.

The final words of the authors addressed the aspect of competency-based education head on: “many medical educators have worked to optimize the educational value of residency and protect trainees from engaging in menial activities from which they do not learn. As such reform continues, however, it risks going too far and sacrificing certain essential educational experiences that can emerge from service activities, as well as the opportunity to teach trainees about service’s importance to the profession”

Overall  the author’s argument came across as annoyed staff physicians who were having to do their own work and no longer being able to pawn it off on their residents.

In general, I strongly disagreed with the authors’ argument. In an era in medical education when time has become a commodity and duty hour restrictions have become reality, we must continue on the path towards ensuring trainees are competent based on pre-defined learning objectives. We should seek efficient and high yield methods for trainees to learn. To continue forcing a resident to do dictations for the same thing over and over simply because they need to learn the value of service seems to go against this approach. It will not help trainees become better doctors and as a result our patients will suffer. And as most of us agree, we became physicians to become experts in patient care and help those who can’t help themselves.

5 thoughts on “NEJM commentary on service in medical education – They got it wrong.

  1. Excellent commentary on service vs learning. As a resident, I understand that service is a large part of our training, but to think that all service is good learning is out of touch with reality. Times have changed, and there is more to learn in less time when compared to the previous generation.

    • Thanks for checking out the post! It’s a challenging issue and as we both agree, time limits our ability to be service-based. One of my staff in Canada posted a great comment below so I encourage you to check it out. I push the argument harder towards competency-based education while he (perhaps) brings me back to reality. Though there should be some balance – my issue however was with the authors who were providing what I felt to be inappropriate examples and overall neglecting key aspects of medical education.

  2. Nice post, big man. Provocative as always.

    I think the authors have at least a few things right here, and you have at least a few things wrong. But on the aggregate, there are valid points on both sides.

    Some caveats:

    1. I am only 3 years out from being a resident myself
    2. I’m rather pro-meded, #FOAMed, progressive learning, learner-centred techniques, etc.
    3. I think EDs, like other areas, should be able to function just fine without house-staff — if they can’t, that’s the department’s issue (not the learners)

    But I’m wary of the competency-based framework. I don’t believe expertise is achieved vis-a-vis completing a checklists of tasks and experiences. I believe in the nuances of our work, the value of strong mentorship, the benefits of being pushed, tested, challenged just a bit beyond one’s comfort zone — as my best mentors did to me when I was a senior resident. The value of repeated exposure towards the development of expertise, and a rich illness script [see: Reason, Klein, Chase and Simon, Elstein, Shulman and Sprathka — and yes, viva la simulation!]. These are not factors that are easily accommodated by the CBL framework. I worry that a pure competency-based model, especially for the ED, a learner could skip over the next three charts in the pile in order to jump to a presentation that they haven’t seen yet/still need a tick box for. I think that’s fine for an off-service PGY-1 who just wants to learn to suture before going off to live a long and prosperous career as a pathologist — but the real challenge for a PGY-5 would be to manage the next three patients, review with their house-staff, handle queries form nursing and other services, AND get to that interesting presentation lying in wait, 3 charts down the queue.

    Do I ask residents to fill out WSIB forms? Follow up on x-rays and micro callbacks while on shift? See volume at the expense of learning? Suck it up to the drudgery of minor when there’s an awesome trauma resuscitation going on just down the hall? Sink or swim when the sh*t is hitting the fan, with no prospects for your staff backing you up in the 11th hour? No. Absolutely not.

    What I *do* try to foster though is that, for senior residents in particular, it is important to understand how all of these elements will need to be accommodated in their future practice as the boss. How those tedious admin decisions are made without sacrificing too much clinical time. How to get to that fun resuscitation then come back and pick up the slack when the volume starts to pile up. We have to be cautious not to over-protect our learners (and yes, I too am still a learner; we all hold this designation until we retire) from some of the realities of independent practice — else being an EM staff will actually seem *a lot harder* than being a PGY-5. If that’s the case, we haven’t done our job as supervisors and mentors.

    Anyway, just my $0.02. Or perhaps I’m just an old born-in-the-70s curmudgeon who’s totally lost the plot.


    • I can see your grey hairs are coming out nicely! But the reply is great, thanks for your thoughts. I think while I may have pushed my point of view further to ensure that it was provocative. Reading your post I think we agree on most things. I would favor the CBL perhaps more than you do but Chris, you can’t be right all the time! But overall, I think you point out that service can be nicely titrated to the learning needs of each resident. And your post articulates well how clinicians should view and approach service/learning with trainees. I took issue with the authors with several of their examples and their strong opinion which I think failed to recognize/acknowledge the new challenges in medical education.

  3. Love the discussion!

    Just to play devil’s advocate Hick’s – who’s to say a competency-based framework can’t incorporate repeated exposures (i.e. the milestone could be something in line with “the learner will see and primarily manage 50 patients with low back pain over the course of a rotation”) or departmental management (“the learner develops the ability to adapt to changing departmental states and flow”), etc.?

    All of what you say is important but could be incorporated into a CBE framework. Couldn’t it?

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