Article review: Service versus education

It's a busy day in the Emergency Department and there are 5 new patients to be seen. The waiting room is overflowing. As the attending, you are getting barraged with a million questions to answer and problems to fix.

There is also a case of a full-thickness burn patient going to the OR in the next few minutes. She'd be a perfect teaching case for the residents.

Should I have the residents go see the new patients, or should I pull them all aside to show them the physical findings and teach about burns for 5-10 minutes?

I constantly struggle with this day-to-day balancing act in the Emergency Department. What's the answer? It depends on how sick ED patients are that day and whether there are active clinical issues, which require my personal attention.

When I'm on the fence (and honestly feeling lazy) about teaching, I think about how much more efficient it would be to do group-teaching, rather than teaching 4 residents individually over the next few weeks on the same topic. This usually sways me towards doing a quick teaching session, especially if it involves showing them an abnormal physical exam finding.

Interestingly, this topic of SERVICE vs EDUCATION comes up in the annual ACGME resident survey (question #19) which asks residents:
  • Do your rotations and other major assignments emphasize clinical education over any other concerns, such as fulfilling service obligations?
The EM Residency Review Committee (RRC) has noted that 30% of residency programs are cited because some of their residents answered this question with "never" or "sometimes". Both of these choices are considered a negative response.

In an article by Quinn and Burnett, they summarize a consensus statement from the 2009 Council of Residency Directors (CORD) Academic Assembly. It was published in the inaugural educational supplement in Academic Emergency Medicine. Similar to how JAMA has an annual medical education supplement, AEM also now has an educational supplement, sponsored by CORD.

Here are the bottom-line summary points:
  1. Clinical service is a critical component of training because residency is essentially an apprenticeship at some level. More studies are needed to determine what the correct balance should be between service and education.
  2. The phrasing of the question is vague and "service obligations" could be interpreted in many ways by residents. I'm still a little unclear about what it means myself. Does the question merely mean that residents are being asked to see patients and take call? Or that residents are being asked to miss conference in order to help see more patients? Or that residents are constantly being asked to do only scut work without any educational value?
  3. Residents should be reminded that many things have educational value during their training. So things like talking with consultants and chart documentation are essential educational competencies, specifically in the area of interpersonal communication and professionalism, respectively.
  4. Faculty should attend faculty development workshops to improve their ability to identify and optimize the "teachable moments".

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:S15–S18.
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