Journal of General Internal Medicine

, Volume 5, Supplement 1, pp S59–S69 | Cite as

The service/education conflict in residency programs

A model for resolution
  • Steven A. Wartman
  • Patricia S. O’Sullivan
  • Michele G. Cyr
Barriers And Conflicts


Residency programs consist of a range of activities involving service to patients and education of residents. The observation that a conflict exists between the service and education components of residency is widespread and has been used to explain many of the problems afflicting such programs today. The authors believe that the service/education conflict is a significant barrier to change in residency programs. A model is presented for residency education that reorganizes the service and education components. First, they present a broad overview of the conflict. Then they provide a brief historical perspective and comment on some of the current recommendations for residency programs. Next, they discuss how principles of adult learning relate to residency and propose a new model of residency that adheres more closely to these principles. Finally, the proposed model is presented in some detail and its implications are discussed. Only if the service and education components of residency are carefully delineated can residency programs adapt to the changing and growing needs of postgraduate medical education.

Key words

ambulatory care education residency teaching 


  1. 1.
    Ebert RV. The training of the physician: the residency I. N Engl J Med. 1964;271:547–9.PubMedCrossRefGoogle Scholar
  2. 2.
    Boissoneau R. Continuing education in the health professions. Rockville, MD: Aspen Systems Corporation, 1980.Google Scholar
  3. 3.
    Schroeder SA, Showstack JA, Gerbert B. Residency training in internal medicine: time for a change? Ann Intern Med. 1986;104:554–61.PubMedGoogle Scholar
  4. 4.
    Stevens R. Issues for American internal medicine through the last century. Ann Intern Med. 1986;105:592–602.PubMedGoogle Scholar
  5. 5.
    Reuben DB, McCue JD, Gerbert B. The residency-practice training mismatch: a primary care education dilemma. Arch Intern Med. 1988;148:914–9.PubMedCrossRefGoogle Scholar
  6. 6.
    Association of Program Directors in Internal Medicine. APDIM NRMP 1989 Bulletin. Washington, DC: March 22, 1989.Google Scholar
  7. 7.
    McCarty DT. Why are today’s medical students choosing high-technology specialties over internal medicine? N Engl J Med. 1987;317:567–9.PubMedCrossRefGoogle Scholar
  8. 8.
    Perkoff GT. Teaching clinical medicine in the ambulatory setting: an idea whose time may have finally come. N Engl J Med. 1986;314:27–31.PubMedCrossRefGoogle Scholar
  9. 9.
    Shine KI. Innovations in ambulatory-care education. N Engl J Med. 1986;314:52–3.PubMedCrossRefGoogle Scholar
  10. 10.
    Accreditation Council for Graduate Medical Education. Special requirements for internal medicine programs. Directory of Graduate Medical Education, Chicago: 1989–1990. (In press.)Google Scholar
  11. 11.
    New York State Department of Health Ad Hoc Advisory Committee on Emergency Services, New York, June 2, 1987.Google Scholar
  12. 12.
    Skeff KM, Stratos G, Campbell M, Jones H. Evaluation of the seminar method for improving clinical teaching. J Gen Intern Med. 1986;1:315–22.PubMedCrossRefGoogle Scholar
  13. 13.
    Wartman SA. Training and educating the future internist: tasks and recommendations.In Jones RF, ed. Adapting clinical education to new forms of sites of health care delivery. Washington, DC: Association of American Medical Colleges, 1987.Google Scholar
  14. 14.
    Waggoner DM, Frengley JD, Griggs RC, Rammelkamp CH. A “firm” system for graduate training in general internal medicine. J Med Educ. 1979;54:556–61.PubMedGoogle Scholar
  15. 15.
    Rabkin MT. The teaching hospital and medical education: one room schoolhouse, multiversity, dinosaur? J Med Educ. 60;1985:92–7.PubMedGoogle Scholar
  16. 16.
    DeGroot LJ, Siegler M. The morning-report syndrome and medical search. N Engl J Med. 1979;301:1285–7.PubMedCrossRefGoogle Scholar
  17. 17.
    Council on Graduate Medical Education. First report of the council, Vol 1. Washington, DC: U.S. Department of Human Services, 1988.Google Scholar
  18. 18.
    Report of the New York State Commission on Graduate Medical Education. Albany, NY: New York State Department of Health, 1986.Google Scholar
  19. 19.
    Federated Council for Internal Medicine. Enhancing standards of excellence in internal medicine training. Ann Intern Med. 1987;107:775–8.Google Scholar
  20. 20.
    Rogers DE. Clinical education and the doctor of tomorrow: an agenda for action. In Gastel B, Rogers DE, eds. Clinical education and the doctor of tomorrow. New York: The New York Academy of Medicine, 1989;109–13.Google Scholar
  21. 21.
    Wartman SA. Moving toward the ambulatory-based residency.In Proceedings of the HRSA Conference on Primary Care Medical Education. Springfield, VA: NTIS, 1988.Google Scholar
  22. 22.
    Kosecoff J, Fink A, Brook R, et al. General medical care and the education of internists in university hospitals. Ann Intern Med. 1985;102:250–7.PubMedGoogle Scholar
  23. 23.
    Knowles MS. The modern practice of adult education: from pedagogy to androgogy (revised edition). Chicago: Follett, 1980.Google Scholar
  24. 24.
    Allan DME, Grosswald SJ, Means RP. Facilitating self-directed learning.In Green JS, Grosswald SJ, Suter E, Walthall DB III, eds. Continuing education for the health professions. San Francisco: Jossey-Bass, 1984.Google Scholar
  25. 25.
    Reuben DB, Novack DH, Wachtel TJ, Wartman SA. A comprehensive support system for reducing house staff distress. Psychosomatics. 1984;25:815–20.PubMedGoogle Scholar
  26. 26.
    Cohen JJ. Maintaining professionals in internal medicine. Careers Intern Med. 1989;5:4, 7.Google Scholar
  27. 27.
    Tosteson DD. Learning in medicine. N Engl J Med. 1979;301:690–4.PubMedCrossRefGoogle Scholar
  28. 28.
    Lurie N, Rank B, Parenti C, Woolley T, Snoke W. How do house officers spend their nights? A time study of internal medicine house staff on call. N Engl J Med. 1989;320:1673–7.PubMedCrossRefGoogle Scholar
  29. 29.
    Katz MH, Schroeder SA. The sounds of the hospital: paging patterns in three teaching hospitals. N Engl J Med. 1988;319:1585–9.PubMedCrossRefGoogle Scholar
  30. 30.
    Parrino TA, Villanueva AG. The principles and practice of morning report. JAMA. 1986;301:690–4.Google Scholar
  31. 31.
    Norcini JJ, Grosso LJ, Shea JA, Webster GD. The relationship between features of residency training and ABIM certifying examination performance. J Gen Intern Med. 1987;2:330–6.PubMedCrossRefGoogle Scholar
  32. 32.
    Ende J, Pozen J, Levinsky N. Enhancing learning during a clinical clerkship: the value of a structured curriculum. J Gen Intern Med. 1986;1:232–7.PubMedCrossRefGoogle Scholar
  33. 33.
    Knight JA. Our physician forebear Sir William Osler as teacher to emulate.In Edwards JC, Marier RL. Clinical teaching for medical residents: roles, techniques and programs. New York: Springer, 1988;35–49.Google Scholar
  34. 34.
    McCall TB. No turning back: a blueprint for residency reform (editorial). JAMA. 1989;261:909–10.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 1990

Authors and Affiliations

  • Steven A. Wartman
    • 1
  • Patricia S. O’Sullivan
  • Michele G. Cyr
  1. 1.Division of General Internal MedicineRhode Island HospitalProvidence

Personalised recommendations