James R. Boex

To begin to understand how residents' work affects their own educations and the hospitals in which most of their training takes place, the authors undertook a systematic review of the literature analyzing residents' activities. This review sought to analyze resident physicians' activities to assess the educational value of residents' work. The published literature was searched in 2001 using the Medline and Science Citation Index databases, and the unpublished literature was searched using bibliographies and key informants. One hundred six studies were rated for methodological rigor using the Cochrane Collaboration protocol, as modified by Bland et al. for nonclinical trials. Only those studies undertaken following the Bell Commission's report in 1987 and whose methodological rigor score fell at or above the median for all studies rated were included in the data synthesis. Results data from 16 studies that included over 1,000 residents in six different specialties, were combined under the definitions of types of residents' activities: marginal, patient care, teaching and learning, and other. This preliminary analysis found that residents devoted approximately 36% of their effort to direct patient care necessary to achieve specialty-specific learning objectives, 15% to the residency program's organized teaching activities, and potentially as much as 35% to delivering patient care of marginal or no educational value. An additional 16% of residents' waking time on duty was spent in other, unspecified activities. It is possible and potentially valuable to consider not only the number of hours worked by residents, but the educational content of their work when considering residency work and hour reforms

In 1995, the authors obtained cost, operations, and educational activity data from 98 ambulatory care sites across the United States in which primary care teaching was occurring and compared those data with the corresponding data from 84 ambulatory care sites where no teaching was going on. The teaching sites in the sample were found to have 24–36% higher operating costs than the non-teaching sites. This overall difference in costs is approximately the same difference in costs earlier estimated for university teaching hospitals compared with non-teaching hospitals. These costs are shared by all involved in the ambulatory education process: sponsors, sites, and faculty. In a related finding, the authors discovered that 30–50% of all ambulatory care sites thought not to be involved in education are in fact teaching at a high level of involvement. Further research into not only the costs but the value of education in the clinical setting is encouraged. The authors also hope that the publication of this report will encourage accrediting bodies and professional organizations to improve the information available about ambulatory care training in general.