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At its annual meeting in June, the AMA House of Delegates called for the introduction of "Service Learning in Medical Education" as a "key component" in medical schools' curricula. Resolution 321 asked that such experiences include "collaboration with a community partner to improve the health of the population." After discussion, the resolution was expanded to include residency programs. Some sections and councils also discussed requiring community service in the context of government's GME financing—as a quid pro quo.
Below is the final wording of Resolution 321:
RESOLVED, That our AMA support the concept of service learning as a key component in medical school and residency curricula; and be it further
RESOLVED, That these experiences include student and resident collaboration with a community partner to improve the health of the population.
Although AMA policy lacks the authority of ACGME and RRC requirements, they reflect a broad-based professional opinion. In the July 2004 issue of the GME E-letter, Paul H. Rockey, MD, MPH, Director of the AMA Division of Graduate Medical Education, asked:
What do you think? Should resident physicians be required to provide some form of community service? Does the specialty matter in the type of service learning that a resident takes on? And once trained in their specialty, should doctors be required to provide some form of community service?
The following are the edited responses we received (with identifying information removed):
NO!
Doctors in training and those in practice already give great amounts of community service. This includes time spent in clinics, dealing with and helping families, patients, health fairs etc, etc--all usually for little, if any pay.
Meanwhile, we all have lives that involve other areas of community service--in and through places we worship, schools, tutoring etc. This need not be formalized as a requirement, as such formalization will only add to another layer of rules and regulations and scheduling.
I think the idea of requiring community service is a noble, but misguided idea. Our primary responsibility should be in providing the specialty training that the individual needs.
My concern about requiring community service is that it would be very difficult to define the requirement and to assess the value to the resident or to the community. Absolutely everything that is required of a trainee has to be documented and evaluated in detail for the RRC/ACGME. Documenting this activity's value and the resident's performance would be a burden without a clear rationale that training is being improved.
Unless additional time is provided for residency training the current work hours severely compromise delivery of appropriate educational material. Additional deletions of time for nonspecific "community service" would only detract from the primary mission of training and educational content delivery.
No, no, no.
Residents are providing service, by their care of patients. Often enough, these patients are poor, and the reimbursement for their care is low. To ask residents to do community service, over and above their usual training, will also lead to further reduction in duty hours. Residents should work hard—and get tired—doing the business of patient care.
I'm unclear about the origin of the initiative and Resolution 321, but, while it may make sense in the UME realm, I find it difficult to endorse for GME. Many residency programs are already struggling with achieving required experiences within duty-hour limitations—they obviously don't have time to devote to further required medical service. The residents in our GME programs deal extensively with patients who are members of underserved populations—they understand health care disparity, if that is a goal of the initiative. Licensing issues vary from state to state. Resident supervision is an important part of the GME effort, as well, and isn't addressed in your communication.
In addition, I must object to a plan to "tie community service to government's GME financing" - federal funding for GME is complex and does need to be re-engineered, and perhaps the element of community service has a place, but funding for GME is truly precarious in many institutions - adding a new service requirement could lead to unforeseen negative outcomes. Please do not push for further complexity to the funding structure of GME on a national level.
At first I thought "who has time?" But, on further consideration, it could be considered as a way to have some of their student debt forgiven, such as working as the on-call doctor in nursing homes.
Perhaps there are already programs in place like this, or for working in a VA hospital, or underserved area for a year.
The Rush Medical College Otolaryngology residents already have instituted a community service component. They volunteer at two "free" clinics in Chicago, one evening per month, and see approximately 15 patients per month at those sites. This was started by one of the residents, who had had a volunteer experience at these clinics as a student.
This is not so much "improving the health of a community", as an individual in an underserved community. I am curious if this would qualify under the guidelines?
Where would OB/GYN residents fit that in? They are maxed to the hilt.
Education of these residents is suffering because they have so many obligations. They need time to learn OB/GYN.
I believe all doctors after residency should contribute time to community service. The community would also benefit because they would have fully trained doctors for once instead of someone who is learning.
Residents in training already perform a high degree of "community service" in providing indigent care and care for Medicaid patients.
Likewise, most physicians after training provide large amounts of uncompensated care, which is a direct benefit to the community.
Requiring resident to provide community service is an enormously arrogant proposal.
Resident physicians provide, as the instruments of the majority of charity care in the United States, at least 80 hours of service each week to those in need. Requiring additional service is to suggest that they should be relieved of any balance in their family and extra-medical lives.
If there were to be a requirement for service it should fall on those who have completed their training, who should demonstrate a lifetime of service and gratitude for the support society may have provided them in their education. Their experience, skill, and efficiency would provide more service per unit time and could perhaps be accommodated in a very busy life, but a less busy one than that or our residents in training.
If residency is not a full-time job there is no such thing. Residents and medical students voluntarily provide tremendous service to society outside of their medical training sites, but to require such a contribution would be patently unjust.
We already require our residents to participate in community service by seeing patients at the local indigent clinic as part of one of their rotations. I could imagine that the government controlling reimbursement to physicians for their services, but then on the other hand someone mandating that physicians perform community service might be a hard pill to swallow for some docs.
Should resident physicians be required to provide some form of community service? ABSOLUTELY NO! They are doing community service working in hospitals that serve the community at wages less than bus drivers and with >$100,000 debt.
Does the specialty matter in the type of service learning that a resident takes on? Yes, ONLY RESIDENTS IN PLASTICS/COSMETIC SURGERY SHOULD BE REQUIRED TO PROVIDE COMMUNITY SERVICE.
And once trained in their specialty, should doctors be required to provide some form of community service? ONLY PLASTIC SURGEONS.
It has been very difficult incorporating the entire required residency curriculum in obstetrics and gynecology into the 80-hour work week. The concept of adding "community service" to these already overburdened and fatigued residents is patently absurd.
No, you can not mandate community service as a part of resident education. As well one can not mandate community service as part of a physician's professional life. In the ideal world community service should be a volunteer function. Occasionally it is mandated by the court or a legal body, but as a punitive function. The AMA would lack a means to measure the adequacy of the community service. It poses too many problems. Resident education is about education; it is not about service (to the hospital, institution, or the community).
In psychiatry, many programs have a community consultation rotation for residents. Not sure what community service would entail, but it might be that we are already doing it.
At our institution it is not necessary to require service learning. 100% of our medical students and many of our faculty and residents voluntarily engage in a large number of community service activities providing care for patients in homeless shelters and health centers serving African Americans, Latinos, Sudanese immigrants, the working poor. They also serve poor rural people in the Dominican Republic, Peru, Nepal and India. They conduct health education programs in schools and churches. All of these are done in collaboration with community partners.
A few of these experiences carry academic credit; most do not. If you create the culture of care and commitment to the underserved, you don't have to require it.
Resounding no to required community service by residents. It's just a way for senior administrators to assuage their own consciences, and it's just taking advantage of a vulnerable population of trainees. As a former associate dean who dealt with these same issues in a med school curriculum, I never favored this activity.
The idea is not a good one. Residents' days and nights are too busy as it is. Most residents (certainly all at our institution) devote much care in county hospitals and the VA, taking care of less fortunate members of our society. Adding a community service requirement would also stretch teaching hospital resources, which are already stretched to the limit.
If the government required all practitioners to provide some percentage of service to indigent populations (once they graduated from residency), that might actually help to ease the burden on teaching hospitals and clinics, who see a disproportionate percentage of such patients. But I doubt it could be legislated and/or enforced.
Have you forgotten, we are physicians?
To this day, at age 64, when awakened in the wee hours of the morning to perform a procedure on a patient at the hospital, this is community service. What other profession provides such service! And you know what? At what ever hour I arrive at the hospital my residents are 10 times busier. My residents would be in violation of Bell commission regulations were they to volunteer for community service.
Surely this should not be a requirement.
It would be best for the House of Delegates to volunteer themselves rather than others for community service. Residents have large outstanding medical school loans, often have young families and many moonlight to make ends meet. I would not support an additional community service requirement. For many in early years of practice non-paying or low paying (Medicaid) patients constitute community service. Perhaps those in high-paying specialties and those who don't take Medicaid patients could provide community service as a payback for their Medicare funded training—eg, plastic surgery, dermatology, radiology, and orthopedics.
Although these things sound good in isolation they are yet one more requirement and one more burden on already stressed residencies.
Keep in mind that residency are working to comply with the ACGME general competency requirements. They are struggling to address the new duty hour limitations. They are trying to meet both the educational needs of the program and train residents in a clinical setting.
This is another mandate that will stretch resources in a time when resources are difficult to garner.
I would suggest that residents in some specialties should, and most likely already do, receive education about community resources that can be called upon to aid in the care of their patients. Requiring residents to spend time volunteering for community agencies seems like a requirement that may not achieve a furtherance of their education.
No, I do not feel residents should be required to perform any community service outside their institution. Enough is performed already taking care of indigent patients in the hospital.
Each year we have two fellows in our sports medicine program. The program requires fellows to participate in community service efforts, such as coordinating medical coverage for many community mass events, including road races and Special Olympic events, and covering athletic events at local high schools and colleges. Our director has worked diligently with the community and the schools in nurturing this collaborative effort because he sees it as a very important component of sports medicine and a great educational experience for the fellows. Developing great relationships within the community is a bonus to everyone involved.
I think it should be considered in the residency programs because it's definitely a "win-win" for everyone involved. When possible the type of community service should reflect the resident specialty as it will enhance the resident learning experience and provide quality healthcare to the population.
I also see great benefits to establishing community service requirements once physicians are trained in their specialty. Community service efforts can help to curtail high costs of health care and potentially reach the population in areas that otherwise, due to financial restraints, may not be possible.
I have spent most of my career with the medically underserved, and am now a residency coordinator. I can't imagine medical training without community service opportunities as part of the curriculum.
That being said, there's few worse experiences than having to deal with people forced to "volunteer" in the underserved setting. Community service requires commitment and a heart for the task at hand . . . these values should be instilled in the process of medical education with great vigor, but I think it would be a mistake to mandate them.
Community service is what we provide 24/7. Anything above residency is not necessary. That is the dumbest thing I have ever heard.
NO - I do not think it should be required. Highly encouraged and rewarded, yes. The reason I feel it should not be required is that there is pressure as it is to reduce work hours. Requiring public service on top of that would probably have to be included in the work hours tracked by program directors and make it even harder for some programs to meet the work hour limits.
Many residents in our program are involved in public service. But what constitutes public service may be quite subjective. Some are involved in coaching sports teams, others are involved in educating kids at local schools about health problems, and others are volunteering on national committees related to health care. Other residents are overwhelmed with what they have to learn in 4 years and balance that with family responsibilities to even think about spending additional time in public service. I reward our residents by making announcements about there achievements in front of their peers and making announcements in the hospital paper and sometimes their local home town newspapers. But I would hope we would not have to make it required. I do use it as a measure of professionalism however when looking at their portfolios during semi-annual evaluations.
Most residents already provide a tremendous amount of service to the community with their long work hours and direct patient care efforts. This is particularly true for patients in the emergency room setting. Resident work is done for many years for little pay and little recognition outside of their own institution.
This proposal seems somewhat comparable to asking US service men and women to perform community service after coming home from the front.
This strikes me as about as bad an idea as I have ever heard. Residency training is already severely pressed for time; residents have too much to learn in too little time, we have too many things we are supposed to teach in too few contact hours, and the work hour regulations only complicate this. To mandate time (which would have to be in the work hour rules!) for "community service" beyond this would be destructive as well as ludicrous.
In addition residencies are very often in facilities serving the medically underserved. At our institution, for example, all our pathology residents work at one time or another in a public (municipal) facility serving a mostly indigent population. So our residents already provide "community service" as part of their regular duties; to require additional time at this would be onerous and improper.
Our residents are already doing a huge community service by coming to work every day—they are basically underpaid professionals who provide high-level care to a huge underserved community. I suspect the same is true of a large number of residency programs, at least those based in public hospitals. I would be horrified if the ACGME believed it was appropriate to require them to do additional community service outside of that.
Our residents regularly perform community service during their 3 years with us. Many go on to practice in underserved populations.
I would think that most residencies in internal medicine have that, as it is looked for by the RRC. As far as community service as a practitioner, it is a good idea, but could be done on a pro bono case basis in clinics versus the "free community clinic" model. I am not sure in my own case that this should be required as it opens the door to "other requirements," as with the malpractice concerns this is probably not reasonable.
Should resident physicians be required to provide some form of community service? Absolutely not. The thought of such a mandate chills me.
Yes there should be a requirement to do 1 year of community health/primary care regardless of specialty that is pursued. This will achieve several goals: 1. It will make young physicians more conscientious of cost containment and evidence-based care plans. 2. It will give young physicians a broader perspective on public health and how to meet the needs of the population as a whole and not simply the individual. 3. It may have them focus on public health as preventing disease (primary prevention) and not treating disease (secondary prevention). 4. It will weed out those individuals who pursue a career in medicine for reasons other than an interest in patient care. 5. It will broaden the perspective of those who wish to specialize. After 8 years of private practice, I left and worked for 7 years in the community health system. It was a very worthwhile experience and I recommend that all new residency graduates spend time in these clinics.
Residents already perform community service—they provide essential care to the sickest people in our country at teaching hospitals throughout the nation. In the middle of the night, at the majority of trauma centers in every city, it is the residents who are first on hand to respond to medical emergency of all types.
There was a time when the very practice of medicine was considered community service! Now, in addition to working (slightly less than) 80 hrs per week at modest pay, and caring for the sickest, most complicated, and often most medically indigent patients in the country, there is the suggestion that training physicians somehow have an unpaid obligation to serve society!
Of course medicine would be improved if more physicians had better understanding of public health concerns, but new additions to the demands for physicians must be recognized as such and must come with realistic expectations and funding. There is a cap on funding for the training of residents. There should also be a cap on unfunded mandates that increase the cost (and time commitments) of resident education.
Taking residents out of current clinical training, to have them carry out "community service time," would dilute clinical training already stretched thin, lead to decreased ability of teaching hospitals to provide care to medically indigent persons (eg, community service), and/or increase operational cost of those programs.
The AMA must underscore the community service nature of the practice of medicine in general and in particular the community service nature of the clinical practice of resident physicians and of teaching hospitals. The AMA must provide a voice to support the needs of training physicians and teaching physicians/hospitals!
I think most residents are already providing major community service during their training. Following training most must pay back loans in excess of $100k. Further most physicians provide charity care as well as accept government and/or insurance mandated discounts.
How in the world can anyone ask for more with a straight face?
This is not a good idea. While community service is always laudable, physicians are generally quite busy and are very well serving the community in their role as care givers.
I do NOT believe that resident physicians should be required to provide some form of community service nor should doctors be required to do this.
Although it is my personal belief that all of us should, at some point in our lives, offer some of our efforts to the benefit of the community (local or world), I do not believe that this should ever be required of physicians in training or of physicians in practice (until there is universal service and all citizens are required to do so).
If there were enough residents in programs so that the institution made such service a rotation, that would be commendable. However, to require these young physicians to devote additional hours outside their required training to do community service is both unreasonable and impractical.
I have no objection to requiring high school students to do some form of community service during their school years, although I think this exercise is only rarely beneficial and can become quite inappropriate on occasion. But I cannot imagine how we can require our residents and fellows to take their time at that point in their lives and devote it to "community service" (whatever the definition of that is). These young physicians, men and women, also have young families and large debts to pay. It is at least as appropriate to expect them to spend time with their families or to moonlight to relieve their debt burdens!
It is an interesting question. As far as while in training in concerned, I don't think it is possible. There are newer and stricter restrictions as far as work times are concerned, and this already limits the learning opportunity in the face of more and more complex medical informatics. It would be very inappropriate and would adversely affect the training if one was to add the time constraints that would be put by community service.
As far as after training goes, I believe that every physician should give back a part of what he received from the community in kind. In that bend of mind my first response would be that mandatory community service sounds very correct. But then the question that I ask myself is that is it appropriate for anyone to force what one wants to do. What we owe to the community is a moral obligation, and nothing more, nothing less. In that setting would it not be a breach of one's independence to make community service mandatory. The next question I ask myself is: why should physicians be treated any different than other professionals? While based on the profession we have chosen, we do have to stay on higher moral grounds, but if community service were mandatory, my response would be it should not be limited to physicians and its scope should be broadened to all professions and all professionals. Now that would be the correct thing to do.
For emergency medicine, many specialty-appropriate community service opportunities exist. Before any mandate from the ACGME or recommendation by the AMA, however, please have this approved by CMS so that residency programs may receive DME and IME funding for this type of experience. In the current funding environment, if one of our EM residents would like to do a rotation at an outreach clinic or a project with the local health department, Medicare will not reimburse the institution for time spent on these activities since they do not take place at the teaching institution. As a result, we have to tell the resident "no."
I helped author this resolution in the Section on Medical Schools, so I obviously support the introduction of service learning as a key component in medical schools. I had not originally included residents but I am glad the House did so. I favor "require" but that language was removed in our discussion in the Section because we historically oppose additional curricular requirements. I do not personally think the specialty matters in the type of project a trainee takes on. I strongly support requiring community service of physicians after training has been completed. Much public money has subsidized medical school and residency training. It is a fair payback. Many physicians are already engaged in such service.
This is a bad idea. Teaching hospitals carry a heavy burden of community service. I thought the care of the poor was a community service. The care of those with Medicaid and without insurance by our residents occurs many times per day per resident. In an era of every increasing mandates, why doesn't the AMA allow the residents to continue to do the magnificent work they are doing for the poor without outside interference?
Medical students and residents already provide hundreds of hours of community service. Taking care of the patients that few other doctors wish to care for and doing it under stressful conditions during which time they are graded vigilantly and paid essentially nothing for their efforts.
I do not believe residents must give community service.
This is just plain ridiculous. Residents serve the community every minute they are on duty, and they are paid less than minimum wage to do so. This is not high school Beta Club. This is a healing profession which by its nature attracts those who would help others. To require additional community service as a part of training would be an insult, much less the pinnacle of hypocrisy, since I guarantee you that the majority of AMA members worry more about their office volume and bottom line than they do about the local free clinic or soup kitchen.
NO! is my vote. It is hard enough with the 80-hour work week to cover the service needs of the hospital all the while trying to provide quality education. This would be more time away from their residency. What kind of community service would a radiology, dermatology, pathology, or anesthesiology resident be able to provide and HOW would it enhance their education?
Community service should be a part of all MDs' lives—without question—but to require it? I think many residents already provide a huge amount of community service thru their care of the uninsured—at least they do at our medical center—so to focus on them seems particularly misguided. The real question should be how do we either stimulate practicing MDs to provide more community service—or better yet, how do we select medical students who will do this continuously during their careers without needing to be forced into it?
I do not believe community service should be required of physicians, either at the resident level or at the practitioner/attending level until such time as attorneys are required to have an organization that cuts their billing and oversees them as physicians have. They should be required to do community service during law school and during practice PRIOR to making it mandatory for physicians to do this.
Strangely, only a few hours before I received your e-mail, I had a final feedback session with one of my graduating residents. When I pressed him on how our program could improve, he mentioned exactly what the AMA Board of Delegates has stressed. He said he had no knowledge how it could be done, but he felt we should provide for more opportunities for community service. Knowing he was a resident so inclined, I had earlier approached him on my own initiative as to what we could do in our program. I too believe we should be doing more. Let me hastily add that in that our residents serve the underprivileged in their continuity clinic, go on the homeless van during one of their rotations, and to a considerable extent also serve the same population on the wards and in this way they are exposed to the health care problems of the urban poor.
At the present time every moment of residency training is spent doing something of importance for a resident's education. The 80-hour work week and associated time constraints (which I fully support) do make opportunities for formal other activities difficult, even if they are not mandatory.
Could we take away some ward months? An excellent idea, but unless the ACGME is willing to lower its minimum requirements for numbers of new patients seen by interns, this is going to be difficult. I do not think these numbers are based on good data, because such data would be impossible to develop. To be truly scientific about coming up with such numbers, one would have to know how many patients with each kind of disease one needed to see before one could be said to be comfortable. How many nosocomial pneumonias does one have to see, how many gastrointestinal hemorrhages, how many myocardial infarctions, etc? Clearly such data is impossible to obtain except, in a vague way, for procedures.
Could we replace electives with months spent doing community service? I would be totally opposed to that as I believe residents need to have the opportunity to decide what they want to do with their professional lives, an experience they obtain during electives. Should we have opportunities available to work in rural or urban areas during electives? I would say absolutely yes. Hospitals then should be allowed to claim their Medicare reimbursements (if that is still going to be the way to fund GME) while residents are away at such electives.
The AMA's proposal is a totally worthwhile proposition, but one that should not come as yet another mandate without an opportunity to be creative and not lose money in the process (ie, for the sponsoring institution). Furthermore, the science behind medicine is becoming increasingly complex with the molecular biology and genetics revolutions, and I am frankly scared that very few people are talking about providing the physicians in training with the knowledge base to continue to stay in touch with future developments in medical science. Where does time for that come from?
Perhaps the answer is that medical school fees should be cut down very considerably, to say levels in Canada or less, for people who would agree to work in areas of need for a few years upon completion of their training. The areas of need would need to be strictly defined. Someone would need to pick up the tab for this to reimburse medical schools. In that case, perhaps cheap student loans ought not be available to medical students so that more people would choose this option.
There is need for a great deal of thinking and not doing the politically correct thing in thoughtless fashion.
Medicine is a service profession in its entirety. Although my program already includes activities of this type, I think this seems like a terrible idea.
What exactly do you have in mind? Yes, every doctor should be a citizen, but the last thing we need is another mandate unfunded in time and money. There already is little enough time in residency to do the stuff we need to do. After all we are training doctors. Further, how many of the members of the AMA are active in service learning?' There is more than a little hypocrisy in this.
I would be much more supportive of mandatory time in a National Health Service Corps after residency and an end to all tuition for medical education.
Community service is a personal obligation of everyone. Although the AMA is right to encourage it, we have no right to require it.
Our residents already provide an incredible amount of community service by caring for indigent patients on our inpatient and clinic services. Although the residents are paid a salary and the hospitals do receive some income for these patients, the residents certainly go above and beyond expectations in providing excellent care for this challenging patient population. They also interact with community resource personnel for discharge planning, substance abuse services, transportation arrangements, pharmaceuticals, and home care.
I think requiring additional community service is unreasonable.
I believe this represents a very noble ideal. Many physicians attempt to "give back" to their communities through volunteerism in community clinics, at health fairs, through public speaking, and by being the team physician for athletic events, etc. As we mentor residents, we should be leading by example and giving them a role model to aspire to, not attempting to mandate "do as I say and not as I do." In many ways residency programs are already "giving back" in that their typical patient population is composed of a large percentage of patients that would otherwise have difficulty accessing health care. Additionally, although the ACGME has strict duty hours limitations, we all know that residents remain hard pressed to find time to complete their daily tasks, read about their patients, and get any sleep. 80 hours still makes a very long work week. Since there is limited time, what should be given less? Dermatology, Cardiology, Continuity Clinic, and all other aspects of training seem to be important also, and most have a required amount of time on rotation. Should we ask them to give up their family time? Can we disregard the 80-hour work week for a noble cause like this? I believe we cannot legislate morality. I believe we should all try to set the best example we can and let each individual decide for themselves if they're doing their part.
Depending on the program, residents already perform community service by seeing indigent patients, volunteering at free clinics, and talking at schools. Many primary care programs pair residents with community docs for the experience. Requiring more of residents is a slippery slope. Requiring more community service means having to include it in the 80-hour work week. Do we want to sacrifice supervised teaching hospital/clinic activities to push residents out to volunteer in community service? Let's train before we worry about shoving them out to the community.
Does the specialty matter in the type of service learning that a resident takes on? Of course the specialty matters. Primary care physicians are much more likely to take an interest in or be equipped to handle global health issues that a community is likely to need addressed.
And once trained in their specialty, should doctors be required to provide some form of community service? As soon as the government pays stipends to medical students (as in Europe) then requirement for community service or service in underrepresented areas (as in many European countries) can be readdressed as payback. As long as docs have $100,000 loans when they start in practice (especially dual doc families) volunteering should be just that—volunteer.
Requiring community service will breed resentment at ANOTHER requirement. How do we teach doctors to WANT to help with the community-that's the answer.
I am a little concerned that the AMA does not consider being a physician seeing patients as a community service. It seems to me that "requiring" physicians to provide community service (however that is defined by the administrators) is another example of administrators having no clue as to what physicians do (not as a "job" but) as professionals. I think that the concept is valid and should be inculcated in the educational environment that we all live, but to "require" it suggests that physicians as a group do not provide community service unless coerced to do so with punitive consequences. I would think that instituting such a program would cost a significant amount of money, adding again to the ever-increasing financial burden of health care in the US. Those funds would be better spent on actual community services instead.
This is simply further proof of how out of touch with the reality of the practice of medicine the AMA is.
Should resident physicians be required to provide some form of community service? May be encouraged but should not be mandatory.
Does the specialty matter in the type of service learning that a resident takes on? Yes, specialty matter in the type of service learning that a resident takes on.
And once trained in their specialty, should doctors be required to provide some form of community service? May be encouraged but should not be mandatory.
Residency training in a rural setting is "service-learning!" We require all of our residents to design and implement a community intervention.
No, it is not necessary to have community service.
It is useful to learn how to administer a medical service in the setting in which the trainee will end up (inpatient, outpatient, solo, part of a group, etc). There seems to be no training in the business side of how to run an office in the private sector, academic setting, public clinic, etc. Many physicians do some kind of administrative work very soon after training. So, formal training on the business side, managerial skills, billing, etc, would be more useful. Such training needs to be flexible, with many options (eg, how to run an office, ward, ICU, academic research unit; managing people; dealing with difficult patients and staff; how to market your services; etc).
Residents should not be required to perform community service, but rather could reasonably be required to engage in service learning ... a supervised community experience with defined learning objectives. This exercise in learning to care for a community is parallel to the resident's clinical experience, in which service is provided in order to learn how to care for individual patients. Yes, the experience should be appropriate for the resident's specialty. And no, practicing physicians cannot be required to perform any kind of service ... they can select the sort of service they wish to provide, or not provide. For example, an ob-gyn could elect not to do obstetrics.
The answer is no! There was a time when residency was a service to the population. The 80-hour work week greatly diminishes this by converting much of what is done residents into shift work with lack of overall responsibility for the patient. At the end of the shift, it's someone else's problem. This shift in mentality has had the unintended consequence of communicating to the individual physician-in-training that residency is about the trainees, not the patients. We are wrong if we make our training efforts about us and not the patient. Unfortunately, those in the middle of the training will never know the difference as they never receive the feedback of being someone's doctor from start to finish.
Academic hospitals are pushed closer and closer to the edge as it is. As 65% to 70% of our work in trauma and critical care is not reimbursed, working 100 hours a week as a faculty is service to the community. Further limiting resident participation in patient care is not the answer.
GET REAL!!!! My opinion is ABSOLUTELY NOT!!!! Physicians perform more "pro bono community service" than any other profession. We always have and we always will.
In these times of diminished time allotted for resident education, where will these community service hours come from? Will they count toward the 80-hour work week? The government gets far more than they pay for re: GME financing. I for one will refuse to participate in any mandated community service activities for either myself or my house staff.
I would hope that the AMA recognizes the great deal of community service provided by residents on a daily basis. A majority of residency programs are in medical centers that are situated in locations where a large proportion of their patients are underserved. Residents are on the front line each day for patients that are uninsured, patients on government insurance programs (Medicaid and Medicare), and patients in VA hospitals. Many of these patients do not have access to physicians in the private sector. Many of the continuity clinics for residents in primary care specialties provide excellent medical services for patients who would otherwise have a hard time finding a physician. Many of the clinics in which surgical and subspecialty residents train provide care for those patients who would not otherwise be able to find a surgeon or subspecialist. Many of the patients that receive care from residents are from areas that have a hard time attracting qualified attending physicians. Residents are on the front line every day for patients in their community. Residents can't say I'm not taking new patients or I don't take that insurance or I don't take Medicaid.
Therefore, I do not think that the AMA or ACGME should require more community service of residents. Does the AMA require community service of its members? I think that, based on the amount of front line care for patients on government-sponsored health care programs (Medicaid, Medicare), the government is getting a good return on its investment, ie, federal funding for GME. Rather, what is needed is for residency programs to train residents in community medicine: how to look at the community as a population rather than just individual patients, how to assess medical needs of the community, how to participate in meeting these needs, how to partner with community-based organizations, how to advocate for patients, and how to help patients access community services. This already is addressed in the Program Requirements of the RRC for Pediatrics, and may be in others as well. Perhaps the AMA's role would be to help develop resources to assist in the training of residents in community medicine.
Community service is an admirable activity for physicians and should be encouraged but I do not think it should be required. For some specialties, eg, oncology, it would only take fellows away from their subspecialty training to do general medicine and I do not think would add to their training. Residents in primary care specialties may benefit most from such activities.
It is clear that as physicians we are doing a poor job at (1) accounting for the amount of free care we provide, which is an excellent community service, (2) accounting for any community-based education that almost certainly goes on now, including office teaching, (3) communicating about the presence of medical care 24/7 because of already mandated coverage for walk-in patients in most hospitals, and (4) keeping sight of the intent of residency education, since duty hour restrictions already limit training and this component—which also fits into the care for the non-insured, incidentally—would complicate this matter.
We should help policy makers understand what is being done now compared to other professionals (ie, law) before more regulations are added.
Some of our residency programs already require community service as a part of their requirements. I think it is a valuable learning experience that puts the residents in touch with community issues and would be beneficial for all residents. I do not think the type of experience should be linked to the specialty.
As far as requiring community service for all practicing physicians, I do not think this should be required. It isn't required in other professions and should be a personal decision. Hopefully, experiences gained in training will result in more practicing physicians doing so.
Yes, I think that community service should be required as part of US residency programs. As community leaders, physicians need to be involved in their community's culture, social issues, and economic well-being. Pro bono community service is one excellent way to prepare young medical students, interns, and residents for their future roles as leaders. In some ways, community service can teach more about health and healing than all the medical schools in our country.
Resident physicians should not be required to perform community service. As medical/surgical educators, we are struggling to make this system work despite unfunded mandates, including the limitation of 80 hours of work per week. There is no time in our curriculum for such community service. Moreover, the entire residency might be considered "community service."
The concept of public service is an excellent one. However, I do not support this as an additional requirement for residents for two reasons. First, many residencies include a large percentage of indigent care, either in public hospitals or clinics. It is an unspoken reality of medical education in the US that most physicians learn their trade by practicing on the poor. Second, the new ACGME rules combined with the move toward hospitalists have already compromised residency training in internal medicine to the point that I worry about the competency of the next generation of internists to take care of sick patients. They will be well-trained in preventive medicine, but not in general internal medicine, which is learned best by taking care of sick people. I do not want to take away any more time from their training.
I think the first argument also applies to subspecialty trainees. However, I am very much in favor of requiring trainees to do a few months of public service after they finish their training, if their education has been subsidized by the government.
Most residents already perform a great service to their community. They spend a large number of hours caring for very ill people, often providing essential care to underprivileged individuals and communities, and are compensated quite poorly. If this is not the definition of community service, I don't know what is.
Fully trained doctors also provide a great deal of community service. Any physician who cares for Medicaid patients is already donating a huge amount of his/her time and expertise for essentially no compensation. The same is true of many other physician activities and insurance plans. To require some additional "community service" will only decrease the amount of time physicians spend caring for the indigent, and putting in extra effort on aspects of care which are already poorly compensated or uncompensated.
If our medical leadership is seriously entertaining questions such as these, it is no surprise that quality physicians are leaving the profession in large numbers or choosing careers that entail no clinical practice.
I suspect that almost all residency programs are providing care to indigent patients through their residency practice or clinic sites. I feel that mandating resident "community service" would be hard to monitor and lead to substantially more paperwork and record keeping. I do strongly support inclusion of healthcare economics and sociocultural issues in all residency curricula.
I also feel that any physician that participates in governmental insurance program, eg Medicare, should be required to participate in all programs including Medicaid and Medicaid HMOs.
Our residents and fellows already perform community service by caring for the indigent patients in our clinics throughout the region.
Residents and fellows providing community service is a valuable learning experience, but it must be part of a supervised, integrated program and not a required add-on. Once in practice, the physician who should have been indoctrinated in med school or at least during further training will naturally provide community service. Again not a requirement.
Residents already perform community service when they care for patients in ERs, OPD clinics, etc. Attending physicians should perform community service either through ER call for the uninsured or covering indigent outreach/screening programs, etc. The amount of commitment should not be excessive. While many physicians will complain, I believe they will feel some personal satisfaction.
Gee, and I thought that just being a doctor was community service. I think that doctors should be involved in their communities, doing the things that nonphysicians do. That could be helping out at their kids' schools, booster clubs, or fund-raisers. Their are charities to get involved in. Soup kitchens, etc. But requiring it? C'mon. This is still a free country! I think that we should stick to requiring competence and mastery of one's medical skills and that's about it!
I DON'T THINK SO.
Residents have already more then enough to deal with. And what is the need for something every resident to have community service to improve the health of population. Are they going to get reimbursed when done with training? If not then it is wasted effort. Plus this should be the part of public health curriculum, NOT residency curriculum.
I think education ABOUT the role of community service in health care should be taught at both the medical school and residency level (one of the six competencies is system-based practice) and, as part of this, experience is necessary. HOWEVER, this needs to be taught with and in the context of how our health care system is a business—by this I mean that we have to talk about the dichotomy (which is as we know becoming more blurred) between nonprofit and for-profit health care organizations. (The "elephant in the room" is this: Taking care of sick people can be profitable; is it okay that health care is financially profitable?)
I teach third year medical students about house calls and home care programs. When I describe one house calls program (Mount Sinai in New York) that is financed by the hospital, I ask them, "Why would a hospital financially support (approximately 50%) such a program?"
Over 90% do not know the answer. They are typically surprised that the hospital can actually benefit financially from these patients (who are frail usually and have a fairly high hospital rate, despite efforts to keep them out of the hospital). They do not understand that hospitals "need" patients, that they make "money" by having patients come to the hospital.
So, yes, I am in favor of education of community service, but only if we tell teach the whole story.
Should resident physicians be required to provide some form of community service? Absolutely NOT! Residents slave away for very little pay, many incurring even more debt during residency. By participation in indigent care, they already contribute more than their salaries already. This amounts to abuse of our trainees. It's a terrible idea. Voluntary community service would be OK, if someone is so inclined. Those students or residents who received NRSA funds already have a significant payback agreement.
Does the specialty matter in the type of service learning that a resident takes on? And once trained in their specialty, should doctors be required to provide some form of community service?
NO! It must be voluntary. Physicians contribute thousands of hours already to community service. Requiring this is another extremely bad idea.
I'll add that I've been an educator and academic physician all my professional life. I believe that physicians are still (despite pressures to demean their status, financial penalties imposed by 3rd party payers, and attempts to regulate practice and medical ethics by heavy-handed organizations that have no idea of the doctor/patient relationship) the most altruistic and helping-minded individuals around.
Already, there is a significant brain-drain away from medicine. Average
Speaking on behalf of myself, not my institution, I feel that it is not wise to require residents to provide some form of community service. And once trained, I also feel it is unwise to require community service. Government-run and -mandated community service has generally been a poor way to provide these services. In addition, to compel each resident and physician to do so at a given time in a given way (yes, it would have to be very narrowly defined to be logistically feasible) is likely to produce a backlash and to be seen as undercutting professionalism.
Physicians and trainees are as likely, and perhaps more likely, than those in other professions to provide community service. This aspect of our professionalism should be modeled, encouraged, and facilitated in all aspects of medical training and practice. To mandate it would, however, be counterproductive.
This is one of the dumbest ideas I've heard in a long time. The
So working 80 hours a week for $10 an hour and providing medical care to millions of indigent and uninsured patients isn't public service? Is the AMA really as out of touch with academic medicine as they usually seem to be? And where are the extra hours supposed to come from for this proposed mandate? Perhaps the bureaucrats of medicine need to butt out and let us get on with the task of training new doctors. It is hard enough as it is.
I believe residents should be required to participate in some form of community service. The service could be medical or nonmedical in nature. This would contribute to developing a more well-rounded individual and give them a sense of something larger than themselves. I don't believe the hours spent in community service should count toward the resident work hour limit.
It seems that once again organizations are attempting to legislate physician behavior. Let us not forget that residents are participants in a graduate education experience. Let us treat residents as we do graduate students in other professions. Should we hope that all physicians will contribute to their communities—yes. Do they—no. Should we hope that everyone will contribute to their communities—yes. Do they—no.
For most of our surgical residents, a significant portion of their time is spent with "service" patients and to require any additional time would be counterproductive. For any residency that has NO service component it might be helpful, but I am not aware of such residencies.
The AMA proposal is unwise. It may be well meaning. It should not be applied to residency programs.
"Requiring" (ie forcing) people to provide community service defeats the purpose and makes that service subpar. Service to one's community must be something a person, whether a physician or layperson feels compelled, "called" if you will, to do. Making community service a requirement of a physician's education would lower the quality and meaningfulness those of us who feel "called" to serve provide.
In all due respect, this is a well-meaning but misguided venture. With the appropriate limitation of residency hours, when do you propose residents perform this service? We need to train physicians to be caring and competent. That is more than a full-time job already. If we are to ask people to do community service, it should be prior to medical school, rather than by diluting the residency experience any further.
This is not a good idea; it ignores the current state of many residency programs: There is barely enough time for training, particularly with the 80-hour work rules, and there are insufficient funds to support the needed teaching and research missions due to the decreased third party payments for faculty patient care. Most residents already go through community service education in medical school and are identified as knowledgeable about community needs through the residency selection process.
As a surgery program director, I am opposed to a requirement for community service during residency. The main function of a residency program is to produce physicians who are well trained in their specialty. While community service has value and contributes to the overall development of a person, there is so much medical knowledge, and in the case of surgery, technical skills to learn, that such a requirement would only dilute and make more difficult the training of these physicians. I also believe that the individuals who enter medical school and residency have already had their basic characters formed and that forcing a service requirement would do little to change character or attitudes at this stage in life. Finally, the residents do perform community service daily. They are involved in the care of patients who have little resources, help them through the system, are their advocates, and often are the front line for critically ill and injured patients.
Please, do not add additional nonmedical requirements to programs that are already struggling to meet the educational demands of the discipline within the confines of the current regulations.
I think all doctors should be required to provide 3-6 months of some kind of community service. This could be done on weekends, or 1 week per month. However, you must not forget that many physicians train at city or county hospitals, and thus provide community service on a daily basis during their training.
In my opinion all this is stupid nonsense discussions you are engaging in. Thanks God you have nothing to say when it comes to residency matters . Please just shut up and leave this to ACGME.
Why should doctors do community service and no one else. Are you telling that as doctors we have to pay back for being doctors!? Somehow doctors have to "earn back" some respectability.
I am sorry to put it this way, but when you say that AMA reflects a "broad-based opinion," I have to say that I hope not. At least you are NOT expressing my opinion. I am a program director, just leave this issue to ACGME and the program directors. We do not need YOUR (restricted to YOU) opinion!!!!
Although AMA policy lacks the authority of ACGME and RRC requirements, they reflect a broad-based professional opinion. What do you think? Should resident physicians be required to provide some form of community service? Does the specialty matter in the type of service learning that a resident takes on? And once trained in their specialty, should doctors be required to provide some form of community service?
YES.
At our psychiatry program, the residents already do quite a bit of community service in the sense that they provide free care for a number of indigents (outpatients) that our hospital does not bill for. We tried to get this moved to our hospital's "free clinic" in order to facilitate this activity but the free clinic doesn't have room. Residents do provide limited service to another free program but it is small and can only accommodate a few of them.
Therefore, in view of the logistical problems, I oppose any new mandates or requirements which will be difficult or impossible to comply with.
This is a grand idea. I think of all the Free Clinics there are and the access the students would have to the true human condition. Serving with a family medicine physician or any physician who has a first response priority is also a great idea, but there's still nothing like the experience one gets "after hours" and in general clinics.
I say all of this while acknowledging that I haven't yet found the time from an academic practice to serve in the free clinic here in town. It's a goal I have for my less busy future, but I must admit I am not setting the example that would inspire our students to staff the opportunity here.
In a perfect world residents should provide community service. That said, unfortunately we live in the real world where residents often have astronomical medical school debt and sometimes a family on top of that. Some residents have such a tremendous debt load that it would be crushing for them to take additional time and be forced to do community service. I don't think mandating community service is a good thing. Those that are able and willing should be encouraged and those that cannot for one reason or another shouldn't be penalized, because the community isn't going to get much benefit from a disgruntled physician.
The idea is certainly laudable. I would argue, however, that the implementation of such practice would be a bad idea for the following reasons: 1) medical residency training is already stretched thin in providing an adequate period of training time and experience prior to graduates entering practice; this problem has been exacerbated by the new work hours guidelines, with no mechanism for recouping the lost experience; time spent in community service would not likely be "high impact" learning and would likely therefore detract from the total quality of residency training; 2) a desire to be involved in ongoing public service is probably not something that the medical education system can "teach" someone; 3) if this desire can become a learned behavior, it may be more fruitful to institute such measures earlier, during med school; and 4) having practiced medicine in developing countries, I am left with the impression that the US medical education system already performs a tremendous public service through its training of quality physicians. Only a portion of the medical care gap between developed countries and the developing world is accounted for by lack of medication and technology; the biggest component of quality medical care is still contributed by a rigorously and completely trained physician. I think placing another straw on the camel's back of medical education could potentially be a distinct public disservice.
Our medical school has a long tradition of volunteer community service on the part of its students, house staff, and faculty. Most of us, from back when I was a medical student in the 1960s to the latest graduating class of 2004, have participated. Over the past few years, we have added competencies to our medical student curriculum, and one of them—Community Context of Care—focuses on this very thing. But taking community service from the realm of volunteerism to "just another requirement" defeats a lot of the purpose. We try to get our trainees to see their connections to the larger community and to feel an internal sense of the "rightness of giving back." An external requirement won't help further that type of motivation. In addition, residencies are struggling with so many requirements already. New requirements become meaningless to the trainees because there are so many. And residency training directors are devoting more and more time and effort to assessing and tracking these new mandates, but since they are always unfunded, do so with very limited resources. I am not in favor of this requirement specifically, or for that matter, of any additional requirements, unless and until someone starts eliminating older requirements as new ones are developed and shows how the added value of new requirements makes them more worthwhile to the trainees than what we do currently.
I am not in favor of forcing residents to do community service. Their time is so precious and many need their free time for family matters. Secondly, the majority of medical schools do a lot of indigent work to begin with, so there is not much difference in doing work say in a free clinic. I fully believe we should make the residents aware of opportunities for community service and to encourage them to participate as their time allows.
Although your intentions are noble, I would suggest you read the Hippocratic Oath and teach that to all residents.
Community service is inherent in most programs as residents routinely take care of indigent patients. Insisting on a "program" for community service adds to an already overcrowded academic and clinical schedule and would result in no practical gain. QUIT ADDING NONSENSE TO OUR PROGRAMS!!!!!!!!!!!!!
I polled our program directors regarding your question about requiring community service of residents in training. The fairly overwhelming response was NO MORE REQUIREMENTS. Although most PDs advocate community service among their residents, the feeling was that with competing priorities and the 80-hour work week, no more requirements should be added to resident's time. Our residents are already performing patriotic duty by being voluntary members of the armed services. They also participate in many causes to support soldiers and their families as well as the local community. Certainly this is looked at as part of the ACGME competencies in evaluating professionalism.
It's specialty specific - in neurosurgery it makes no sense.
I think all physicians, not merely residents, should provide community service equivalent to the amount of government subsidy that was provided for their education.
I don't feel that physicians should be required to perform community service. This is a very individual choice to make. Many people feel very satisfied with the service they provide every day at work. I've done enough "compulsory" community service in high school and college and I know first hand that if you are doing something because "you have to" it's not a genuine experience and becomes something you resent.
Residents: No for required community service. Even with the 80-hour work week, I'd much prefer to see residents affirm their families, their avocations, and their self-discovery...Geez, I sound like a shrink, and I'm not all that warm and fuzzy.
Attendings and community physicians: Hmmm!!! That's a more interesting question and raises the issue of "professionalism" in a larger societal construct. Do we have an obligation to our communities beyond the clinical services we provide? I think, yes. But I've fallen from grace with regards to the typical community service stuff like church (much to spouse's dismay) and attendance at Rotary (way too upbeat for me). But I still feel obligated to public health and health care advocacy groups like the Alzheimer's association. Again, however, this is within the broad umbrella of a health professional.
So I guess I align myself with the position that physicians should have community service as part of their moral obligation to serve, but it should be tailored to their individual interests, and NOT MANDATED FOR LICENSURE OR RECERTIFICATION REQUIREMENTS.
As an Associate Dean for GME for the past 12 years, 1) I have had the opportunity to watch the transition of graduate medical education (and the residents) quite closely. 2) I have also accepted the fact that the generational changes (GenX and Millennium) are now hard upon us. Residents now are clearly different--some ways better, some ways not so. (Are they more professional than their immediate predecessors? It's too early to tell, but their role models are the same and I anticipate that professionalism will still be a major issue.) 3) And most immediately, I have survived the first year of the duty hour limits, and am reminded of the law of unintended consequences--we already have pretty compelling evidence that residents aren't sleeping any more and aren't reading any more.
I believe that it is not only possible, but highly desirable, that residents should participate in activities that are identifiable as providing measurable community service, as an important component of mastering the third competency domain, attitude/behavior. But these should be developed WITHIN the residency program rather than added on outside. There are plenty of opportunities all around us for residents to perform a community service without having to invent new things for them to do. Rather, they can be "repackaged" and "marketed," with a specific requirement that residents maintain a "portfolio" of their community activities as a component of documenting their acquisition of competency.
For some residencies, where the residents rarely work more than 40-50 hours per week, a requirement for ADDITIONAL, EXTERNAL community service might be workable and might be acceptable. But for the majority of the residencies, this would be viewed as an unhelpful imposition, would significantly confound the current duty hours requirement, and could even end up becoming a negative, grasping defeat out of the jaws of victory.
I wholeheartedly support the notion of definable community service, but within the construct of the existing residency training model.
The AMA's call for residency programs to include community service in order to qualify for GME financing is driven by admirable intent. However, hospitals with training programs are already providing the lion's share of health care and educational services to the uninsured, and many, such as my own hospital, are having difficulty with financial solvency due to this. The current method of GME reimbursement helps to offset this burden. Therefore, I am not in favor of making community service a prerequisite for GME funding. It is already occurring, and a mandate will only serve as a public relations ploy which will add considerably to the bureaucratic and financial burden to teaching hospitals.
While working in community (county) hospital these residents are exposed to community problems and learn to deal with them. I do not think they should be required to do any community service during residency period.
I am the director of the required 4-week family medicine clerkship. We require a community project of all our students which gets them out of their preceptors' offices and into community settings where they can learn more about their patients than medical history. We strongly believe that this is one aspect in developing cultural competence. In addition we have students work at a student organized free clinic on Saturdays, which gives them access to patients who are not frequently seen in the places where medical students typically work. They learn that these uninsured patients are no different than other patients that they see and get experience in providing some "free care" as professional.
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