Education and Service: Definitions Are the Easy Part

In this issue of the Journal of Graduate Medical Education, Galvin and Buys1 have performed a service (here is that word) by pointing out that we long have been misusing the word service in graduate medical education (GME). Properly, the word means doing good things for others. Thus, it evokes the best of medicine—compassionate care for our patients, tending to their needs even if it is inconvenient for ourselves, and understanding that we as a profession have broader responsibilities to our community and society as well as to our immediate patients. Yet, as an educational community we have long incorrectly used the term to connote exploitation. Small wonder that young physicians unfamiliar with the culture and context of medical education can be confused when they hear accreditors and policy makers use the term with a pejorative tone. The misuse of the term service is as old as GME. The first report on the subject, Graduate Medical Education,2 published in 1940, emphasized that internship and residency should be oriented toward education, not service. “The satisfactory internship should be primarily educational in character. … To this end, the intern's day should not be so occupied with service duties that he cannot find sufficient time for educational pursuits.”2(p267) Similarly, the next important report, Medical Schools in the United States at Mid-Century,3 published in 1953, sharply drew the distinction between education and service. “There has been a constant and continuing effort on the part of educational bodies to make the internship a truly educational experience. At the same time, the demand by the hospital for the services of interns has continually increased.”3(p267) And so it has gone through the present. Although the term service is clearly not the best, the linguistic problem is easily solved. We simply could substitute the term exploitation for service. This clearly is what medical educators from the beginning meant when they used the term service. They were referring to the panoply of duties necessary to patient care that can readily be done by nonphysicians and that add little of educational value to the residents' experience. As the authors wrote in Graduate Medical Education, “In improving the educational value of internships, hospitals must work out plans to relieve the intern from many routine procedures which he is now performing but which have relatively little educational value.”2(p59) And, “No intern should be asked to waste his valuable time serving as a high-class orderly in a hospital.”2(p90) Residents for generations have had their own term for this type of labor: scut work. I myself have been wondering about the advisability of adopting another term, perhaps exploitation, ever since Eric Holmboe of the American Board of Internal Medicine a year or two ago brought to my attention the fact that we have been misusing the term service, just as Galvin and Buys have done now. However, the term service is deeply ingrained in our educational culture, and I am not certain of the possibility, or even the desirability, of our finding another word, as long as the context makes clear that we are speaking of the economic exploitation of residents. What word to use is for the community of medical educators to decide. However, the problem of the economic exploitation of interns and residents remains extremely serious, regardless of which word we choose to use for it. In seeking to correct the problem, it may be helpful to keep certain points in mind. First, the problem is as old as GME itself and reflects the roots of the system. The modern residency, introduced by Osler and Halsted at the opening of The Johns Hopkins Hospital in 1889, grew in part out of the apprenticeship system.4 This very fact—that residency in some ways represented an institutionalized apprenticeship—made residents vulnerable to economic exploitation, much as medical preceptors of old had their apprentices clean the barn and feed the horses as part of their indenture. Second, true clinical education requires that most time be spent at the bedside, not in the classroom. One of the dangers of using the term education versus service is to forget the centrality of working with patients to learning medicine. Lectures, reading, conversation, and reflection are all essential, but as supplements to the experience gained at the bedside. Medical educators of the past knew this. To say that GME is educational in character “does not mean that a formal, didactic program should be carried on but rather that the atmosphere surrounding the intern should be educational.”2(p64) Some medical educators today have forgotten this fundamental educational principle. Third, some necessary clinical work is mundane. The most important educational principle in GME is the assumption of responsibility.5(pp90–92) This means, among other things, that if something is necessary for a resident's patient, the resident will do it, even if it is not really in the job description. Thus, responsible residents will wheel their acutely ill patients to the radiology department at 2 am themselves if a transport orderly is not available. How do we tell the difference between responsible patient care that is part of learning and scut work? By using common sense. It is one thing for residents to draw blood samples on their own patient if no phlebotomist is around. It is another for them to come in an hour or two early every morning to draw all of the blood ordered on all of the patients on the floor because the hospital does not wish to spend the money for a phlebotomy team. Last, relieving residents of noneducational burdens has never been easy and will not be now. Every step that might be taken in this direction will cost someone something in terms of time, money, or both. Faculty who provide more and better teaching, particularly in their supervision and one-on-one conversations with residents, will have less time for research or to be clinically productive, that is, to increase the clinical revenues they produce. (This offensive term symbolizes much of our present dilemma in medical education and health care.) To reduce nonprofessional chores like scheduling appointments, hospitals will have to hire more administrative staff. To reduce the inexcusably large patient load and work compression that has occurred—a problem noted by Glavin and Buys—more physicians or midlevel practitioners will be needed (and also a relaxation of current duty hour restrictions so that residents can stay a bit later if there is important work yet to be done). Nationwide, the Institute of Medicine in a recent report calculated that the cost of such changes would be $1.9 billion.6 We have long needed to do more to achieve a better education-service balance in GME. We have made some progress in recent years, but there is much more to be done.