Non-Teaching Service Patients Versus Patients Without Teaching Value

The Accreditation Council for Graduate Medical Education (ACGME) surveys residents annually to ensure that the clinical learning environment, resident education, and resident experiences meet expectations of the Common Program Requirements. Under the category of Clinical Experience and Education, one of the questions on the internal medicine Resident/Fellow Survey asks, “Do you routinely provide care for patients on the non-teaching service?”¹  Our program received the following comment: “…in the internal medicine section of the resident survey, residents are routinely seeing non-teaching patients.”

This report provoked thoughts about the interpretation of non-teaching service vs non-teaching patients. The subtle shift in terminology between “non-teaching service” (in the survey) to “non-teaching patient” (in the report) is presumably unintentional. However, in our opinion it is emblematic of a risk that GME learners and some attending physicians may acquire a similar implicit attitude, namely that patients on the non-teaching service are of low pedagogical value.

Inpatient teaching services are a vital integrant of residency education. Historically, all the patients in teaching hospitals were admitted under the care of resident physicians. This led to increased service obligations, tipping the balance between education and service. Work hour mandates and institutional pressures to improve throughput necessitated differentiation of separate services—teaching and non-teaching—to address these concerns.

Teaching service includes learners, led by a faculty physician. They typically admit patients from their own residency clinics, high-acuity patients, those with high social determinants of health needs, and patients without a primary care physician. Non-teaching service on the other hand, is defined by the absence of resident physicians on the care team²  where patient care is directly led by a hospitalist physician with no formal role in resident education. Allocation of patients to non-teaching service may come from overflow from teaching services, directly from independent community physicians, from emergency departments, or as patient preference.

We postulate that usage of the terms non-teaching service and non-teaching patients are ubiquitous in residency settings. Furthermore, these terms, and their conflation, may create unintentional confusion and reinforce the view that a patient either has or does not have teaching value. Because residents are not expected to attend to patients on non-teaching service, such patients are often delegated to the category of having “low learning value.” Fueled by this misleading interpretive phenomenology, patients on non-teaching services are regarded as non-teaching patients (ie, the terms become interchangeable). This is reflected in our experience with the ACGME Resident/Fellow Survey, as well as in residency policy communications, where the term non-teaching patient can be found (eg, at the University of Chicago and Tufts University).^3,4  Even in scholarly research aimed at challenges for teaching hospital faculty, we find the term non-teaching patients suggestively juxtaposed with educational opportunities. For instance, Hoffman et al write, “time for scholarship, such as research and publication, competes with clinical education, quality improvement, and non-teaching patient care.”⁵  We believe that this phenomenon is worse in hospitals due to demands of throughput, which translates to improved efficiency. Thus, patients are viewed as “work units”⁶  that are measured in terms of cost effectiveness and length of stay.

Following a lower-than-ideal compliance rate on this ACGME Resident/Fellow Survey question, in an open discussion, our residents were asked who they considered non-teaching patients. They interpreted the question as patients with low or non-teaching value. In our communications with residents, they were emphatic in their opinion that some patients had no teaching value—for example, those in inpatient rehabilitation units, those awaiting discharge to long term care facilities, “social admissions,” and patients requiring pain management. This was consistent with observations by Repp et al that allocation of patients to non-teaching service based on perceived teaching value might convey attitudes that “real medicine” is comprised of higher intensity and acuity of care, that diagnostic testing and procedures are more important than communication and counseling, or that social determinants of health are not in the purview of the physician.² 

This linguistic bias presupposes that these patients are less in need of quality treatments, empathy, or physicians’ time, and may have unintentional far-reaching impact and consequence, such as lost opportunities to optimize patients’ care or to address underlying risk factors to achieve better outcomes. Legendary Dr Faith Fitzgerald stated in her 1999 essay “Curiosity” that, “medical education itself suppresses the expression of curiosity”⁶  as manifest by an open-minded, intellectual interest in the whole patient. Allowing residents to think that patients on the non-teaching service do not have teaching value lends to suppression of this curiosity. It is a disservice to our education system and a failure in training future physicians that there exists any patient who does not have a lesson of value to learners and educators. She continues, “For whatever reason—economics, efficiency, increased demands on physicians for documentation, technology, or the separation of education from patient care—curiosity in physicians is at risk.”⁶ 

The interpretation of some questions on the ACGME Resident/Fellow Survey has, at times, been perceived as ambiguous, which led to the development of an educational presentation by the Association of Program Directors in Internal Medicine (APDIM) Council titled Toolkit to Better Understand the ACGME Resident Survey.⁷  However, this presentation does not address the interpretation of “non-teaching service” vs “teaching service.”

These authors agree with the ACGME’s intention to preserve a resident’s learning experience by protecting them from unnecessary, or excessive, service obligations. Nevertheless, the interpretation of this requirement shifts when learners and educators perceive that a patient on any service is of either teaching or non-teaching value. In discussions with our residents about the meaning of “non-teaching patient,” our faculty offered a different viewpoint, one that pointed out knowledge that can be gained from each patient. We demonstrated to them that the terminology of non-teaching service can be confusing, as illustrated by their own interpretation of non-teaching service as non-teaching patient. Following this educational dialogue, our subsequent year’s survey report showed a significant improvement in this metric.

We propose the following for consideration by the medical education body:

1. Clarify the interpretation of non-teaching service as separate and distinct from meaning a non-teaching patient. We believe that this is relevant to all learners across all teaching programs.

2. Embed this clarification in ACGME Resident/Fellow Survey preparation, such as that delivered by the APDIM Council.

3. Rename the “non-teaching service,” as was recommended by Repp et al in their 2018 article.²  We suggest the terms “non-resident service” or “non-resident hospitalist service.”

4. Educate faculty on being intentional about teaching learners that every patient has teaching value apart from the ACGME Core Competency of Patient Care, such as the Competencies of Professionalism, Interpersonal and Communication Skills, Systems-Based Practice, and Practice-Based Learning and Improvement.

5. Emphasize that medical education must address the need for inclusivity of all patients and their equitable care.

Academic centers are the platform for providing the highest quality teaching to their learners. It behooves educators to emphasize the incredible value and gratification of bedside teaching and learning from every patient we meet. We believe that the nomenclature of non-teaching patients or non-teaching services creates biases stemming from misguided heuristics to students, residents, and faculty.

Every patient is a teaching patient.

The online supplementary data contains a visual abstract.