Resident Perceptions of Service Versus Clinical Education

摘要

What was known The Accreditation Council for Graduate Medical Education states that education needs to have priority over service in residents' assignments, but the definition of service is not clear.;What is new Semistructured interviews with residents revealed that education included patient care, teacher-learner interactions, and learning activities, whereas the category service encompassed tasks with little or no educational value, some patient care, and community service.;Limitations Small sample (9 residents) and the framing of the question may have resulted in respondents not addressing overlap between the categories.;Bottom line Residents used service to describe negative experiences that interfered with educational goals and positive experiences at the core of the profession's higher calling, contributing to definitional confusion around the term.;Service–noun 1. an act of helpful activity.1;Introduction The Accreditation Council for Graduate Medical Education (ACGME) surveys residents annually regarding their training experiences. A question on the 2010 survey asked, “How often has your clinical education been compromised by excessive service obligations?”2 A similar question on previous ACGME Resident Surveys (2007 and 2009) asked, “Do your rotations and other major assignments emphasize clinical education over any other concerns, such as fulfilling service obligations?”2 Both questions give a negative connotation to service and set up an oppositional framework of evaluating and categorizing training experiences, and figuring out how to define clinical education and service obligations is left to the interpretation of the survey respondent. Further, determining whether there is an appropriate balance in the residency program is necessarily dependent upon the resident's categorization scheme, and it is also subjective. To our knowledge, there are no accepted definitions or guidelines regarding the appropriate balance of clinical education and service in graduate medical education (GME). Yet, residency programs must somehow achieve this balance in the eyes of their residents, lest the programs be cited by their respective Residency Review Committees.3 This problem of balancing service and education was traced by medical education historians back to the early 20th century. Muller and colleagues4 propose that this problem originated in 1910 as an unintended consequence of Flexner's focus on science in medical education. Muller and colleagues4 argued that the focus on science shifted medical education to a natural science and away from a social endeavor focused on the human condition, and thereby marginalized the importance of service or voluntary health care to poor and underserved communities. Others argued the advent of GME in hospitals opened the door for exploitation of inexpensive trainee labor in the 1920s and 1930s and fostered an economic basis for emphasizing service over education.5 Efforts to examine, define, and restore the balance of service and education in specific residency training programs have been described by faculty in internal medicine, surgery, emergency medicine, and radiology.3,6–9 Although outcomes of the recent remedial efforts have not yet been made available, it is clear that service and education must first be defined, and it is likely that a component of these definitions will be specialty specific. Surgical and emergency medicine residents differed from their respective faculty in their assessments of educationally valuable experiences, and even upper-level surgical residents disagreed with lower-level surgical residents.3,6 Thus, to remediate perceived imbalances, we must first understand what our residents mean and how they have judged their educational experiences and categorize them as service versus education. The objective of this project was to understand how residents of one program in obstetrics and gynecology (Ob-Gyn) conceptualized service and clinical education in their daily