The Role of Professional Identity Formation in Balancing Residency Service Versus Educational Needs.

Abstract

Residency is a unique time in one’s medical career. It is a time of intense learning and mentorship, as well as work and service. The aspects of service and education in residency have often been regarded as being on the opposite ends of a spectrum. As an example, consider the scenario of a resident who has decided, midresidency, to move into another specialty. In order to provide the best preparation for this new career choice, one might assume that freeing up time to participate in research projects and prepare for application into the newly chosen specialty would be the best course of action. After all, once the decision has been made to change specialties, what educational value remains in being part of a specialty that one will never practice? Certainly, various logistical and professional concerns may exist regarding completing clinical duties to minimize disruptions of colleagues’ schedules resulting from a resident leaving a program midyear. However, the completion of such obligations would seem to fall squarely in the ‘‘service’’ category, with little to no educational utility. This underscores the fact that service and education in residency are often considered opposing, and mutually exclusive, considerations. There is a resident survey given by the Accreditation Council for Graduate Medical Education (ACGME), which is conducted to monitor compliance with the accreditation standards, and residents are asked how often their clinical education is comprised of excessive service obligations. 1 The ACGME highlights the emphasis on learning activities and supports the principle that the balance of education and service should be weighted on the side of education. The ACGME’s expectation that education should receive a higher priority than service likely is rooted in the exploitation of residents dating back to the 1920s and 1930s, when interns were relegated to paperwork and inserting intravenous lines, while having limited opportunities for didactics or clinical rounds. 2 The ACGME standards emphasize the educational aspects of residency training. However, who really determines what constitutes ‘‘excessive service obligations’’? Currently, the arbiter is on the trainee, and this has led to some challenges. 3,4 In addition, neither ‘‘education’’ nor ‘‘service’’ is defined by the ACGME, and trainees responding to the survey may not be aware of the experiential learning that occurs during service provision. As those who have entered or completed medical training are aware, there are essential tasks residents must perform that fall under the heading of ‘‘work’’ or ‘‘service,’’ such as administrative duties or scheduling. The work required of the residents and their attending teams to effectively care for patients on an inpatient service and manage busy clinic schedules can be significant. While the educational experience may be the primary factor focused on during residency training, this focus may present a false dichotomy in how service aspects are ‘‘balanced,’’ particularly as education and service aspects often are intertwined. In contrast to viewing the relationship of education and service as a ‘‘balance’’ between the 2 dimensions, the educational experience can be understood as a dynamic process. In some instances, the emphasis will be on education, and in other instances, on service.