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.

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