Balancing service and education: improving internal medicine residencies in the managed care era

Service vs education: situational and perceptional differences in surgery residency

OBJECTIVE

This study determined whether situational or perceptional differences exist when trying to define what constitutes "service" and "education" in surgery residency in relation to the Accreditation Council of Graduate Medical Education (ACGME) survey.

DESIGN

An institutional review board-approved, single institute, cross-sectional study was conducted through a survey. Participants were asked to rate common resident tasks. Participants were also asked general questions regarding "service" and "education."

SETTING

Wright State University surgery program, Dayton, OH.

PARTICIPANTS

The study included 69 participants, which included medical students (19), residents (26), nurses/advanced practitioners (14), and attending surgeons (10).

RESULTS

A significantly high number of attending surgeons reported that writing a history and physical examination is educational compared with residents and students. Similar results were found regarding talking with patients/families. Drawing blood and starting peripheral intravenous access were universally rated as service tasks. For laparoscopic cholecystectomy, when the resident had done one previously, it was universally thought educational. When the resident had done more, most attending surgeons thought the task educational, but residents and students thought it much less educational. When analyzing only residents, in talking with families, most interns rated this as service, whereas postgraduate years 2 and 3 reported it as more educational and postgraduate years 4 and 5 ranked it equally as service and educational. Similar results were seen in answering nursing phone calls and writing admission orders. Residents (88%) and attending surgeons (90%) agreed that service is part of residency training. Only 40% of residents, however, stated they know what the term "service" means in regard to the ACGME survey. Overall, 80% of attending surgeons and 44% of residents agree that "service" has not been well defined by the ACGME.

CONCLUSIONS

Situational and perceptional differences do exist regarding "service" and "education" in our program, and most participants are unclear about the terms. As the definitions are situational and change with the person queried, then should this be the ACGME standard to assess programs and issue citations?

Competency is not enough: integrating identity formation into the medical education discourse

Despite the widespread implementation of competency-based medical education, there are growing concerns that generally focus on the translation of physician roles into "measurable competencies." By breaking medical training into small, discrete, measurable tasks, it is argued, the medical education community may have emphasized too heavily questions of assessment, thereby missing the underlying meaning and interconnectedness of how physician roles shape future physicians. To address these concerns, the authors argue that an expanded approach be taken that includes a focus on professional identity development. The authors provide a conceptual analysis of the issues and language related to a broader focus on understanding the relationship between the development of competency and the formation of identities during medical training. Including identity alongside competency allows a reframing of approaches to medical education away from an exclusive focus on "doing the work of a physician" toward a broader focus that also includes "being a physician." The authors consider the salient literature on identity that can inform this expanded perspective about medical education and training.

Relationship between resident workload and self-perceived learning on inpatient medicine wards: a longitudinal study

BACKGROUND

Despite recent residency workload and hour limitations, little research on the relationship between workload and learning has been done. We sought to define residents' perceptions of the optimal patient workload for learning, and to determine how certain variables contribute to those perceptions. Our hypothesis was that the relationship between perceived workload and learning has a maximum point (forming a parabolic curve): that either too many or too few patients results in sub-optimal learning.

METHODS

Residents on inpatient services at two academic teaching hospitals reported their team and individual patient censuses, and rated their perception of their learning; the patient acuity; case variety; and how challenged they felt. To estimate maximum learning scores, linear regression models with quadratic terms were fit on learning score.

RESULTS

Resident self-perceived learning correlated with higher acuity and greater heterogeneity of case variety. The equation of census versus learning score, adjusted for perception of acuity and case mix scores, showed a parabolic curve in some cases but not in others.

CONCLUSION

These data suggest that perceived resident workload is complex, and impacted by additional variables including patient acuity and heterogeneity of case variety. Parabolic curves exist for interns with regard to overall census and for senior residents with regard to new admissions on long call days.

Academic health centers and public health departments: partnership matters

BACKGROUND

The Institute of Medicine has called for increased population-based training for healthcare professions students, and particularly medical students. For this to be effective, students should receive such training in the locations where population-based approaches to care take place, such as public health departments (HDs). However, little is known about currently existing relationships between academic health centers (AHCs) and HDs.

METHODS

During the spring and summer of 2003, e-mail surveys on this topic were sent to the 104 members of the Association of Academic Health Centers, and 500 members of the National Association of City and County Health Officers and the Association of State and Territorial Health Officers. Results were received from 50 AHCs and 201 HDs.

RESULTS

Survey results suggest that large numbers of healthcare professions students--residents, medical students, and others--are currently being trained in many HDs nationwide. The web of relationships between AHCs and HDs extends beyond education into research, service, and other purposes.

CONCLUSIONS

These preliminary results require verification. Nevertheless, they raise questions about the types and quality of the education being offered in health departments, the impact of AHC/HD relationships on both parties, and how existing relationships may be enhanced to meet current and future national needs.