Service Versus Education: Finding the RightBalance: A Consensus Statement from theCouncil of Emergency Medicine ResidencyDirectors 2009 Academic Assembly ‘‘Question19’’ Working GroupAntonia Quinn, DO and Patrick Brunett, MD

AbstractMany emergency medicine (EM) residency programs have recently received citations for their residents’responses to Question 19 of the Accreditation Council on Graduate Medical Education annual survey,which asks residents to rate their program’s emphasis on clinical education over service obligations. Tothe best of our knowledge, no prior investigations or consensus statements exist that specifically addressthe appropriate balance between educational activity and clinical service in EM residency training. Theobjective of this project was to create a consensus statement based on the shared insights of academicfaculty and educators in EM, with specific recommendations to improve the integration of educationwith clinical service in EM residency training programs. More than 80 EM program directors (PDs),associate and assistant PDs, and other academic EM faculty attending an annual conference of EM edu-cators met to address this issue in a discussion session and working group. Participants examined thecurrent literature on resident service and education and shared with the conference at large their collec-tive insight and experience and possible solutions to this challenge. A consensus statement of specificrecommendations and effective educational techniques aimed at balancing service and educationrequirements was created, based on the contributions of a diverse group of academic emergency physi-cians. Recommendations included identifying the teachable moment in all clinical service; promoting res-ident understanding of program goals and expectations from the beginning; educating residents aboutthe ACGME resident survey; and engaging hospitals, institutional graduate medical education depart-ments, and residents in finding solutions.

ACADEMIC EMERGENCY MEDICINE 2009; 16:S15–S18 ª 2009 by the Society for Academic EmergencyMedicine

Keywords: residency education

INTRODUCTION

A ll emergency medicine (EM) residents are annu-ally required to complete an online surveydeveloped by the Accreditation Council on

Graduate Medical Education (ACGME). According tothe ACGME website, ‘‘The Resident ⁄ Fellow survey is an

additional method to monitor graduate medical clinicaleducation and to provide early warning of potential non-compliance with ACGME accreditation standards.’’1 Aresponse rate of 70% of each program’s residents isrequired for the program to receive an aggregate reportof its survey results.

The response of ‘‘sometimes’’ or ‘‘never’’ is consid-ered negative and noncompliant. A combined negativeresponse rate to any question by more than 20% ofresidents completing the survey generally results in anautomatic citation from the ACGME at the next sitevisit. When the program receives the final report of itssurvey results, all noncompliant responses are high-lighted in gray and have been colloquially named ‘‘graybox’’ citations.

One of the more-controversial questions on the AC-GME annual resident survey is Question 19. It asksresidents, ‘‘Do your rotations and other major assign-

ª 2009 by the Society for Academic Emergency Medicine ISSN 1069-6563doi: 10.1111/j.1553-2712.2009.00599.x PII ISSN 1069-6563583 S15

From the Department of Emergency Medicine, Kings CountyHospital Center ⁄ SUNY Downstate Medical Center, (AQ)Brooklyn NY; Department of Emergency Medicine, OregonHealth and Science University, (PB) Portland, OR.Received August 9, 2009; accepted August 10, 2009.Presented at the Council of Emergency Medicine ResidencyDirectors Academic Assembly, Las Vegas, NV, March 5–7, 2009.CoI: The author reports that there are no conflicts of financialinterest.Address for correspondence and reprints: Antonia Quinn, DO,e-mail: antonia424@earthlink.net.

ments emphasize clinical education over any other con-cerns, such as fulfilling service obligations?’’ Unfavor-able combined response rates of ‘‘sometimes’’ or‘‘never’’ on Question 19 have consistently beenreported at approximately 30% for EM programs over-all, the highest negative response rate of all of the sur-vey questions (personal communication, Louis Binder,MD, Emergency Medicine Residency Review Commit-tee member. Council of Emergency Medicine ResidencyDirectors Academic Assembly, March 2009).

The prevalence of these ‘‘gray box’’ responses toQuestion 19 prompted the Council of Emergency Medi-cine Residency Directors (CORD) to convene a work-shop at the CORD annual Academic Assembly inMarch 2009 to explore the current balance betweenclinical service and education in EM residency trainingprograms. A group of EM program directors (PDs),associate and assistant PDs, and other academic EMfaculty attended the workshop, one of four similar ses-sions at the conference exploring best practices in EMtraining.

The participants shared their insights and experi-ences with regard to increasing demands on residentsas service providers, the integration of education withclinical service, and ways to optimize education in thebusy emergency department (ED). Consensus recom-mendations were shared with the general CORD mem-bership at the conclusion of the Academic Assembly.

METHODS

Each year, PDs, EM faculty, and educators meet for theCORD EM Academic Assembly. CORD sponsors thisconference with the stated goal of improving the qual-ity of instruction in EM residency training programs byexpanding and updating the education, knowledge andskills of its attendees.

At the 2009 conference, more than 80 PDs, associateand assistant PDs, and EM faculty members fromdiverse program types participated in a discussion andworking group to address the high unfavorableresponse rate to Question 19 of the ACGME residentsurvey. A program director (PB) and an assistant PD(AQ) moderated this session. Before the meeting, themoderators developed topics and questions to facilitatethe discussion. Topics included the definition of clinicalservice, integration of education into clinical activities,tools to improve overall quality of EM graduate medi-cal education (GME) in an era of increasing servicedemands, and strategies to reduce the likelihood ofreceiving a citation for Question 19.

During the working group session, the moderatorstranscribed key points of discussion, which were sum-marized in a PowerPoint (Microsoft Corp., Redmond,WA) presentation. The session moderators and work-ing group members then reconvened with the CORDgeneral membership at the conclusion of the Aca-demic Assembly to share and further discuss theirfindings. The intent of the initial breakout session andsubsequent general discussion was to gain under-standing of the current balance of service and educa-tion in widely divergent training programs, to sharewith the participants solutions that have proven

successful, and to raise questions for further study.During both sessions, the moderators acknowledgedthe practical experience of the participants in this areaand actively solicited the sharing of expertise betweengroup members.

RECOMMENDATIONS

The following is a synopsis of the recommendationsfrom the working group and general sessions.

The Survey

1. Is the currently accepted threshold of 20% negativeresponse rate to Question 19 a realistic or evi-dence-based rationale for a program to receive acitation in this domain? Clinical service is integralto the professional life of a physician-in-training.There will always be a minimal level of serviceexpected of residents and faculty alike. It may beimpossible to further lower the service obligationsduring residency and provide adequate clinicalexperience. Further study is necessary to helpdefine the optimal or acceptable service-to-educa-tion ratio in residency training. Such investigationsshould address EM and non-EM residencies andideally would proceed with the support and collab-oration of the ACGME.

2. The survey question itself warrants revision. Thequestion is awkwardly constructed and may beprone to misinterpretation by some residents. Theterm ‘‘service obligations’’ used in this question isalso somewhat vague. A formal proposal fromCORD to ACGME leadership should be consideredto clarify the structure, wording, and intent of thequestion.

3. Question 19 is currently nested among other ques-tions of clearly negative connotation, which maybias respondents to answer in the negative.

4. The same survey instrument goes to all post-graduate trainees in ACGME-approved programs,and pertains to aggregate resident experienceregardless of rotation. Hence, the survey, andQuestion 19 specifically, do not differentiatebetween EM and non-EM residencies or betweenED and non-ED rotations, which may have widelydivergent service demands and educational envi-ronments.

The Citation

1. Programs that receive citations based on theirresponse to Question 19 are advised to leveragethe citation to their advantage with departmentchairs and hospital directors. The acknowledge-ment of an ongoing problem by an outside regula-tory body may be used to justify requests foradditional resources (e.g., midlevel providers) tohelp shift the service–education balance.

2. Any ACGME citation should be viewed as an effec-tive starting point for enhanced discussion and col-laboration between the training program, Directorof Institutional Operations, and GME office to

S16 Quinn and Brunett • SERVICE VERSUS EDUCATION: FINDING THE RIGHT BALANCE

explore creative solutions for preventing a repeatcitation.2

3. As a result of this citation, pressure may bebrought to bear on offending services or facultythat may not value or promote resident educationover clinical service, potentially leading toimproved clinical staffing or greater facultyengagement in teaching.

More Education

1. Explore ways to supplement the ongoing servicecomponent of residency training with an equal andbalanced education component. Program leadersare advised to train faculty to identify and capitalizeon the ‘‘teachable moment’’ in every encounter.Recognize the learning gaps in all residents,regardless of their level of training. Every clinicalactivity has the potential to be a learning opportu-nity for the resident.

2. Impress upon residents that time spent communi-cating with patients, families, primary providers,and consultants is not merely part of their clinicalworkload, but also enhances their communicationskills and professionalism.

3. Faculty are encouraged to spend more ‘‘face time’’with their residents during even mundane or roteclinical activities. Residents can interpret simplyinteracting with faculty in a clinical setting as edu-cational time.

4. A citation in this domain may be regarded as a callfor a more-robust faculty-development program.Training faculty to acquire and use new teachingskills and facilitating behavior change among clini-cal educators may help shift the balance from ser-vice toward education.

Current Clinical Practice and Documentation

1. Emphasize to residents that what may appear as‘‘scut work’’ is actually on-the-job training for req-uisite emergency physician tasks in their futureclinical positions. Acknowledge that complete andaccurate documentation, proficient use of the elec-tronic medical record (EMR), and computerizedphysician order entry are all important skills thatemployers will expect after residency.

2. Teach best practices with regard to the EMR.‘‘Smart phrases,’’ complaint-specific templates, andother techniques may help streamline the work ofdocumentation and hence decrease the perceivedburden of clinical service.

Share the Workload

1. A proportion of service components currentlybeing performed by residents should be shifted tomidlevel providers, ancillary staff, or EM facultywhenever possible.

2. The group acknowledged that costs may be prohib-itive for expanding the midlevel staff in the currenteconomic environment. A further caveat was thatmidlevel providers may compete with residents forgood learning cases.

Teach to the Test

1. Teach residents about the purpose and content ofthe ACGME resident survey. Educate them aboutQuestion 19 and other areas of potential programconcern before they complete the survey.

2. Actively seek feedback from residents to addressthis and other issues. Partner with them to helpidentify and implement needed changes in thetraining program.

3. Remind residents of the ‘‘nonclinical’’ rotations(electives, toxicology, emergency medical services,teaching rotations) they experience over the courseof their residency training. These rotations shouldbe considered when assessing the overall service–education balance.

DISCUSSION

Residents and faculty differ in their beliefs about whatis educational and valuable to them. Residents thrive inenvironments that promote ‘‘face time’’ with faculty.3,4

Residents believe that faculty who provide teaching atthe bedside and who offer immediate feedback aresuperior educators.5 Residents value skilled instructorshighly, regardless of the busy nature of the ED,6 buttheir activities must be well defined and integrated withclinical work. Residents do not value hours of paper-work such as procedure logging and ‘‘scut work’’ thatis not integrated with learning. Residents may considereven tasks as fundamental as speaking with familiesand other providers as extra work that does not con-tribute to their overall education (data not published).Understanding these resident perceptions is essentialfor improving GME programs. Although some facultymay not agree with residents with respect to the bur-den of clinical service obligations, the academic facultyis ultimately responsible for understanding and inform-ing resident expectations.

Working group participants described certain corevalues as worth preserving. Many clinical educatorsembrace the apprenticeship model of residency train-ing, in which service and education are not mutuallyexclusive. Service is how residents gain needed experi-ence. Faculty also believe that clinical service teachespatient care, professionalism,7 and communicationskills.

Whatever one’s educational philosophy, the demandson residents appear to be increasing. Residents canspend up to 35% of their time in activities of marginalor no educational value, including activities such as dis-charge planning, retrieving test results, transportingpatients, and certain aspects of documentation.8

Any attempt to balance service obligations and edu-cation needs will require a more evidence-basedapproach. This process should begin at the programlevel but will ideally be done in collaboration with keyregulatory bodies including the ACGME and ResidencyReview Committee. The working group suggestedbeginning with a multi-center resident survey to ascer-tain their definition of service and to better understandwhat is valued in clinical service from an EM residentperspective. Furthermore, an accurate assessment of

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exactly how much time is spent during an ED shift per-forming ‘‘pure’’ clinical service is necessary.

CONCLUSIONS

According to the ACGME resident survey, EM resi-dents currently believe that service requirements arestressed over medical education in their respective pro-grams 30% of the time. Although the optimum balanceof service and education is yet to be determined, educa-tors in EM must address this phenomenon. The Serviceversus Education CORD Working Group developed fivemain points to improve the education of our futureemergency physicians.

• Identify the teachable moment in all clinical service.• Promote resident understanding of residency goals

and expectations from the beginning.• Educate residents about the survey.• Engage residents in finding solutions.• Engage GME and hospitals in recognizing the prob-

lem and finding solutions.

References

1. Accreditation Council on Graduate Medical Educa-tion. Website homepage. Available at: http://www.acgme.org/acWebsite/Resident_Survey/res_Index.asp.Accessed Sep 18, 2009.

2. Cohen JJ. Honoring the ‘‘E’’ in GME. Acad Med.1999; 74:108–13.

3. Chisholm CD, Whenmouth LF, Daly EA, CordellWH, Giles BK, Brizendine EJ. An evaluation of emer-gency medicine resident interaction time with facultyin different teaching venues. Acad Emerg Med. 2004;11:149–55.

4. Phy MP, Offord KP, Manning DM, Bundrick JB,Huddleston JM. Increased faculty presence oninpatient teaching services. Mayo Clin Proc. 2004;79(3):332–6.

5. Roop SA, Pangaro L. Effect of clinical teaching onstudent performance during a medicine clerkship.Am J Med. 2001; 110:205–9.

6. Kelly SP, Shapiro N, Woodruff M, Corrigan K,Sanchez LD, Wolfe RE. The effects of clinical work-load on teaching in the emergency department. AcadEmerg Med. 2007; 14:526–31.

7. Aldeen AZ, Gisondi MA. Bedside teaching in theemergency department. Acad Emerg Med. 2006;13:860–6.

8. Boex JR, Leahy PJ. Understanding residents’ work:moving beyond counting hours to assessing educa-tional value. Acad Med. 2003; 78(9):939–44.

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