COMMENTARY

Education and Service: Definitions Are the

Easy Part

n this issue of the Journal of Graduate Medical

Education, Galvin and Buys1 have performed a service
(here is that word) by pointing out that we long have
been misusing the word service in graduate medical
education (GME). Properly, the word means doing good
things for others. Thus, it evokes the best of medicine
compassionate care for our patients, tending to their needs
even if it is inconvenient for ourselves, and understanding
that we as a profession have broader responsibilities to our
community and society as well as to our immediate
patients. Yet, as an educational community we have long
incorrectly used the term to connote exploitation. Small
wonder that young physicians unfamiliar with the culture
and context of medical education can be confused when
they hear accreditors and policy makers use the term with a
pejorative tone.
The misuse of the term service is as old as GME. The
first report on the subject, Graduate Medical Education,2
published in 1940, emphasized that internship and residency should be oriented toward education, not service.
The satisfactory internship should be primarily educational in character. To this end, the interns day should
not be so occupied with service duties that he cannot find
sufficient time for educational pursuits.2(p267) Similarly,
the next important report, Medical Schools in the United
States at Mid-Century,3 published in 1953, sharply drew
the distinction between education and service. There has
been a constant and continuing effort on the part of
educational bodies to make the internship a truly educational experience. At the same time, the demand by the
hospital for the services of interns has continually
increased.3(p267) And so it has gone through the present.
Although the term service is clearly not the best, the
linguistic problem is easily solved. We simply could
substitute the term exploitation for service. This clearly is
what medical educators from the beginning meant when
they used the term service. They were referring to the
panoply of duties necessary to patient care that can readily
be done by nonphysicians and that add little of educational
value to the residents experience. As the authors wrote in
Kenneth M. Ludmerer, MD, is Mabel Dorn Reeder Distinguished Professor of
Medicine and the History of Medicine at the School of Medicine, Washington
University.
Corresponding author: Kenneth M. Ludmerer, MD, Washington University,
School of Medicine, Campus Box 8066, 660 South Euclid Avenue, St. Louis,
MO 63110, KLUDMERE@DOM.wustl.edu
DOI: http://dx.doi.org/10.4300/JGME-D-12-00255.1

Kenneth M. Ludmerer, MD

Graduate Medical Education, In improving the educational value of internships, hospitals must work out plans
to relieve the intern from many routine procedures which
he is now performing but which have relatively little
educational value.2(p59) And, No intern should be asked
to waste his valuable time serving as a high-class orderly in
a hospital.2(p90) Residents for generations have had their
own term for this type of labor: scut work.
I myself have been wondering about the advisability of
adopting another term, perhaps exploitation, ever since
Eric Holmboe of the American Board of Internal Medicine
a year or two ago brought to my attention the fact that we
have been misusing the term service, just as Galvin and
Buys have done now. However, the term service is deeply
ingrained in our educational culture, and I am not certain
of the possibility, or even the desirability, of our finding
another word, as long as the context makes clear that we
are speaking of the economic exploitation of residents.
What word to use is for the community of medical
educators to decide.
However, the problem of the economic exploitation of
interns and residents remains extremely serious, regardless
of which word we choose to use for it. In seeking to correct
the problem, it may be helpful to keep certain points in
mind.
First, the problem is as old as GME itself and reflects
the roots of the system. The modern residency, introduced
by Osler and Halsted at the opening of The Johns Hopkins
Hospital in 1889, grew in part out of the apprenticeship
system.4 This very factthat residency in some ways
represented an institutionalized apprenticeshipmade residents vulnerable to economic exploitation, much as
medical preceptors of old had their apprentices clean the
barn and feed the horses as part of their indenture.
Second, true clinical education requires that most time
be spent at the bedside, not in the classroom. One of the
dangers of using the term education versus service is to
forget the centrality of working with patients to learning
medicine. Lectures, reading, conversation, and reflection
are all essential, but as supplements to the experience
gained at the bedside. Medical educators of the past knew
this. To say that GME is educational in character does not
mean that a formal, didactic program should be carried on
but rather that the atmosphere surrounding the intern
should be educational.2(p64) Some medical educators today
have forgotten this fundamental educational principle.
Journal of Graduate Medical Education, December 2012 547

COMMENTARY

Third, some necessary clinical work is mundane. The

most important educational principle in GME is the
assumption of responsibility.5(pp9092) This means, among
other things, that if something is necessary for a residents
patient, the resident will do it, even if it is not really in the
job description. Thus, responsible residents will wheel their
acutely ill patients to the radiology department at 2 AM
themselves if a transport orderly is not available. How do
we tell the difference between responsible patient care that
is part of learning and scut work? By using common sense.
It is one thing for residents to draw blood samples on their
own patient if no phlebotomist is around. It is another for
them to come in an hour or two early every morning to
draw all of the blood ordered on all of the patients on the
floor because the hospital does not wish to spend the
money for a phlebotomy team.
Last, relieving residents of noneducational burdens has
never been easy and will not be now. Every step that might
be taken in this direction will cost someone something in
terms of time, money, or both. Faculty who provide more
and better teaching, particularly in their supervision and
one-on-one conversations with residents, will have less time
for research or to be clinically productive, that is, to
increase the clinical revenues they produce. (This offensive
term symbolizes much of our present dilemma in medical
education and health care.) To reduce nonprofessional

548 Journal of Graduate Medical Education, December 2012

chores like scheduling appointments, hospitals will have to

hire more administrative staff. To reduce the inexcusably
large patient load and work compression that has
occurreda problem noted by Glavin and Buysmore
physicians or midlevel practitioners will be needed (and
also a relaxation of current duty hour restrictions so that
residents can stay a bit later if there is important work yet
to be done). Nationwide, the Institute of Medicine in a
recent report calculated that the cost of such changes would
be $1.9 billion.6
We have long needed to do more to achieve a better
education-service balance in GME. We have made some
progress in recent years, but there is much more to be
done.
References
1 Galvin SL, Buys E. Resident Perceptions of Service Versus Clinical Education.
J Grad Med Educ. 2012:4(4):472478.
2 Graduate Medical Education: Report of the Commission on Graduate Medical
Education. Chicago: University of Chicago Press; 1940.
3 Deitrick JE, Berson RC. Medical Schools in the United States at Mid-Century.
New York, NY: McGraw-Hill; 1953.
4 Ludmerer KM. Time to Heal: American Medical Education From the Turn of
the Century to the Era of Managed Care. New York, NY: Oxford University
Press; 1999.
5 Ludmerer KM. Let Me Heal: The Development of Residency Training in the
United States and the Struggle to Preserve Excellence in American Medicine.
New York, NY: Oxford University Press, under contract.
6 Institute of Medicine. Resident Duty Hours: Enhancing Sleep, Supervision, and
Safety. Washington, DC: The National Academies Press; 2009.