By: Allen B. Repp, MD, MSc, professor and vice chair for quality, Department of Medicine, The Larner College of Medicine at The University of Vermont, Burlington, Vermont
For years I’ve been trying to eradicate a word from my vocabulary. Yet, in my role as an academic hospitalist, I still find myself uttering it almost every day. Everyone around me is saying it, too. The word isn’t vulgar. It’s “nonteaching.”
What does it mean? Medicine services at many academic medical centers (AMCs) in the US are divided into teaching and nonteaching services. Teaching services usually include a team of medical students and resident physicians led by a faculty physician. In contrast, patient care on nonteaching services is often directed by an attending physician without the participation of medical learners.
Over the past 15 years, I’ve witnessed the phrase “nonteaching service” become common parlance. The increasing usage directly correlates to the marked growth in nonteaching services, driven predominantly by restrictions of resident duty hours and patient loads and the desire to enhance the clinical learning environment. In this context, the word reflects the good intentions and potential for nonteaching services to promote the teaching mission of AMCs.
So what’s wrong with saying “nonteaching”? Despite noble goals, the structure of some nonteaching services has resulted in unintended consequences that may controvert the missions of AMCs. Our accompanying article in Academic Medicine, “What the Nonteaching Service Can Teach Us,” enumerates several ramifications of nonteaching service structure on learners, faculty, and patients. Here I will highlight how patient allocation to nonteaching services can interfere with educational objectives.
At some AMCs, patients are assigned to teaching services and nonteaching services based on perceived teaching value. As a result, teaching services frequently have patients with higher acuity illnesses that require more testing and procedures such as renal failure, respiratory failure, or severe sepsis, whereas nonteaching services have patients with lower acuity problems such as substance use disorders, chronic pain syndromes, frailty, and dementia. This unequal distribution can deprive learners of the opportunity to develop their knowledge of crucial clinical topics in contemporary medicine.
The impact of these educational gaps may be best appreciated by the recent residency graduate who steps into the role of an attending physician. In fact, an insightful new faculty physician in our division recently reflected that he felt unprepared to manage nonoperative fragility fractures (as well as a number of other common conditions), primarily because patients with these diagnoses were assigned to a nonteaching service during his residency training experience. This sparked a thoughtful discussion in our group and ultimately prompted us to write our article.
Perhaps most troubling, perceived teaching value may be conflated with overall value. In AMCs, the “nonteaching” label can easily become derogatory. Learners may come to equate higher acuity conditions, intense diagnostic testing, and costly interventions with “real medicine.” Inadvertently, we may be teaching future generations of physicians to overvalue intense diagnostic and treatment approaches and to discount the management of patients with chronic conditions and socioeconomic drivers of disease. In doing so, we may be perpetuating the very biases and stigmas we strive to extinguish.
Our article proposes seven design principles for nonteaching services to help address these concerns. Several focus on education and bear summarizing here:
- Structure the nonteaching service to reflect the core values and curricular objectives of the educational program.
- Minimize assignment of patients based on perceived teaching value.
- Incorporate clinical experiences to educate learners about critical but commonly overlooked topics from frailty, dementia, and chronic pain to communication skills, social determinants of health, and payment systems.
As we work toward enriching the clinical learning environment, I’ll continue to search for a suitable substitute for the word “nonteaching.”