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Balancing Clinical Service and Education in the Radiology Residency
Balancing Clinical Service and Education in the Radiology Residency1 Brady K. Huang, MD, Meghan Lubner, MD, Charles S. Resnik, MD
Rationale and Objectives. Among the various medical disciplines, the radiology residency faces unique challenges when balancing clinical service and education, which have not been explored in the literature. Materials and Methods. The authors present a summary of material generated during collaborative sessions at the 56th Annual Meeting of the Association of University Radiologists in Seattle, Washington, in March 2008, including strategies on maintaining an appropriate emphasis on education in the face of increasing service obligations, with a review of the pertinent literature. Results. Although the topic of service and education has been explored in the medical and surgical literature, little has been published in the radiology literature. The portability of radiology and the relative lack of patient contact can lead to the redistribution of residents as a matter of convenience to fill service gaps, often at the expense of the educational goals of training programs. Residents and faculty members alike must take part in both service and educational obligations without compromising patient care. Physician extenders, call schedule optimization, and other strategies and resources can help ensure that a proper balance is maintained. Conclusion. The radiology residency presents unique challenges to the service and education balance. The authors highlight several strategies to address these challenges. Key Words. Graduate medical education; residents; service; education. ª AUR, 2009
Balancing service and education in residency training programs is a difficult task facing program directors and clinical faculty members. Although some of these challenges are common across the various specialties of graduate medical education, there are aspects that are unique to radiology. Some of these factors include the portability of radiology as a service and the relative lack of continuity of patient care. Although the service versus education debate has been explored in the surgical and internal medicine literature (1–5), the radiology literature has not addressed these issues, which become more pressing in the face of increasing demands to Acad Radiol 2009; 16:1161–1165 1 From the Department of Imaging Sciences, University of Rochester Medical Center, 601 Elmwood Avenue, Box 648, Rochester, NY 14642 (B.K.H.); the Department of Radiology, University of Wisconsin–Madison, Madison, WI (M.L.); and the Department of Radiology, University of Maryland School of Medicine, Baltimore, MD (C.S.R.). Received January 30, 2009; accepted March 5, 2009. Address correspondence to: B.K.H. e-mail: bradyhuang@ gmail.com
ª AUR, 2009 doi:10.1016/j.acra.2009.03.005
provide faster and more efficient service. Duty-hour restrictions also have the potential to significantly affect the balance of service and education. DISCUSSION To begin to discuss service and education, these concepts must be better defined. Merriam-Webster’s Collegiate Dictionary (6) lists several definitions of ‘‘service,’’ including ‘‘the occupation or function of serving,’’ ‘‘contribution to the welfare of others,’’ ‘‘a helpful act,’’ and ‘‘useful labor that does not produce a tangible commodity.’’ ‘‘Education’’ also has several definitions: ‘‘the action or process of educating or of being educated’’ or ‘‘the knowledge and development resulting from an educational process.’’ The term ‘‘service’’ implies a recipient who benefits from the service provided, without little if any benefit to the provider. In contrast, ‘‘education’’ implies a two-way exchange between a teacher and learner, which ultimately prepares the learner for future careers and opportunities.
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Unfortunately, these two concepts are difficult to define individually in the context of graduate medical education. The distinction is blurred because resident activities encompass a combination of both service and education. In the apprenticeship model of graduate medical education, service activities can be educational for trainees. However, the perceptions of these activities vary from the resident to faculty levels, as well as with the training level of residents. The concept of resident service arises from the dual role of residents both as trainees and as employees of their institutions. Residents have obligations to their patients, their hospitals, and their senior physicians. This concept has not been formally examined in the radiology literature but has been studied in the surgical and medical literature (1–5).
Review of the Literature The more recent interest in this discussion has been related to work-hour restrictions by the Accreditation Council for Graduate Medical Education (ACGME) on surgical training programs. Programs have had to find creative ways to maximize education in the face of these guidelines. Reines et al (1) explored this by surveying 125 surgical residents and 71 surgical faculty members across eight institutions and found that faculty members and residents agreed on the educational value of most activities. However, 40% of residents felt that more than half of their time was spent in pure service, significantly more than the 10% of faculty members who shared this sentiment. Twenty-five percent of residents and a similar percentage of faculty members were dissatisfied with the service-education balance. In 1993, Wood et al (2) surveyed 22 internal medicine residents in a 772-bed teaching hospital regarding their nightcall activities, which preceded the more recent duty-hour guidelines implemented by the ACGME. In this study, residents and faculty members perceived an even balance of service and education activities. Activities that were perceived as weighted toward education included procedures and emergency department admissions, while serviceweighted activities included performing cardiac resuscitations and answering pages and calls with or without patient visits. Ultimately, Wood et al concluded that educational aspects of night-call duties were an integral part of residents’ training. Boex and Leahy (3) performed a meta-analysis of 16 studies that reviewed the activities of >1000 residents in predominantly internal medicine and surgery training programs from 1988 to 2000. Their analysis divided resident activities into four categories: marginal (defined as activities felt to be of marginal or no educational value), patient care, teaching and learning, and other. Boex and Leahy found that marginal and patient care activities each constituted approximately one third of all activities, without a statistically
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significant difference in the proportion of time spent in these two activities. The remaining third was split evenly between teaching and learning and other activities. They did find that the amount of time residents devoted to service activities of marginal value was statistically greater (P = .001) than the amount of time devoted to teaching and learning. Marginal activities included documentation and paperwork, patient or specimen transport, seeking laboratory results, discharge planning, and procedures such as drawing blood. Patient care activities included obtaining histories and performing physical exams, work rounds, discussing care with patients, and performing specialty-related procedures. Teaching and learning activities included library time, attending rounds, conferences, teaching, program planning, speaking with consultants, and providing feedback. Other activities were those that did not fall into any of these categories. It is important to note that graduate medical education follows an apprenticeship model, as opposed to the didactic model of undergraduate medical education. In practice, graduate medical education encompasses aspects of both models. Although some of these typical service-oriented activities fall in line with the apprenticeship model, they prepare trainees for the essential aspects of daily practice and are educational in this regard. Overall, the literature demonstrates that activities considered purely service do exist and that they potentially detract from the educational goals of training programs.
Service Versus Education Issues in the Radiology Residency In radiology residencies, typical service-oriented activities include performing and monitoring contrast injections, phoning results on exams not read by the telephoning resident, scheduling exams, obtaining consents for exams and procedures, and looking up laboratory or other ancillary data. Conversely, typical educational activities include view box teaching, interesting case discussions and case conferences, didactic lectures, independent reading, writing scholarly papers, and preparing presentations. Again, some of these service activities fall in an apprenticeship model and lend some inherent educational value. The training levels of surgical residents have been shown to affect their perceptions of service versus education. Reines et al (1) found that junior surgical residents were more willing to accept additional time for pure service than senior residents or faculty members. Senior residents also felt they needed more time allocated to pure education compared to junior residents. Anecdotally, junior radiology residents may perceive interpreting plain radiographs or performing simple procedures as more educational than senior residents, who might consider these service activities. However, these are
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generalizations, with no formal data examining these perceptions in the radiology literature. Although one might believe that radiology residencies are relatively immune to duty-hour violations compared to other training programs, there is still a considerable percentage of noncompliant programs since the ACGME implementation of the common duty-hour regulations in 2003. The most recent data show that diagnostic radiology and diagnostic radiology subspecialty training programs that were reviewed and cited for duty-hour violations accounted for 5.4% and 11.4% of programs, respectively, compared to an average of 7.0% across all specialties and subspecialties (7). The ACGME data do not provide any specific details about program size or type to make any inferences as to which type of programs might be prone to duty-hour violations. Interestingly, some surgical subspecialties, such as urology and plastic surgery, had smaller percentages of programs in violation compared to diagnostic radiology. Ultimately, the ACGME data reveal that duty-hour violations continue to exist in radiology training programs, and work-hour restrictions for these programs may negatively affect education. A practice that can also affect the balance of service and education is ‘‘pulling’’ or redistributing radiology residents from one service to fill shortages on another. This is not an uncommon practice in many radiology training programs. Shortages occur for a variety of reasons but are often related to unscheduled resident leave or sickness. Pulls tend to occur from less busy or elective services to busier services, which can interfere with elective time. This may also interfere with the continuity of residents’ learning experiences in a given subspecialty if frequently pulled to cover another. Also, residents who are pulled tend to be at higher training levels to fill service gaps. Thus, more senior residents who are pulled may lose the educational value of being on an advanced subspecialty elective. There is certainly variability across training programs, and this may not necessarily be a common practice at some programs. Several factors unique to radiology training programs facilitate pulling residents from one service to another, compared to nonradiology training programs. As the model for telemedicine, radiology is a portable service. With the advent of the filmless environment, residents are able to perform their duties from nearly any location where there is a picture archiving and communication system, even at offsite locations. Another factor unique to radiology is a relative lack of continuity of care compared to other areas of medicine. When a medical or surgical resident is unable to perform patient care duties resulting from absence or sickness, patient care may be compromised, because another resident may be inadequately prepared to assume responsibility. In addition, the transferring of duties or ‘‘sign out’’ that is routinely performed in other disciplines occurs on a smaller scale, if at all, in radiology. These inherent differences are also reflected in
the language of program specific ACGME requirements. For example, there are specific limits on patient census and new patient admissions for internal medicine residents (8). Other than a clause stating that ‘‘no new patients may be accepted after 24 hours of continuous duty,’’ there are no specific restrictions mentioned in the program requirements for diagnostic radiology (9), because radiology residents may theoretically ‘‘see’’ many more patients over a given time period. In fact, the ACGME program requirements for diagnostic radiology place minimum limits on the volume of radiologic examinations on a per resident basis, although there are no defined maximum limits. Also, there is no specific language regarding redistribution in the ACGME program requirements. Overall, the nature of radiology allows resident redistribution without a significant negative impact on patient care while potentially affecting the educational goals of the residency. There are several strategies to manage resident redistribution. It is important to establish thresholds for redistributing residents at the outset, which can be based on the number of available faculty members or residents or the number of cases and examinations. Subspecialty-specific policies regarding redistribution should be in place, and pulls should ideally take place within a subspecialty to provide a continuous resident experience. Ideally, redistribution should be tracked with a payback system in place. This can help discourage unscheduled absences, protect elective time, and preserve educational continuity. Tracking can also be used to monitor how service expectations may vary in specific subspecialties. Alternatives to redistribution should also be considered. These might include allowing residents to continue working in their respective subspecialties while remotely interpreting exams from a common electronic work list, as permitted. Using a night float system helps avoid postcall absences because of duty-hour regulations. This limits the potential need for pulls encountered in a traditional 24-hour call system. ‘‘Day float’’ rotations, in which senior residents act as radiology consultants or cover postcall absences on a variety of different services, can help avoid pulling residents from other services. Some institutions simply use a ‘‘no pull’’ policy. Because there is currently no language regarding resident redistribution in the ACGME program requirements (9), these policies would be most appropriately implemented at the institutional level, given the operational diversity of various programs. The ever increasing demand for radiology services has translated into increased workload, particularly at academic institutions. In a 2006 survey by the Society of Chairmen of Academic Radiology Departments, Lu et al (10) collected data from 1134 radiologists at 24 academic departments and showed a 15% statistically significant increase in the mean clinical workload over 3 years, as well as a 22% increase in
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the mean relative value units per full-time equivalent. They showed that workload was increasing in both exam complexity and the number of overall procedures. They also showed that the productivity of radiologists is continually increasing, with a shift toward more complex exams, such as computed tomography and magnetic resonance imaging. In this context, it is imperative to be mindful of balancing resident education with increasing service needs. Reines et al (1) proposed three solutions, including the use of midlevel providers, establishing a mentorship model, and strengthening the resident curriculum. Using midlevel providers provides ‘‘flexibility for resident participation in educational conferences within the duty hour restrictions.’’ Physician assistants or nurse practitioners have been used in teams with residents or on nonteaching services that provide minimal educational value. Although midlevel providers can be used in busy radiology practices, other physician extenders, such as medical students or trained secretarial staff members, can be helpful for performing tasks such as making or answering phone calls or looking up ancillary patient data. Podnos et al (4) demonstrated that ‘‘health technicians’’ who aided surgical residents with noneducational tasks increased operating room time for the residents. Brasel et al (5) found that surgical residents’ work week went beyond the 80-hour limit nearly half the time and that they spent >20% of their time in noneducational activities. As a result, their department doubled the number of physician extenders, although finding the resources and funding was yet another barrier. Even with Medicare being the largest source of funding for graduate medical education, the number of residency-funded positions is capped, which necessitates creative solutions (11). The mentorship model is also tantamount to ‘‘improving resident education under duty hour restrictions’’ (1). Faculty mentorship helps maintain and shape the educational experience of trainees by exploring academic interests and addressing weaknesses. Programs should also ‘‘strengthen and formalize the resident curriculum based on data and best educational practices.[and] should have a clearly defined curriculum that is monitored with specific outcome measures’’ (1). This falls in line with the ACGME Program Director Guide to the Common Program Requirements, section IV.A (‘‘Educational Program Curriculum Components’’), which outlines several curricular components, including overall educational goals, competency-based goals and objectives for each assignment, didactic sessions, and the delineation of resident responsibilities (12). It is important for radiology training programs to incorporate these components in the face of increasing service requirements. Improving the educational value of busy services is a challenge that requires participation on the part of both residents and faculty members. As one of the ACGME core competencies, residents must demonstrate professionalism, which includes being punctual. This ensures that the work
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flow is maintained, helps with the educational balance, and sets an example of good work ethic for junior residents. Other specific work flow issues must also be addressed to maximize efficiency. As mentioned earlier, physician extenders are helpful in this respect, performing tasks such as answering and redirecting phone calls, functioning as reading room coordinators, and serving as liaisons to referring clinicians, information technology specialists, nurses, and technologists. Pager alert systems can reduce the number of nonessential phone calls and disruptive interactions. Faculty members need to be equally involved in improving work flow, by being easily accessible to residents and other staff members. The dictation of cases by faculty members may have to be the standard on busy services, which would help further establish them as role models and team members. Dedicated teaching time should be set aside whenever possible, either in the form of case review or didactic sessions, even if for short periods of time. Throughout the workday, every case should be seen as an opportunity to teach and learn. Systematic reviews of faculty teaching performance should be performed to target areas of weakness. Removing residents from a service might be considered if the faculty consistently demonstrates minimal teaching involvement. Conversely, it is important to recognize and reward faculty members who consistently demonstrate a commitment to teaching. These faculty members may receive recognition, such as teaching awards and in some cases monetary compensation. In addition, some institutions have instituted academic relative value units, which might include time dedicated to educational and mentorship activities along with other various domains of nonclinical performance, which may be more difficult to measure (13). An element of service should be considered an important part of any training program. Learning to take responsibility for managing the work flow on a given subspecialty rotation and being intimately involved in the day-to-day running of the subspecialty work engages residents, makes them an integral part of the team, and prepares them for some of the challenges they may face in their own future practices. Although a heavy burden of service may compromise education, a certain element of service may be beneficial, and emphasis should be placed on finding an appropriate balance of the two. However, patient welfare and safety should ultimately be the first priority of any clinical team, regardless of the effect on resident education.
CONCLUSION The ACGME Program Director Guide to the Common Program Requirements, section VI.A (‘‘Duty Hours Principles’’), states that ‘‘1. The program must be committed to and be responsible for promoting patient safety and resident
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well-being and to providing a supportive educational environment. 2. The learning objectives of the program must not be compromised by excessive reliance on residents to fulfill service obligations. 3. Didactic and clinical education must have priority in the allotment of residents’ time and energy. 4. Duty hour assignments must recognize that faculty and residents collectively have responsibility for the safety and welfare of patients’’ (12). These statements help to define a framework for balancing education and service. Although the first and last statements both stress patient safety, the second and third statements emphasize the reduction of service-oriented activities detracting from the educational experience. Constantly increasing patient volumes create a potentially dangerous situation in which the burden is shifted to residents. This is especially important in the context of radiology training programs. Education and service are intimately intertwined, and measures must be taken to ensure that a proper balance is maintained. The collection of more formal data may be helpful to further explore these facets of radiology training programs. This includes better defining activities considered educational and noneducational and determining the amount of time residents spend in these areas. For the time being, the strategies presented here may help better equip programs to face the service versus education challenges. REFERENCES 1. Reines HD, Robinson L, Nitzchke S, et al. Defining service and education: the first step to developing the correct balance. Surgery 2007; 142: 303–310.
2. Wood VC, Markert RJ, McGlynn TJ. Internal medicine residents’ perceptions of the balance between service and education in their night-call activities. Acad Med 1993; 68:640–642. 3. Boex JR, Leahy PJ. Understanding residents’ work moving beyond counting hours to assessing educational value. Acad Med 2003; 78: 939–944. 4. Podnos YD, Williams RA, Jimenez JC, et al. Reducing the non-educational and nonclinical workload of the surgical resident: defining the role of the health technician. Curr Surg 2003; 60:529–532. 5. Brasel KJ, Pierre AL, Weigelt JA. Resident work hours: what they are really doing. Arch Surg 2004; 139:490–494. 6. Merriam-Webster’s collegiate dictionary. 11th ed. Springfield, MA: Merriam-Webster, 2003. 7. Accreditation Council for Graduate Medical Education. The ACGME’s approach to limit resident duty hours 2007-08: a summary of achievements for the fifth year under the common requirements. Available at: http://www.acgme.org/acWebsite/dutyHours/dh_achieveSum0708.pdf. Accessed February 17, 2009. 8. Accreditation Council for Graduate Medical Education. Program requirements for residency education in internal medicine. Available at: http://www.acgme.org/acWebsite/downloads/RRC_progReq/ 140pr703_u704.pdf. Accessed February 24, 2009. 9. Accreditation Council for Graduate Medical Education. ACGME program requirements for graduate medical education in diagnostic radiology. Available at: http://www.acgme.org/acWebsite/downloads/ RRC_progReq/420_diagnostic_radiology_07012008.pdf. Accessed February 24, 2009. 10. Lu Y, Zhao S, Chu PW, et al. An update survey of academic radiologists’ clinical productivity. J Am Coll Radiol 2008; 5:817–826. 11. Jackson VP. Funding for graduate medical education. J Am Coll Radiol 2006; 3:945–948. 12. Accreditation Council for Graduate Medical Education. ACGME program director guide to the common program requirements. Available at: http:// www.acgme.org/acWebsite/navPages/commonpr_documents/ CompleteGuide_v2%20.pdf. Accessed January 29, 2009. 13. Mezrich R, Nagy PG. The academic RVU: a system for measuring academic productivity. J Am Coll Radiol 2007; 4:471–478.
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Rationale and Objectives. Among the various medical disciplines, the radiology residency faces unique challenges when balancing clinical service and education, which have not been explored in the literature. Materials and Methods. The authors present a summary of material generated during collaborative sessions at the 56th Annual Meeting of the Association of University Radiologists in Seattle, Washington, in March 2008, including strategies on maintaining an appropriate emphasis on education in the face of increasing service obligations, with a review of the pertinent literature. Results. Although the topic of service and education has been explored in the medical and surgical literature, little has been published in the radiology literature. The portability of radiology and the relative lack of patient contact can lead to the redistribution of residents as a matter of convenience to fill service gaps, often at the expense of the educational goals of training programs. Residents and faculty members alike must take part in both service and educational obligations without compromising patient care. Physician extenders, call schedule optimization, and other strategies and resources can help ensure that a proper balance is maintained. Conclusion. The radiology residency presents unique challenges to the service and education balance. The authors highlight several strategies to address these challenges. Key Words. Graduate medical education; residents; service; education. ª AUR, 2009
Balancing service and education in residency training programs is a difficult task facing program directors and clinical faculty members. Although some of these challenges are common across the various specialties of graduate medical education, there are aspects that are unique to radiology. Some of these factors include the portability of radiology as a service and the relative lack of continuity of patient care. Although the service versus education debate has been explored in the surgical and internal medicine literature (1–5), the radiology literature has not addressed these issues, which become more pressing in the face of increasing demands to Acad Radiol 2009; 16:1161–1165 1 From the Department of Imaging Sciences, University of Rochester Medical Center, 601 Elmwood Avenue, Box 648, Rochester, NY 14642 (B.K.H.); the Department of Radiology, University of Wisconsin–Madison, Madison, WI (M.L.); and the Department of Radiology, University of Maryland School of Medicine, Baltimore, MD (C.S.R.). Received January 30, 2009; accepted March 5, 2009. Address correspondence to: B.K.H. e-mail: bradyhuang@ gmail.com
ª AUR, 2009 doi:10.1016/j.acra.2009.03.005
provide faster and more efficient service. Duty-hour restrictions also have the potential to significantly affect the balance of service and education. DISCUSSION To begin to discuss service and education, these concepts must be better defined. Merriam-Webster’s Collegiate Dictionary (6) lists several definitions of ‘‘service,’’ including ‘‘the occupation or function of serving,’’ ‘‘contribution to the welfare of others,’’ ‘‘a helpful act,’’ and ‘‘useful labor that does not produce a tangible commodity.’’ ‘‘Education’’ also has several definitions: ‘‘the action or process of educating or of being educated’’ or ‘‘the knowledge and development resulting from an educational process.’’ The term ‘‘service’’ implies a recipient who benefits from the service provided, without little if any benefit to the provider. In contrast, ‘‘education’’ implies a two-way exchange between a teacher and learner, which ultimately prepares the learner for future careers and opportunities.
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Unfortunately, these two concepts are difficult to define individually in the context of graduate medical education. The distinction is blurred because resident activities encompass a combination of both service and education. In the apprenticeship model of graduate medical education, service activities can be educational for trainees. However, the perceptions of these activities vary from the resident to faculty levels, as well as with the training level of residents. The concept of resident service arises from the dual role of residents both as trainees and as employees of their institutions. Residents have obligations to their patients, their hospitals, and their senior physicians. This concept has not been formally examined in the radiology literature but has been studied in the surgical and medical literature (1–5).
Review of the Literature The more recent interest in this discussion has been related to work-hour restrictions by the Accreditation Council for Graduate Medical Education (ACGME) on surgical training programs. Programs have had to find creative ways to maximize education in the face of these guidelines. Reines et al (1) explored this by surveying 125 surgical residents and 71 surgical faculty members across eight institutions and found that faculty members and residents agreed on the educational value of most activities. However, 40% of residents felt that more than half of their time was spent in pure service, significantly more than the 10% of faculty members who shared this sentiment. Twenty-five percent of residents and a similar percentage of faculty members were dissatisfied with the service-education balance. In 1993, Wood et al (2) surveyed 22 internal medicine residents in a 772-bed teaching hospital regarding their nightcall activities, which preceded the more recent duty-hour guidelines implemented by the ACGME. In this study, residents and faculty members perceived an even balance of service and education activities. Activities that were perceived as weighted toward education included procedures and emergency department admissions, while serviceweighted activities included performing cardiac resuscitations and answering pages and calls with or without patient visits. Ultimately, Wood et al concluded that educational aspects of night-call duties were an integral part of residents’ training. Boex and Leahy (3) performed a meta-analysis of 16 studies that reviewed the activities of >1000 residents in predominantly internal medicine and surgery training programs from 1988 to 2000. Their analysis divided resident activities into four categories: marginal (defined as activities felt to be of marginal or no educational value), patient care, teaching and learning, and other. Boex and Leahy found that marginal and patient care activities each constituted approximately one third of all activities, without a statistically
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significant difference in the proportion of time spent in these two activities. The remaining third was split evenly between teaching and learning and other activities. They did find that the amount of time residents devoted to service activities of marginal value was statistically greater (P = .001) than the amount of time devoted to teaching and learning. Marginal activities included documentation and paperwork, patient or specimen transport, seeking laboratory results, discharge planning, and procedures such as drawing blood. Patient care activities included obtaining histories and performing physical exams, work rounds, discussing care with patients, and performing specialty-related procedures. Teaching and learning activities included library time, attending rounds, conferences, teaching, program planning, speaking with consultants, and providing feedback. Other activities were those that did not fall into any of these categories. It is important to note that graduate medical education follows an apprenticeship model, as opposed to the didactic model of undergraduate medical education. In practice, graduate medical education encompasses aspects of both models. Although some of these typical service-oriented activities fall in line with the apprenticeship model, they prepare trainees for the essential aspects of daily practice and are educational in this regard. Overall, the literature demonstrates that activities considered purely service do exist and that they potentially detract from the educational goals of training programs.
Service Versus Education Issues in the Radiology Residency In radiology residencies, typical service-oriented activities include performing and monitoring contrast injections, phoning results on exams not read by the telephoning resident, scheduling exams, obtaining consents for exams and procedures, and looking up laboratory or other ancillary data. Conversely, typical educational activities include view box teaching, interesting case discussions and case conferences, didactic lectures, independent reading, writing scholarly papers, and preparing presentations. Again, some of these service activities fall in an apprenticeship model and lend some inherent educational value. The training levels of surgical residents have been shown to affect their perceptions of service versus education. Reines et al (1) found that junior surgical residents were more willing to accept additional time for pure service than senior residents or faculty members. Senior residents also felt they needed more time allocated to pure education compared to junior residents. Anecdotally, junior radiology residents may perceive interpreting plain radiographs or performing simple procedures as more educational than senior residents, who might consider these service activities. However, these are
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generalizations, with no formal data examining these perceptions in the radiology literature. Although one might believe that radiology residencies are relatively immune to duty-hour violations compared to other training programs, there is still a considerable percentage of noncompliant programs since the ACGME implementation of the common duty-hour regulations in 2003. The most recent data show that diagnostic radiology and diagnostic radiology subspecialty training programs that were reviewed and cited for duty-hour violations accounted for 5.4% and 11.4% of programs, respectively, compared to an average of 7.0% across all specialties and subspecialties (7). The ACGME data do not provide any specific details about program size or type to make any inferences as to which type of programs might be prone to duty-hour violations. Interestingly, some surgical subspecialties, such as urology and plastic surgery, had smaller percentages of programs in violation compared to diagnostic radiology. Ultimately, the ACGME data reveal that duty-hour violations continue to exist in radiology training programs, and work-hour restrictions for these programs may negatively affect education. A practice that can also affect the balance of service and education is ‘‘pulling’’ or redistributing radiology residents from one service to fill shortages on another. This is not an uncommon practice in many radiology training programs. Shortages occur for a variety of reasons but are often related to unscheduled resident leave or sickness. Pulls tend to occur from less busy or elective services to busier services, which can interfere with elective time. This may also interfere with the continuity of residents’ learning experiences in a given subspecialty if frequently pulled to cover another. Also, residents who are pulled tend to be at higher training levels to fill service gaps. Thus, more senior residents who are pulled may lose the educational value of being on an advanced subspecialty elective. There is certainly variability across training programs, and this may not necessarily be a common practice at some programs. Several factors unique to radiology training programs facilitate pulling residents from one service to another, compared to nonradiology training programs. As the model for telemedicine, radiology is a portable service. With the advent of the filmless environment, residents are able to perform their duties from nearly any location where there is a picture archiving and communication system, even at offsite locations. Another factor unique to radiology is a relative lack of continuity of care compared to other areas of medicine. When a medical or surgical resident is unable to perform patient care duties resulting from absence or sickness, patient care may be compromised, because another resident may be inadequately prepared to assume responsibility. In addition, the transferring of duties or ‘‘sign out’’ that is routinely performed in other disciplines occurs on a smaller scale, if at all, in radiology. These inherent differences are also reflected in
the language of program specific ACGME requirements. For example, there are specific limits on patient census and new patient admissions for internal medicine residents (8). Other than a clause stating that ‘‘no new patients may be accepted after 24 hours of continuous duty,’’ there are no specific restrictions mentioned in the program requirements for diagnostic radiology (9), because radiology residents may theoretically ‘‘see’’ many more patients over a given time period. In fact, the ACGME program requirements for diagnostic radiology place minimum limits on the volume of radiologic examinations on a per resident basis, although there are no defined maximum limits. Also, there is no specific language regarding redistribution in the ACGME program requirements. Overall, the nature of radiology allows resident redistribution without a significant negative impact on patient care while potentially affecting the educational goals of the residency. There are several strategies to manage resident redistribution. It is important to establish thresholds for redistributing residents at the outset, which can be based on the number of available faculty members or residents or the number of cases and examinations. Subspecialty-specific policies regarding redistribution should be in place, and pulls should ideally take place within a subspecialty to provide a continuous resident experience. Ideally, redistribution should be tracked with a payback system in place. This can help discourage unscheduled absences, protect elective time, and preserve educational continuity. Tracking can also be used to monitor how service expectations may vary in specific subspecialties. Alternatives to redistribution should also be considered. These might include allowing residents to continue working in their respective subspecialties while remotely interpreting exams from a common electronic work list, as permitted. Using a night float system helps avoid postcall absences because of duty-hour regulations. This limits the potential need for pulls encountered in a traditional 24-hour call system. ‘‘Day float’’ rotations, in which senior residents act as radiology consultants or cover postcall absences on a variety of different services, can help avoid pulling residents from other services. Some institutions simply use a ‘‘no pull’’ policy. Because there is currently no language regarding resident redistribution in the ACGME program requirements (9), these policies would be most appropriately implemented at the institutional level, given the operational diversity of various programs. The ever increasing demand for radiology services has translated into increased workload, particularly at academic institutions. In a 2006 survey by the Society of Chairmen of Academic Radiology Departments, Lu et al (10) collected data from 1134 radiologists at 24 academic departments and showed a 15% statistically significant increase in the mean clinical workload over 3 years, as well as a 22% increase in
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the mean relative value units per full-time equivalent. They showed that workload was increasing in both exam complexity and the number of overall procedures. They also showed that the productivity of radiologists is continually increasing, with a shift toward more complex exams, such as computed tomography and magnetic resonance imaging. In this context, it is imperative to be mindful of balancing resident education with increasing service needs. Reines et al (1) proposed three solutions, including the use of midlevel providers, establishing a mentorship model, and strengthening the resident curriculum. Using midlevel providers provides ‘‘flexibility for resident participation in educational conferences within the duty hour restrictions.’’ Physician assistants or nurse practitioners have been used in teams with residents or on nonteaching services that provide minimal educational value. Although midlevel providers can be used in busy radiology practices, other physician extenders, such as medical students or trained secretarial staff members, can be helpful for performing tasks such as making or answering phone calls or looking up ancillary patient data. Podnos et al (4) demonstrated that ‘‘health technicians’’ who aided surgical residents with noneducational tasks increased operating room time for the residents. Brasel et al (5) found that surgical residents’ work week went beyond the 80-hour limit nearly half the time and that they spent >20% of their time in noneducational activities. As a result, their department doubled the number of physician extenders, although finding the resources and funding was yet another barrier. Even with Medicare being the largest source of funding for graduate medical education, the number of residency-funded positions is capped, which necessitates creative solutions (11). The mentorship model is also tantamount to ‘‘improving resident education under duty hour restrictions’’ (1). Faculty mentorship helps maintain and shape the educational experience of trainees by exploring academic interests and addressing weaknesses. Programs should also ‘‘strengthen and formalize the resident curriculum based on data and best educational practices.[and] should have a clearly defined curriculum that is monitored with specific outcome measures’’ (1). This falls in line with the ACGME Program Director Guide to the Common Program Requirements, section IV.A (‘‘Educational Program Curriculum Components’’), which outlines several curricular components, including overall educational goals, competency-based goals and objectives for each assignment, didactic sessions, and the delineation of resident responsibilities (12). It is important for radiology training programs to incorporate these components in the face of increasing service requirements. Improving the educational value of busy services is a challenge that requires participation on the part of both residents and faculty members. As one of the ACGME core competencies, residents must demonstrate professionalism, which includes being punctual. This ensures that the work
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flow is maintained, helps with the educational balance, and sets an example of good work ethic for junior residents. Other specific work flow issues must also be addressed to maximize efficiency. As mentioned earlier, physician extenders are helpful in this respect, performing tasks such as answering and redirecting phone calls, functioning as reading room coordinators, and serving as liaisons to referring clinicians, information technology specialists, nurses, and technologists. Pager alert systems can reduce the number of nonessential phone calls and disruptive interactions. Faculty members need to be equally involved in improving work flow, by being easily accessible to residents and other staff members. The dictation of cases by faculty members may have to be the standard on busy services, which would help further establish them as role models and team members. Dedicated teaching time should be set aside whenever possible, either in the form of case review or didactic sessions, even if for short periods of time. Throughout the workday, every case should be seen as an opportunity to teach and learn. Systematic reviews of faculty teaching performance should be performed to target areas of weakness. Removing residents from a service might be considered if the faculty consistently demonstrates minimal teaching involvement. Conversely, it is important to recognize and reward faculty members who consistently demonstrate a commitment to teaching. These faculty members may receive recognition, such as teaching awards and in some cases monetary compensation. In addition, some institutions have instituted academic relative value units, which might include time dedicated to educational and mentorship activities along with other various domains of nonclinical performance, which may be more difficult to measure (13). An element of service should be considered an important part of any training program. Learning to take responsibility for managing the work flow on a given subspecialty rotation and being intimately involved in the day-to-day running of the subspecialty work engages residents, makes them an integral part of the team, and prepares them for some of the challenges they may face in their own future practices. Although a heavy burden of service may compromise education, a certain element of service may be beneficial, and emphasis should be placed on finding an appropriate balance of the two. However, patient welfare and safety should ultimately be the first priority of any clinical team, regardless of the effect on resident education.
CONCLUSION The ACGME Program Director Guide to the Common Program Requirements, section VI.A (‘‘Duty Hours Principles’’), states that ‘‘1. The program must be committed to and be responsible for promoting patient safety and resident
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well-being and to providing a supportive educational environment. 2. The learning objectives of the program must not be compromised by excessive reliance on residents to fulfill service obligations. 3. Didactic and clinical education must have priority in the allotment of residents’ time and energy. 4. Duty hour assignments must recognize that faculty and residents collectively have responsibility for the safety and welfare of patients’’ (12). These statements help to define a framework for balancing education and service. Although the first and last statements both stress patient safety, the second and third statements emphasize the reduction of service-oriented activities detracting from the educational experience. Constantly increasing patient volumes create a potentially dangerous situation in which the burden is shifted to residents. This is especially important in the context of radiology training programs. Education and service are intimately intertwined, and measures must be taken to ensure that a proper balance is maintained. The collection of more formal data may be helpful to further explore these facets of radiology training programs. This includes better defining activities considered educational and noneducational and determining the amount of time residents spend in these areas. For the time being, the strategies presented here may help better equip programs to face the service versus education challenges. REFERENCES 1. Reines HD, Robinson L, Nitzchke S, et al. Defining service and education: the first step to developing the correct balance. Surgery 2007; 142: 303–310.
2. Wood VC, Markert RJ, McGlynn TJ. Internal medicine residents’ perceptions of the balance between service and education in their night-call activities. Acad Med 1993; 68:640–642. 3. Boex JR, Leahy PJ. Understanding residents’ work moving beyond counting hours to assessing educational value. Acad Med 2003; 78: 939–944. 4. Podnos YD, Williams RA, Jimenez JC, et al. Reducing the non-educational and nonclinical workload of the surgical resident: defining the role of the health technician. Curr Surg 2003; 60:529–532. 5. Brasel KJ, Pierre AL, Weigelt JA. Resident work hours: what they are really doing. Arch Surg 2004; 139:490–494. 6. Merriam-Webster’s collegiate dictionary. 11th ed. Springfield, MA: Merriam-Webster, 2003. 7. Accreditation Council for Graduate Medical Education. The ACGME’s approach to limit resident duty hours 2007-08: a summary of achievements for the fifth year under the common requirements. Available at: http://www.acgme.org/acWebsite/dutyHours/dh_achieveSum0708.pdf. Accessed February 17, 2009. 8. Accreditation Council for Graduate Medical Education. Program requirements for residency education in internal medicine. Available at: http://www.acgme.org/acWebsite/downloads/RRC_progReq/ 140pr703_u704.pdf. Accessed February 24, 2009. 9. Accreditation Council for Graduate Medical Education. ACGME program requirements for graduate medical education in diagnostic radiology. Available at: http://www.acgme.org/acWebsite/downloads/ RRC_progReq/420_diagnostic_radiology_07012008.pdf. Accessed February 24, 2009. 10. Lu Y, Zhao S, Chu PW, et al. An update survey of academic radiologists’ clinical productivity. J Am Coll Radiol 2008; 5:817–826. 11. Jackson VP. Funding for graduate medical education. J Am Coll Radiol 2006; 3:945–948. 12. Accreditation Council for Graduate Medical Education. ACGME program director guide to the common program requirements. Available at: http:// www.acgme.org/acWebsite/navPages/commonpr_documents/ CompleteGuide_v2%20.pdf. Accessed January 29, 2009. 13. Mezrich R, Nagy PG. The academic RVU: a system for measuring academic productivity. J Am Coll Radiol 2007; 4:471–478.
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