Wednesday, July 14, 2004

Incentive Compensation and training residents. How shall we manage the intersection? (Part 2)

Last month I told you about the economic challenges we were confronting out of the transformation of our practice into one with both clinical and academic missions. I wrote about our charting improvement initiative and engaging concerned staff colleagues in both developing solutions and seeking the engagement of the broad group in the implementation of the solutions. I’ve promised that this month I would discuss modifying incentive structures so that an academic mission can be explicitly accommodated. Let’s consider some relevant observations.

As long-time readers know I have a bias towards quantitative evaluation whenever possible, thus, the recent publication[1] of a relative value scale for teaching gives me some hope for including more quantitative evaluation of teaching contributions among physician staff; however, this tool alone, even fully implemented as described by the authors probably won’t serve as the sole measure for academic productivity. Aside from my general reluctance based on Deming’s warning about management on numbers alone (see my July 2003 column) in the case of teaching and scholarly activities, how shall we assign value when the work done benefits the worker—the teaching physician—too?

Just as maximizing revenue isn’t unique to clinical practices—as an emed-l poster commented, “academic programs in particular, considering the payer environment most of them are in, need the clinical production efficiency every bit or more than the community ED.” referring to using RVUs as the driver for all compensation. Yet, in a double coverage ED, the process of supervising residents, particularly supervising senior year residents who are themselves overseeing the work of more junior residents, I would accumulate many more RVUs/hour worked than a physician in the same ED just seeing patients. Since the other physician's work indirectly facilitates me spending time with the residents and accumulating their RVUs, some adjustment is probably appropriate to fairness.

In the context of direct teaching activity, while Khan and colleagues’ approach shows some merit, as another poster has opined in the past, “One must have adequate protected time (which is quite expensive) to further the department's goals. Someone who runs the department, runs the residency, runs a course in the medical school, directs the research for the department—all of these need protected time. I've seen papers published about how protected time is counted, and am quite shocked, to be frank, that attendings are given (paid) protected time to attend (not teach, just attend) resident conferences and faculty meetings. Not that I don't think they shouldn't attend. But, if you have to divvy up for every minute that your faculty member spends beyond strictly clinical hours and reward it with paid protected time, you're paying out hundreds of thousands of dollars a year just to have your folks come sit in a room, with little to show at the end of the year. It is crucial that protected time unfunded by outside resources be used wisely, if we hope to progress as a specialty. If you have to ‘spend’ it for every minute outside of a clinical shift, nothing will be left for the larger stuff, like having a productive department as a whole.”

This colleague works where the group has come to a common understanding, where certain duties are “just part of the deal . . . there were some irreducible contributions as faculty which would not be measured against ‘protected time’. This included attending faculty meetings, grand rounds, and being asked to give a talk on some subject every month or two, if needed. It may also include participation in hospital and medical school committees.”

You might argue that we should be separately compensated or supported for all of the non-clinical activities and that's a nice idea but not reality at our hospital or in the academic environments I know. I don't think full support for academic activities exists anywhere; that corner of our society is still a bit of a social welfare state.

So taking all these inputs together, I've chosen to consider the issue along the lines of the “Leading Beyond the Bottom Line” principles I've written about, adapting these principles first articulated by American College of Physician Executive authors.

It seems to me that our developing clinical and academic department should strive for the pareto optimum among patient care, community service, organizational economic well-being, staff well-being (economic, professional development and others) and unique to the academic environment, a fifth good: academic accomplishment (perhaps measured through RRC approval, peer academic recognition, scholarly productivity including grant funding and others as per Khan). I don't believe that it is possible to divorce clinical center productivity from the rest and optimize it alone. We teach residents from almost every specialty, a significant fraction of patients admitted in most teaching hospitals come through the ED, we teach medical students, etc. These academic interactions matter in our institutional standing, and for those at the medical school seeking promotion and tenure (hence compensation) and other tangible and intangible aspects of life in our clinical and academe.

I still think we're in an era of “local solutions.” I'm a big supporter for all of these metrics as inputs, but not direct drivers of resource allocation decisions or incentive pay. Ultimately, in seeking a pareto optimum, I subscribe to Deming’s admonition (his seventh “deadly disease”) that not all measures are known or even knowable. As a consequence a degree of subjectivity remains and it's the leader's responsibility to exert that subjectivity “fairly.”

Yet, as we at Maimonides Medical Center undertake to develop a fair allocation method, I’ll offer this essay and references to my colleagues on our Faculty Practice Finance Committee and seek their solutions and their engagement of their colleagues in crafting a solution. When we get there I’ll let you know how it turns out.

[1] Khan NS, Simon HK. Development and implementation of a relative value scale for teaching in emergency medicine: the teaching relative value unit. Acad Emerg Med, 10(8):904-7, 2003.

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