Teaching vs Clinical Productivity: A Zero Sum Gain?

Michael Greenwald, MD  FACEP, FAAP
Associate Professor, Pediatrics and Emergency Medicine
Emory University/Children’s Healthcare of Atlanta

It’s déjà vu all over again.  Each winter we (or at least some of us) seem genuinely shocked at how busy it’s become in the ED.  We get to enjoy a brief respite over the winter holidays and then the surge returns until that last RSV prion fades in the spring.  And just as we find ourselves in “battle mode” for the onslaught of febrile children with their insidious runny noses and ever present coughs, our affection for teaching trainees seems to wane.

It’s not that we’ve lost our commitment to education, but it’s hard to maintain the  romance of summer when all we seem to hear during the colder months are concerns over longer wait times, extended work hours and how we are not meeting our various “productivity” goals.   And while we may not consciously worry about how this tension affects personal compensation, ultimately our attention to teaching will struggle to compete when patients per hour (and not effective teaching) translates into the number on your paycheck and performance reviews from your boss. 1, 2

But perhaps this is all a false narrative. Is effective teaching truly in competition with patient care?  Many clinicians at various stages seem to think so.  When asked in a poll of residents at my institution: what is the biggest obstacle to teaching? the single most common answer was: not enough time to teach.  When I pose this question to attendings at various faculty development workshops I get the same answer.  There now appears to be a consensus that inadequacies in medical education must be due to new and growing pressures to see more patients in less time.  If only I didn’t have so many patients to see then I would be a better teacher.

Frankly, I don’t buy it.  Yes— today we hear more from administrators (directly or indirectly) about “the numbers”.  Perhaps we have not yet learned how to deal with that dialogue.  But it has always been busy.  Current trainees insist that today’s clinical load is larger and more complex than their predecessors.  Really?  I remember routinely having a dozen patients per intern on the wards and taking calls every third night on some rotations.  (Back then “call” meant working 30 hrs).  I remember doing lots of LPs because we saw infants rapidly decline due to H flu and Group B Strep.  I remember that our PICU seemed to be filled with children dying from complications related to their transplants because we hadn’t yet figured out how to handle many of those complications.  Finally current faculty may be shocked to learn that the desire for more protected teaching time and better compensation for teaching is not new either. 3

Teaching something worthwhile to a trainee does not require lots of time.  A clinician-teacher who confuses precepting with giving a lecture will surely fail to recognize this truth

What may be “new” is the perception of our teaching responsibilities and what it means to be “effective” in teaching and patient care.  Making an accurate diagnosis or at least the right disposition seldom takes a lot of time.  Some patients may feel that “spending time” listening to them = good doctor, but experienced clinicians know how to demonstrate their concern while abbreviating the history taking to expedite care.  Similarly— teaching something worthwhile to a trainee does not require lots of time.

A clinician-teacher who confuses precepting with giving a lecture will surely fail to recognize this truth.  The utility of precepting is to match a memorable clinical example with a nugget of wisdom.  Expounding on that example detracts from the poignancy of the moment.  You may have lots to share about the topic—but when it comes to precepting—less is more.

Finally— effective clinicians and effective teachers are not mutually exclusive.  The communication skills required to target and address learning needs of a trainee are the same essential tools we use to make a diagnosis and direct patient care. While each of us has different strengths there are plenty of physicians who maintain high “clinical productivity” and high marks for teaching at the same time.  And for those in administration who operate under the misguided notion that trainees detract from clinical productivity our research suggests that this is not the case.4

This is not an either/or situation.  Yes— it is busy again.  And just as it will slow down in the summer it will get busy again next winter.  Time to re-kindle that teaching relationship we pledged last July.  It will fulfill us now just as it did then because what we love about teaching never changes.

 

 

  1. Khan NS, Simon HK. Development and Implementation of a Relative Value Scale for Teaching in Emergency Medicine: The Teaching Value Unit ACAD EMERG MED d August 2003, Vol. 10, No. 8. 904-907.
  1. Barone MA, Dudas RA, Stewart RW et al. Improving teaching on an inpatient pediatrics service: a retrospective analysis of a program change. BMC Medical Education 2012, 12:92; 1-8.
  1. Skeff KM, Bowen, JL and Irby DM. Protecting time for teaching in the ambulatory care setting. Acad Med Aug 1997;72;8;694-697.
  1. Usatine, R P; Nguyen, K; Randall, J et al. Four exemplary preceptors’ strategies for efficient teaching in managed care settings. Academic Medicine. 72(9):766-9, September 1997

 

 

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