The Accreditation Council for Graduate Medical Education (ACGME) assesses programs' compliance with the accreditation standards. One critical dimension is an appropriate balance between education and service.1 In its annual survey, the ACGME assesses this balance by asking residents whether their education has been compromised by excessive service obligations.2 By using this language, the ACGME implies that education and service are mutually exclusive pursuits that must be balanced against one another. We contend that this represents a false dichotomy. Activities labeled as “service” enable learning about essential aspects of practicing medicine. These activities should be regulated by educators, or risk becoming a hidden curriculum.
Education theory suggests that learning takes place all of the time, although it might not correspond to what is being formally and intentionally taught.3 Therefore, it is flawed to imply that learning does not take place during service activities. When activities deemed to be service related are thought to be noneducational, the learning that inevitably takes place while engaging in them is not under the custody of educators. It escapes the formal scrutiny conferred by learning goals, objectives, and performance metrics. Thus, service learning becomes part of a hidden curriculum, an unregulated set of influences on medical education that involves organizational structure and culture.3
Another flaw in the claim that education and service are unique, opposing constructs stems from the lack of agreement on what constitutes service in residency in the first place. Service is defined variably by residents, with examples ranging from participating in administrative tasks and completing paperwork, to involvement in routine patient care, to engaging in community service activities.4 There is also disagreement between residents and program directors in the same program about whether service activities substantially interfere with clinical education. More often than their program directors, residents perceive excessive sacrifice of education due to service.5 This disagreement likely relates to different definitions of service, as well as different perceptions of the educational value of service activities.5 Although faculty supervisors may recognize the educational value of such activities, if they do not legitimize that value through educational objectives and assessments, residents will perceive the activity as void of educational merit.
We propose that the ACGME abandon the false dichotomy of education and service, and focus instead on whether the learning taking place in the array of activities of residency training, including “service activities,” meaningfully contributes to the educational goals and objectives of the program. Specifically, the ACGME Resident Survey items that assess whether service compromises education should be removed. In their place, items should be added, such as “How frequently are you expected to participate in activities that are outside the scope of professional practice (eg, do not require being a physician to complete) and lack educational goals, objectives, and metrics?” This would compel residents and educators to formally appraise and regulate all activities, including those outside formal didactic education, and pay more purposeful attention to what residents should be learning in order to be successful physicians. Further, the ACGME could use data generated from these survey items to identify outlier programs, in which a high proportion of resident activities are not constructed and assessed as part of the educational program.
Beyond the ACGME Resident Survey, efforts to avoid a false dichotomy of education and service apply to other aspects of graduate medical education. For example, the development of milestones for particular specialties may consider how to avoid the implication that education and service are mutually exclusive. Instead, the milestones should embrace the conceptual framework that all activities contribute to trainees' education. Activities traditionally designated as service that meaningfully add to resident education should be integrated into the milestones. Integration will involve assessing these activities for educational content and developing metrics to determine resident progress. Activities that do not lend themselves to formal and intentional educational structure should be identified and minimized to the extent possible.