Pause for Thought . . . Is the service:education debate a waste of time?


By: Lynfa Stroud

“He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.”
William Osler

Lately I’ve been thinking about some terms that we frequently use in medical education: service and education.  In these discussions, “education” usually refers to teaching in a formal setting (such as classroom during an academic half-day) or informal setting (e.g. at the bedside), whereas  “service” usually refers to “clinical service”, or the process of caring of patients and all that this entails (paperwork, phone calls, dictating notes, chasing down tests, etc, etc). These terms come up often during individual meetings with residents, committee meetings, and accreditation reviews. Large amounts of time and talk are taken up with ensuring that rotations and programs have an appropriate “education to service” ratio. My perception is that over time these have evolved to the point that they have become somewhat of a false dichotomy, with the implication that “education” is good, and that “service” is bad.

This puzzles me. If you ask any second-year medical student where he or she wants to be, it is on the wards or in a clinic or in the OR. They are itching to get out of the classroom and into the clinical setting.  However, in residency there seems to be for many residents a point where this seems to reverse. Instead, the clinical setting becomes a place to escape from in order to attend teaching sessions in a classroom or simulation lab.

Sure, not everything done in the context of clinical care is glamorous or on the scientific cutting-edge. In fact, we have a pejorative term for a lot of what goes on – “scut”. But there seems to be a disconnect between how important this “scut” or “service” is to patient outcomes and the recognition of it as a valuable skill to acquire.  For example, errors on a discharge prescription, failing to set-up home care services, or not hunting down prior radiology reports (all which likely qualifying as “scut”) can potentially harm our patients, or at a minimum lead to less than ideal care. It’s essential to learn to do these tasks and to learn to do them well with attention to detail. Ultimately, it is often these things that make as much difference to patients’ health and their experience of the health care system as any specific intervention.

This is not to say that the medical expert role isn’t important. But it is to say that we seem to overvalue it and the time protected for learning it, rather than recognizing the value of learning everything else that we do for patients. I think residents may place value on “education” sessions because the medical expert role is overvalued and overrepresented in our assessments. If we as educators placed greater emphasis on the importance of these “service” skills, through better formative assessments, inclusion on high-stakes summative assessments, or ideally and most-meaningfully on eventual resident-level feedback metrics that included patient-outcomes, residents may come to see greater value in the “service” and perceive it less as detracting from “education”.

At the end of the day, there needs to be greater recognition that “service” IS “education”. It’s an education for what real-life practice will be. Because as one very smart medical educator once said, “once you’re finished residency, we just call ‘service’ ‘work’”.