- Email: [email protected]
Service vs Education: Situational and Perceptional Differences in Surgery Residency
2014 APDS SPRING MEETING
Service vs Education: Situational and Perceptional Differences in Surgery Residency Kimberly M. Hendershot, MD, Randy Woods, MD, Priti P. Parikh, PhD, Melissa Whitmill, MD and Mary Runkle, BS Department of Surgery, Wright State University Boonshoft School of Medicine, Dayton, Ohio 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 sur-
geons 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.
Correspondence: Inquiries to Kimberly M. Hendershot, MD, Department of Surgery, Wright State University, One Wyoming Street, WCHE Building, 7th Floor, Dayton, OH 45409-2793; fax: (937) 208-2105; e-mail: [email protected]
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 C 2014 programs and issue citations? ( J Surg 71:e111-e115. J Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)
KEY WORDS: service,
education, surgery residency requirements, ACGME requirements, service vs education dilemma
COMPETENCIES: Patient Care, Medical Knowledge, Practice-Based Learning and Improvement
INTRODUCTION The Accreditation Council of Graduate Medical Education (ACGME) surveys all general surgery residents annually regarding “service” obligations vs clinical “education” during residency.1 The residents’ response to this survey determines the compliance of the program to ACGME standards and all noncompliant responses may be reviewed by the residency review committee in surgery with one result being the issuance of citations to the programs. Moreover, this noncompliance also raises a question on the balance and emphasis between the “service” and “education” components in the programs.2,3 Several studies have tried to establish this balance and identify ideal residency experiences.2-4 However, very few studies have
Journal of Surgical Education & 2014 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 e111 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2014.06.006
focused on the causes of this noncompliance. We believe that the definitions of these terms remain somewhat nebulous. This directly affects the survey responses and creates a conflict within the residency programs as to how to improve upon these scores, especially when the score is low and a citation is issued. Galvin and Buys,5 Sanfey et al.,6 and Quinn and Brunett3 have shown that the definition of these terms may depend on the perception of the person queried, but there is little research done in this area especially for general surgery residency programs. This study, therefore, determined whether there are situational or perceptional differences present when trying to define what constitutes “service” and “education” in surgery residency, and whether there is any need to update these definitions.
METHODS An institutional review board–approved question-based survey was given to Wright State University Boonshoft School of Medicine participants, including medical students, surgical residents, surgical nurses/advanced practitioners (AP), and attending surgeons. (Note that there were no attempts to educate the participants before the survey being distributed.) The internally validated survey consisted of 88 questions, with 74 of the questions related to specific resident tasks and 14 of the questions related to the terms “service” and “education.” Participants were asked to rate common resident tasks on a 5-point Likert scale (1 being pure service and 5 being pure education). Participants were also asked general questions regarding “service” and “education” and rated their agreement on a 5-point Likert scale (1 being strongly disagree and 5 being strongly agree).
The broad categories and related questions in each category are given later. Table 1 also gives examples of some of the specific questions contained in the survey. (1) Activities related to documentation: Questions were related to history and physical examinations (H&Ps), daily progress notes, and writing prescriptions. (2) Communications related to clinical care: Questions were related to daily rounding, talking with patients/ families, answering nursing phone calls, discharge planning, transporting patients, and seeing patients in an outpatient setting. (3) Skills, nonspecific: Questions were related to drawing blood for laboratory tests and starting peripheral intravenous (PIV) access. (4) Education: Questions were related to teaching medical students and completing their evaluations. (5) Skills, surgery specific: Questions were related to simple laceration repair, complex laceration repair, central line placement, and performing a laparoscopic cholecystectomy (LC). Some general questions about the terms “service” and “education” were also posed (Table 2). An analysis was done by condensing the Likert scale (1 and 2 were service, 3 was a combination of service and education, and 4 and 5 were education). The questions were analyzed based on the role of the participant (student, resident, nurse/AP, and attending surgeon), and then several questions were additionally analyzed from only the resident perspective, looking at the postgraduate year (PGY) (interns, PGYs 2 and 3 combined, and PGYs 4 and 5 combined).
TABLE 1. Survey Questions Regarding Specific Resident Tasks Instructions: Imagine yourself as a surgical resident. Please rate the following activities in regards to their level of “service” vs “education,” with 1 being pure service and 5 being pure education. Category Documentation
Communication in clinical care Skills, nonspecific Education Skills, surgery specific
e112
Examples of Specific Questions Performing a History and Physical examination for a patient being admitted to your service Writing admission orders for a patient being admitted to your service Writing a daily progress note on a patient on your service before rounds with your attending surgeon Writing prescriptions for a patient on your service Doing daily patient rounds with the resident team and the attending surgeon Talking with the family of a patient on your service Speaking with the discharge planner regarding a patient on your service Answering phone calls from the nurse regarding a patient on your service Drawing blood on a patient on your service Starting an IV on a patient on your service Completing an evaluation for a student or resident who is under you while on a service Teaching the medical students Attending teaching conferences Doing a Laparoscopic Cholecystectomy—you have only done 1 before Doing a Laparoscopic Cholecystectomy—you have done 20 before Doing a Laparoscopic Cholecystectomy—you have done many before and have met your quota for the American Board of Surgery Journal of Surgical Education Volume 71/Number 6 November/December 2014
TABLE 2. General Questions Regarding “Service” and “Education” Service is doing tasks with little to no educational value Education is taking advantage of opportunities to learn no matter what the setting Education opportunities cannot be predicted and may arise at unexpected times Service is a part of residency training Service is an important part of being a physician Service has not been well defined by the ACGME I do not know what the term “service” means in regards to the ACGME survey
RESULTS A total of 120 surveys were distributed via paper and electronic format, with 69 responses (58% response rate). Participants included 19 medical students, 26 residents, 14 nurses/AP, and 10 attending surgeons. Our results show that a significantly high number of attending surgeons (80%) reported that writing an admission H&P is educational compared with residents (27%) and students (11%) (Table 3). Similarly, talking with families about their patients was rated as educational by 70% of attending surgeons, 15% of residents, and 5% of students. Moreover, drawing blood for laboratory tests and starting PIV access were universally rated as service tasks. Regarding LC, when the resident had done one previously, it was universally thought educational. When the resident had done 20 previously, 80% attending surgeons, 54% residents, and 37% students still felt the task was educational. When the resident had met their American Board of Surgery quota for LC, 80% of attending surgeons, 42% of the residents, and 16% of the students thought it was an educational endeavor (Table 4). When analyzing the responses given by the residents, in talking with families, 50% of interns rated this as service, whereas 30% of PGYs 2 and 3 reported it as education (PGYs 4 and 5 ranked it equally as service and education). The same trend was seen in answering nursing phone calls about patients (60% of PGY 1 rated it service, 40% of PGYs 2 and 3 as education, and all PGYs 4 and 5 as a mixture of both) and in writing admission orders (0% interns rated as education, 40% of PGYs 2 and 3 ranked as education, and all PGYs 4 and 5 rated it as a mixture of both). 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.
DISCUSSION Our study shows that situational and perceptional differences do exist in regard to “service” and “education” in our program, and most participants are unclear about these terms. The tasks such as writing an admission H&P and talking with patients/families were perceived as educational by most of our attending surgeons, but not by our students and residents. These results corroborate with Sanfey et al.6 where they observed a similar pattern. They showed that activities performed for documentation purposes lost educational value for residents. As educators, we spend considerable time teaching good history taking and physical examination skills to our students in medical school. Similarly, in surgical residency, honing the critical thinking and judgment skills needed to determine which patients will need surgery are a major part of preparing our residents to be successful surgeons. To many of the attending surgeons, this comes down to taking a good H&P and having really meaningful conversations with our patients and their families. However, these activities are perceived more as services to our residents and students. In our current era, perhaps the extensive use of radiologic testing, especially before surgical consultation, takes much of the mystery out of the diagnostic dilemma. The H&P becomes less about discovery and planning and more about “paperwork” so the patient can start to be treated. We also observed that tasks, such as drawing blood, starting a PIV, and transporting patients, were all seen as
TABLE 3. Results for Writing an H&P as a Service vs Education Task Participants
Service
Mixture of Service and Education
Education
Medical students (n ¼ 19) Resident, fellows (n ¼ 26) Attending surgeons (n ¼ 10) Nurses, advanced practice provider (n ¼ 14) Total (n ¼ 69)
26% (5) 15% (4) 10% (1) 14% (2) 17% (12)
63% (12) 58% (15) 10% (1) 22% (3) 45% (31)
11% (2) 27% (7) 80% (8) 64% (9) 38% (26)
Journal of Surgical Education Volume 71/Number 6 November/December 2014
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TABLE 4. Results for Doing a Laparoscopic Cholecystectomy (LC) as a Service vs Education Task Students (n ¼ 19) Svc LC—you have only done 1 before LC—you have done 20 before LC—you have done many before and have met your ABS quota
Mix
Residents (n ¼ 26) Ed
Svc
Mix
Attending Surgeons (n ¼ 10) Ed
Svc
Mix
Ed
5% (1) 16% (3) 79% (15) 0% (0) 23% (6) 77% (20) 0% (0) 10% (1) 90% (9) 21% (4) 42% (8) 37% (7) 0% (0) 46% (12) 54% (14) 10% (1) 10% (1) 80% (8) 53% (10) 32% (6) 16% (3) 8% (2) 50% (13) 42% (11) 10% (1) 10% (1) 80% (8)
Svc, service; Mix, mixture of service and education; Ed, education; ABS, American Board of Surgery.
service endeavors by our attending surgeons and residents. Such tasks have been ambiguous and are rated as sometimes educational and sometimes services by Sanfey et al.6 However, one may argue that knowing how to do some of these tasks (e.g., drawing blood and starting a PIV) could be very useful in a situation where these needed to be done and no one else could do them. Such tasks, therefore, could be more educational than service, in certain settings and certain contexts. In regard to surgical skills (including LC), there was a definite trend on the resident and student side to see these tasks as decreasing in educational value as the number performed increased. Attending surgeons tended to view the surgical skills as educational no matter the number done. These differences in perception bring to light the issue of the number of times one needs to perform a procedure to become “competent.” As far as we know, there is no scientific data in the surgical literature that determine the number needed to become competent for all the different types of bedside and surgical procedures that we perform. There seems to be a fundamental difference in how one perceives a state of competence, a time when education is no longer needed. Again, perhaps it is related to perception: learners think that after a smaller number of procedures are done that they “know” how to do the procedure, whereas those with more experience realize that knowing the steps in a procedure is only the beginning of becoming competent in that procedure. Understanding anatomical anomalies, dealing with unanticipated pathology, and maneuvering through unexpected complications intraoperatively are just some of the additional skills that will truly make someone competent in a particular surgical procedure. Therefore the perceptional differences, at least when it comes to surgical skills, may not be able to be resolved because the learners may never know what they do not know until they finally come to know it. The ambiguity between the terms “service” and “education” is not unique to general surgery. Several other residency specialties have attempted to answer this question, including internal medicine and emergency medicine (EM). The internal medicine perspective concluded that “mutual adherences to fundamental guidelines of fairness and personal responsibility” would help alleviate the conflict between service and education, but there were no practical e114
solutions for how to manage the controversy regarding service vs education.7 EM residency program directors formed a work group to investigate this issue and concluded that residents and faculty have different individual opinions about what is educational or not educational. They identified several ways to improve education in EM rotations and discussed educating residents about how to answer the specific ACGME survey questions about service vs education (“teach to the test”).3 However, the fundamental fact remains that we still do not have clarity about the meaning of these terms, which the ACGME uses to assess the residency programs. We believe that until the “service” and “education” terms are better defined, there may never be a right answer to the questions about which tasks belong in which category.
CONCLUSIONS Our study shows that the definitions of “service” and “education” are situational or perceptional or both and change with the person queried. Moreover, both our residents and attending surgeons agreed that the term “service” is not well defined by the ACGME. We may need to refine these terms to promote consistency in the ACGME process of assessing programs. This might be a significant first step toward improving the framework for resident education. Our study has a limitation that it is a single-institution study and so reflects the opinion of one institution. Future studies are being planned for expanding the study to include other surgery residency programs to see whether there are differences based on type of programs (e.g., university based, community based, or hybrid programs) or whether regional differences exist.
REFERENCES 1. Accreditation Council for Graduate Medical Education.
ACGME resident/fellow survey. 〈Available at: http:// www.acgme.org/acgmeweb/tabid/97/DataCollectionSys tems/ResidentFellowSurvey.aspx〉; Accessed 24.03.14.
Journal of Surgical Education Volume 71/Number 6 November/December 2014
2. Griffen WO Jr. Surgical residency: on-the-job training
or education? Am J Surg. 1980;140(6):720-723. 3. 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(12):S15-S18. 4. Ben-Menachem T, Estrada C, Young MJ, et al. Balanc-
ing service and education: improving internal medicine residencies in the managed care era. Am J Med. 1996;100(2):224-229.
5. Galvin SL, Buys E. Resident perceptions of service
versus clinical education. J Grad Med Educ. 2012;4 (4):472-478. 6. Sanfey H, Cofer J, Hiatt JR, et al. Service or education:
in the eye of the beholder. Arch Surg. 2011;146 (12):1389-1395. 7. McCue JD. Addressing the service versus education
conflicts created by residency training in ambulatory care settings. J Ambul Care Manage. 1995;18(2): 84-90.
Journal of Surgical Education Volume 71/Number 6 November/December 2014
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Service vs Education: Situational and Perceptional Differences in Surgery Residency Kimberly M. Hendershot, MD, Randy Woods, MD, Priti P. Parikh, PhD, Melissa Whitmill, MD and Mary Runkle, BS Department of Surgery, Wright State University Boonshoft School of Medicine, Dayton, Ohio 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 sur-
geons 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.
Correspondence: Inquiries to Kimberly M. Hendershot, MD, Department of Surgery, Wright State University, One Wyoming Street, WCHE Building, 7th Floor, Dayton, OH 45409-2793; fax: (937) 208-2105; e-mail: [email protected]
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 C 2014 programs and issue citations? ( J Surg 71:e111-e115. J Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)
KEY WORDS: service,
education, surgery residency requirements, ACGME requirements, service vs education dilemma
COMPETENCIES: Patient Care, Medical Knowledge, Practice-Based Learning and Improvement
INTRODUCTION The Accreditation Council of Graduate Medical Education (ACGME) surveys all general surgery residents annually regarding “service” obligations vs clinical “education” during residency.1 The residents’ response to this survey determines the compliance of the program to ACGME standards and all noncompliant responses may be reviewed by the residency review committee in surgery with one result being the issuance of citations to the programs. Moreover, this noncompliance also raises a question on the balance and emphasis between the “service” and “education” components in the programs.2,3 Several studies have tried to establish this balance and identify ideal residency experiences.2-4 However, very few studies have
Journal of Surgical Education & 2014 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 e111 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2014.06.006
focused on the causes of this noncompliance. We believe that the definitions of these terms remain somewhat nebulous. This directly affects the survey responses and creates a conflict within the residency programs as to how to improve upon these scores, especially when the score is low and a citation is issued. Galvin and Buys,5 Sanfey et al.,6 and Quinn and Brunett3 have shown that the definition of these terms may depend on the perception of the person queried, but there is little research done in this area especially for general surgery residency programs. This study, therefore, determined whether there are situational or perceptional differences present when trying to define what constitutes “service” and “education” in surgery residency, and whether there is any need to update these definitions.
METHODS An institutional review board–approved question-based survey was given to Wright State University Boonshoft School of Medicine participants, including medical students, surgical residents, surgical nurses/advanced practitioners (AP), and attending surgeons. (Note that there were no attempts to educate the participants before the survey being distributed.) The internally validated survey consisted of 88 questions, with 74 of the questions related to specific resident tasks and 14 of the questions related to the terms “service” and “education.” Participants were asked to rate common resident tasks on a 5-point Likert scale (1 being pure service and 5 being pure education). Participants were also asked general questions regarding “service” and “education” and rated their agreement on a 5-point Likert scale (1 being strongly disagree and 5 being strongly agree).
The broad categories and related questions in each category are given later. Table 1 also gives examples of some of the specific questions contained in the survey. (1) Activities related to documentation: Questions were related to history and physical examinations (H&Ps), daily progress notes, and writing prescriptions. (2) Communications related to clinical care: Questions were related to daily rounding, talking with patients/ families, answering nursing phone calls, discharge planning, transporting patients, and seeing patients in an outpatient setting. (3) Skills, nonspecific: Questions were related to drawing blood for laboratory tests and starting peripheral intravenous (PIV) access. (4) Education: Questions were related to teaching medical students and completing their evaluations. (5) Skills, surgery specific: Questions were related to simple laceration repair, complex laceration repair, central line placement, and performing a laparoscopic cholecystectomy (LC). Some general questions about the terms “service” and “education” were also posed (Table 2). An analysis was done by condensing the Likert scale (1 and 2 were service, 3 was a combination of service and education, and 4 and 5 were education). The questions were analyzed based on the role of the participant (student, resident, nurse/AP, and attending surgeon), and then several questions were additionally analyzed from only the resident perspective, looking at the postgraduate year (PGY) (interns, PGYs 2 and 3 combined, and PGYs 4 and 5 combined).
TABLE 1. Survey Questions Regarding Specific Resident Tasks Instructions: Imagine yourself as a surgical resident. Please rate the following activities in regards to their level of “service” vs “education,” with 1 being pure service and 5 being pure education. Category Documentation
Communication in clinical care Skills, nonspecific Education Skills, surgery specific
e112
Examples of Specific Questions Performing a History and Physical examination for a patient being admitted to your service Writing admission orders for a patient being admitted to your service Writing a daily progress note on a patient on your service before rounds with your attending surgeon Writing prescriptions for a patient on your service Doing daily patient rounds with the resident team and the attending surgeon Talking with the family of a patient on your service Speaking with the discharge planner regarding a patient on your service Answering phone calls from the nurse regarding a patient on your service Drawing blood on a patient on your service Starting an IV on a patient on your service Completing an evaluation for a student or resident who is under you while on a service Teaching the medical students Attending teaching conferences Doing a Laparoscopic Cholecystectomy—you have only done 1 before Doing a Laparoscopic Cholecystectomy—you have done 20 before Doing a Laparoscopic Cholecystectomy—you have done many before and have met your quota for the American Board of Surgery Journal of Surgical Education Volume 71/Number 6 November/December 2014
TABLE 2. General Questions Regarding “Service” and “Education” Service is doing tasks with little to no educational value Education is taking advantage of opportunities to learn no matter what the setting Education opportunities cannot be predicted and may arise at unexpected times Service is a part of residency training Service is an important part of being a physician Service has not been well defined by the ACGME I do not know what the term “service” means in regards to the ACGME survey
RESULTS A total of 120 surveys were distributed via paper and electronic format, with 69 responses (58% response rate). Participants included 19 medical students, 26 residents, 14 nurses/AP, and 10 attending surgeons. Our results show that a significantly high number of attending surgeons (80%) reported that writing an admission H&P is educational compared with residents (27%) and students (11%) (Table 3). Similarly, talking with families about their patients was rated as educational by 70% of attending surgeons, 15% of residents, and 5% of students. Moreover, drawing blood for laboratory tests and starting PIV access were universally rated as service tasks. Regarding LC, when the resident had done one previously, it was universally thought educational. When the resident had done 20 previously, 80% attending surgeons, 54% residents, and 37% students still felt the task was educational. When the resident had met their American Board of Surgery quota for LC, 80% of attending surgeons, 42% of the residents, and 16% of the students thought it was an educational endeavor (Table 4). When analyzing the responses given by the residents, in talking with families, 50% of interns rated this as service, whereas 30% of PGYs 2 and 3 reported it as education (PGYs 4 and 5 ranked it equally as service and education). The same trend was seen in answering nursing phone calls about patients (60% of PGY 1 rated it service, 40% of PGYs 2 and 3 as education, and all PGYs 4 and 5 as a mixture of both) and in writing admission orders (0% interns rated as education, 40% of PGYs 2 and 3 ranked as education, and all PGYs 4 and 5 rated it as a mixture of both). 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.
DISCUSSION Our study shows that situational and perceptional differences do exist in regard to “service” and “education” in our program, and most participants are unclear about these terms. The tasks such as writing an admission H&P and talking with patients/families were perceived as educational by most of our attending surgeons, but not by our students and residents. These results corroborate with Sanfey et al.6 where they observed a similar pattern. They showed that activities performed for documentation purposes lost educational value for residents. As educators, we spend considerable time teaching good history taking and physical examination skills to our students in medical school. Similarly, in surgical residency, honing the critical thinking and judgment skills needed to determine which patients will need surgery are a major part of preparing our residents to be successful surgeons. To many of the attending surgeons, this comes down to taking a good H&P and having really meaningful conversations with our patients and their families. However, these activities are perceived more as services to our residents and students. In our current era, perhaps the extensive use of radiologic testing, especially before surgical consultation, takes much of the mystery out of the diagnostic dilemma. The H&P becomes less about discovery and planning and more about “paperwork” so the patient can start to be treated. We also observed that tasks, such as drawing blood, starting a PIV, and transporting patients, were all seen as
TABLE 3. Results for Writing an H&P as a Service vs Education Task Participants
Service
Mixture of Service and Education
Education
Medical students (n ¼ 19) Resident, fellows (n ¼ 26) Attending surgeons (n ¼ 10) Nurses, advanced practice provider (n ¼ 14) Total (n ¼ 69)
26% (5) 15% (4) 10% (1) 14% (2) 17% (12)
63% (12) 58% (15) 10% (1) 22% (3) 45% (31)
11% (2) 27% (7) 80% (8) 64% (9) 38% (26)
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TABLE 4. Results for Doing a Laparoscopic Cholecystectomy (LC) as a Service vs Education Task Students (n ¼ 19) Svc LC—you have only done 1 before LC—you have done 20 before LC—you have done many before and have met your ABS quota
Mix
Residents (n ¼ 26) Ed
Svc
Mix
Attending Surgeons (n ¼ 10) Ed
Svc
Mix
Ed
5% (1) 16% (3) 79% (15) 0% (0) 23% (6) 77% (20) 0% (0) 10% (1) 90% (9) 21% (4) 42% (8) 37% (7) 0% (0) 46% (12) 54% (14) 10% (1) 10% (1) 80% (8) 53% (10) 32% (6) 16% (3) 8% (2) 50% (13) 42% (11) 10% (1) 10% (1) 80% (8)
Svc, service; Mix, mixture of service and education; Ed, education; ABS, American Board of Surgery.
service endeavors by our attending surgeons and residents. Such tasks have been ambiguous and are rated as sometimes educational and sometimes services by Sanfey et al.6 However, one may argue that knowing how to do some of these tasks (e.g., drawing blood and starting a PIV) could be very useful in a situation where these needed to be done and no one else could do them. Such tasks, therefore, could be more educational than service, in certain settings and certain contexts. In regard to surgical skills (including LC), there was a definite trend on the resident and student side to see these tasks as decreasing in educational value as the number performed increased. Attending surgeons tended to view the surgical skills as educational no matter the number done. These differences in perception bring to light the issue of the number of times one needs to perform a procedure to become “competent.” As far as we know, there is no scientific data in the surgical literature that determine the number needed to become competent for all the different types of bedside and surgical procedures that we perform. There seems to be a fundamental difference in how one perceives a state of competence, a time when education is no longer needed. Again, perhaps it is related to perception: learners think that after a smaller number of procedures are done that they “know” how to do the procedure, whereas those with more experience realize that knowing the steps in a procedure is only the beginning of becoming competent in that procedure. Understanding anatomical anomalies, dealing with unanticipated pathology, and maneuvering through unexpected complications intraoperatively are just some of the additional skills that will truly make someone competent in a particular surgical procedure. Therefore the perceptional differences, at least when it comes to surgical skills, may not be able to be resolved because the learners may never know what they do not know until they finally come to know it. The ambiguity between the terms “service” and “education” is not unique to general surgery. Several other residency specialties have attempted to answer this question, including internal medicine and emergency medicine (EM). The internal medicine perspective concluded that “mutual adherences to fundamental guidelines of fairness and personal responsibility” would help alleviate the conflict between service and education, but there were no practical e114
solutions for how to manage the controversy regarding service vs education.7 EM residency program directors formed a work group to investigate this issue and concluded that residents and faculty have different individual opinions about what is educational or not educational. They identified several ways to improve education in EM rotations and discussed educating residents about how to answer the specific ACGME survey questions about service vs education (“teach to the test”).3 However, the fundamental fact remains that we still do not have clarity about the meaning of these terms, which the ACGME uses to assess the residency programs. We believe that until the “service” and “education” terms are better defined, there may never be a right answer to the questions about which tasks belong in which category.
CONCLUSIONS Our study shows that the definitions of “service” and “education” are situational or perceptional or both and change with the person queried. Moreover, both our residents and attending surgeons agreed that the term “service” is not well defined by the ACGME. We may need to refine these terms to promote consistency in the ACGME process of assessing programs. This might be a significant first step toward improving the framework for resident education. Our study has a limitation that it is a single-institution study and so reflects the opinion of one institution. Future studies are being planned for expanding the study to include other surgery residency programs to see whether there are differences based on type of programs (e.g., university based, community based, or hybrid programs) or whether regional differences exist.
REFERENCES 1. Accreditation Council for Graduate Medical Education.
ACGME resident/fellow survey. 〈Available at: http:// www.acgme.org/acgmeweb/tabid/97/DataCollectionSys tems/ResidentFellowSurvey.aspx〉; Accessed 24.03.14.
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