Categories
Medical Education

Gender Bias In Lecture Acoustics

Last month, I attended the American College of Chest Physicians annual meeting. At one of the sessions, I realized I could hear the men talking but I had a hard time hearing the women despite the fact that they were all standing in front of the same lectern and all speaking in what seemed to be normal conversational speech. I realized that there can be implicit gender bias in lecture acoustics and that women need to be aware of some of these sources of acoustic bias in order to be effective speakers. There are several sources of acoustic gender bias. In this post, at the risk of being a male talking about female gender bias, I’ll explore several of these.

Gender differences in vocal frequency

Male and female voices occupy different sound frequencies. A typical male voice extends from 150 Hz to 6,000 Hz and a typical female voice extends from 350 to 8,000 Hz. However, in normal voiced speech, a male voice is 85 – 180 Hz and a female voice is 165 – 255 Hz. Certain vocal sounds occur at higher frequencies than others. For example, the sound of “J”, “M”, or “Z” occurs at a low frequency whereas the sound of “K”, “F”, or S” occurs at a much higher frequency.

Humans are wired to associate lower frequency voices with authority. In a study of male CEOs, the size of the company that a CEO ran correlated with the frequency of his voice – a lower voice pitch was associated with running a larger company and correlated with a higher salary. Interestingly, the average frequency of adult women’s voices has fallen by 23 Hz since 1960 which may reflect evolving societal differences in women in positions of authority. Because children have higher pitched voices than adults, a high-pitched voice can make a person sound young or inexperienced.

Many sound systems are adjusted to make the (often male) CEO sound great and this can put people with higher frequency voices at an inherent disadvantage unless there is someone tending the sound system who can make everyone sound just as great as the CEO.

We lose high frequency hearing with age

As we get older, our ability to hear high frequencies is diminished. Business owners use this to their advantage when they install a Mosquito alarm outside their buildings. This device emits an annoying 17,400 Hz noise that loitering teenagers can hear but older people are oblivious to. High frequency hearing loss begins at age 30 and increases with each decade of life.

As a result, many older people have a hard time hearing female voices with their higher frequency pitch. This is not an issue if you are lecturing to a group of college students. However, if you are lecturing to an older group of people or giving a presentation at a board meeting full of older board members, then a higher frequency voice is harder to hear. A woman often needs to speak slightly louder to be heard as well as her male colleague.

Equipment bias

There are two pieces of equipment that can affect how women’s voices project as opposed to men’s voices: the microphone and the equalizer. Each microphone will have a frequency rating that reflects how well it picks up different sound frequencies. A microphone that is better at picking up lower frequencies will tend to make a male voice sound louder and a female voice sound softer.

A second way that the microphone can cause discrimination by the “proximity effect”. This occurs because lower frequencies tend to be lost the further away a person is to the microphone. The average American man is 5 foot 9 inches tall where as the average American woman is 5 foot 4 inches tall, a difference of 5 inches. If a lectern microphone is set to position that microphone for the height of a man’s head, then a woman’s head is going to be 5 inches further away from that microphone with the effect of losing her lower frequency elements of speech. Therefore, simply by being closer to the microphone, you can augment the lower, or base frequencies in your voice. An easy way to demonstrate this is to use the “voice memo” app on your phone and record your voice saying the same thing with the phone 2 inches, 12 inches, and 24 inches away from your mouth. At 2 inches, your voice will have more base elements and will sound deeper and richer.

Microphones come in two general categories, directional and omnidirectional. A directional microphone picks up sounds from one specific direction and should be positioned so that it is pointed toward the source of that sound. An omnidirectional microphone picks up sounds from all directions from the microphone. The microphones on lecture room lecterns are usually directional so that the speaker’s voice is picked up but room noise is minimized. However, even with a directional microphone, as you increase the distance from the microphone, room noises will start to creep into the audio if the audio technician is attempting to maintain your voice at a constant volume. To ensure optimal acoustics, be sure that the directional microphone is pointed at your mouth.

 

Two other effects of the distance to the microphone is on reverberation and “popping noise”. Reverberation, or the echo of one’s voice in a room, becomes more evident when there are non-porous materials in the room (for example, concrete walls) and when one gets further from the microphone that they are speaking into. Those echos can make words harder to hear. If a person gets too close to a microphone, then the microphone can pick up puffs of air that can accompany sounds like the letters “p” or “b” and this can result in a distracting popping sound to one’s speech. Professional musicians overcome this by using a pop-filter composed of a piece of stocking-like material stretched and mounted as a screen between the microphone and the singer’s mouth. Pop-filters are impractical in a typical lecture room. The best distance is usually 6-12 inches between microphone and mouth; this distance is the best compromise between reducing popping sounds at the same time as reducing reverberation and room noise.

In order to account for different frequencies, equalizers are often used by sound engineers. An equalizer allows the engineer to preferentially amplify sounds in different frequency ranges and this can be used to “equalize” voices of different pitches, for example, men versus women. The bass and treble knobs on a radio are the most simple form of an equalizer. An equalizer in a lecture room can have between 5 and 31 sliders with each controlling a range of frequencies. Most lecture rooms don’t come with professional sound engineers, however, and so equalizers in a sound system may be set to a factory default frequency preference or the equalizer may be run by an audio-visual staff member with little idea of acoustic optimization. If you ever go to a small venue concert, the singer will almost always recognize the person running the sound system at the end of the show – how well that person manages the equalizer can make an enormous difference in how the singer sounds. The person running the lecture room sound system is just as important to the effectiveness of the lecturer.

Room bias

The acoustic response of a room if affected by many variables but one of the more important is the degree of absorption of different frequencies. Porous materials in a room, for example, carpet or fabric, can reduce reverberation and echos but will also absorb high frequency sounds. Thus, a person with a high frequency voice may not seem to be as loud as a person with a lower frequency voice. The more porous materials are in a room, the more a woman’s voice can be lost.

The individual’s “voice brand”

There are 5 main features of a person’s individual voice brand: intensity, inflection, rate, frequency, and quality. Adopting different elements of each of these features can significantly impact the effect a voice can have on a listener.

Intensity is the loudness of a voice in decibels. Too soft of a voice can come across as meek and timid but too loud of a voice can come across as if you are shouting or angry.

Inflection is the intonation of voice or the degree to which the pitch varies. An excessively monotone voice has little variation in the frequency of the words spoken and can come across as uninteresting. An excessively up-and-down voice with constant swings in the frequency of words can come across as unintelligent.

Rate is the speed of one’s speech. Too slow comes across as condescending but too fast comes across as being rushed. Varying the rate of speech can be an effective way of emphasizing certain points. A good rate range is 162-175 words per minute.

Frequency is the pitch of the voice, usually measured in hertz (Hz). Too high of a frequency can make one sound young or less intelligent, as discussed above. Too low of a frequency can be authoritative but can also come across as aggressive.

Quality are those characteristics of a voice that can create an “interesting voice”. Two voice qualities to avoid in public speaking are the “glottal fry” and “up-talking”. Glottal fry is when a person takes their voice down to an unnaturally low pitch during part of a phrase resulting in a creaky or graveling timber. A study of voice perception found that people over age 40 believe that speakers using vocal fry sound like they lack authority. Up-taking, or high rising terminal, is when a person increases the frequency of their voice at the end of a sentence. This results in a tone that sounds like a question and can make the speaker come across as unsure of themself or uncomfortable.

So what can women do?

To create an equal acoustic playing field, there are some things that you cannot control. For example, you cannot control the shape of the room, the extent of porous room materials, or the frequency rating of the microphone. However, there are some things that you can control and you can use these to your advantage.

The first thing one can do is to speak louder. As men and women speak in a loud (but not shouting) voice, the differences between the acoustic perception of different frequencies of sound become less apparent. So, if a woman speaks slightly louder than normal, she can eliminate the auditory perception gap that exists between male speech and female speech, particularly in the lower vocal frequencies. This becomes more necessary when a woman is speaking to an audience of mostly older persons.

A second strategy involves speaking with the person running the sound equipment for the lecture room (when such a person exists!). Many times, they will have set the equalizer to a default setting or they will have optimized it for whoever the first speaker is. If that first speaker is a man with a low pitched voice, then the woman who is the second speaker will often be acoustically disadvantaged. Asking the sound technician to be sure to adjust the equalizer when you are giving your presentation will remind that technician that you are aware of the importance of what they do and ensure that he or she optimizes the settings for the unique frequencies of your voice.

A third strategy is to adjust the microphone height. In order to retain the authoritative lower frequency vocal intonations, one has to maintain proximity to the microphone. Sometimes this may mean adjusting the height of a lectern (if it is adjustable) and sometimes this means bending a flexible goose-neck microphone down to an appropriate height. Stand close to the microphone with a goal of your mouth being 6-12 inches away. Be sure that the microphone is pointing directly at your mouth. Lavalier microphones are a great choice because they stay pointed directly at the mouth and they stay a fixed 8 inches from the mouth.

A fourth strategy is to adjust your voice brand. Most of us do not really know how we sound to others. Recording a practice session of your presentation and then listening  to it can help you identify features such as glottal fry and up-talking that may not have much impact on younger audiences but can make you seem less authoritative to older audiences. Ensure that your rate is 162-175 words per minute and that your intonation is neither too monotone nor too up-and-down.

To be successful, it is important to not only be qualified but to also sound qualified.

November 12, 2019

Categories
Medical Economics Medical Education

The Total Cost To Train A Physician

It costs more than $1.1 million to train a doctor in the United States. The societal investment in creating physicians is enormous and has widespread implications for American health care in everything from acceptance of international medical graduates to the future use of non-physician health care providers.

Breaking down the costs

Depending on the specialty, tt takes 11 to 15 years to train a physician when you count college, medical school, residency, and fellowship. At each of these steps there are direct costs and indirect costs. Some of these costs are paid by the physician in training and some of these costs are paid for by society in general (usually through state or federal taxes). Here is a breakdown of the direct and indirect costs at each step along the way:

Undergraduate education. Colleges essentially have 3 sources of income: tuition, endowment, and government funds. For this reason, the total cost to educate an undergraduate is considerably more than what the student actually pays in tuition. It becomes complicated because most colleges not only have to finance the education of students but also have to finance the research activities that professors must perform in order to keep their jobs. Thus, it is hard to separate the costs of education from the costs of research. Public colleges receive state government funds to subsidize their education and research activities and this results in lower tuition for in-state residents than for out-of-state residents. The out-of-state tuition and fees best reflects the cost to teach an undergraduate without the state governmental subsidy. Private colleges and universities generally do not receive state governmental subsidies and have considerably higher tuition costs. For the purpose of this analysis, I used the current cost of attendance for out-of-state freshman at the Ohio State University that includes tuition, fees, books, room, board, and miscellaneous expenses if living on-campus which is $49,556. For four years of college, this would be a total cost of $198,224.

Medical school. Colleges of medicine have the same 3 sources of income as undergraduate colleges so for this analysis, I used the current cost of attendance for an out-of-state medical student at the Ohio State University College of Medicine. Once again, this estimate is for tuition and fees as well as estimated living expenses. Unlike undergraduate college, the cost of medical school varies considerably for each of the four years of training: year one = $80,019, year two = $76,026, year three = $114,442, and year four = $114,542. Totaling all four years, the cost to go to medical school is $385,029.

Residency. There are both direct and indirect costs of resident education. The direct costs are the resident’s salary and benefits. At the Ohio State University Medical Center, these costs are $51,510 for a first year resident (intern) and increases each year so that a fourth year resident cost is $56,636. However, the direct costs are only the tip of the iceberg when it comes to the total cost to train a resident. There is the cost of everything from hospital call rooms, to residency program administrator salaries, to part of the salaries of chairmen and faculty to cover otherwise non-compensated teaching time. Most of these indirect costs are ultimately paid from federal tax dollars- either by Medicare payments to teaching hospitals for graduate medical education or by the higher Medicare payments for clinical services that teaching hospitals get paid (as opposed to non-teaching hospitals). In 2014, the Alliance for Academic Internal Medicine estimated that the total direct and indirect costs to train a resident is $183,416 per year. For the 3 years of residency it takes to become a general internist, pediatrician, family physician, or hospitalist, the cost is $550,248. It takes longer to train other specialists, for example, an obstetrician is 4 years ($733,664), a gastroenterologist is 6 years ($1,100,496), and an interventional cardiologist is 7 years ($1,283,912).

Total costs. Adding all of these together, the total costs to train physicians is astounding. This demonstrates that society has an enormous investment in each physician in the United States.

  • $1,133,501 – general internist, family physician, pediatrician
  • $1,316,917 – obstetrician, psychiatrist
  • $1,500,333 – general surgeon, endocrinologist
  • $1,683,749 – gastroenterologist, pulmonary/critical care, general cardiologist
  • $1,867,165 – interventional cardiologist, neurosurgeon

Implications for U.S. healthcare

International medical graduates. One of the best ways to reduce the cost of training doctors is to get someone else to pay for it. If you can get another country to cover the costs of college and medical school, then the cost to American society drops. Therefore, the U.S. cost to train a family physician who is an international medical graduate is $583,253 less than a family physician who is a U.S. medical graduate. In other words, the cost to American society of an international medical graduate is about half that of a U.S. medical graduate.

Non-physician providers. Nurse practitioners and physician assistants are far less expensive to train than physicians. The typical NP or PA training consists of 4 years of undergraduate training plus 2 years of NP/PA training. The costs to become an NP or PA is approximately $84,598 after college (tuition and living expenses) and the total cost including college is $282,822. In other words, the cost to train a family practice NP/PA is only one-fourth of the cost of training a family practice physician. Given that NPs and PAs increasingly have a similar scope of practice as physicians, from a societal standpoint, it will be a lot less expensive to train an NP or PA than it is to train a physician to do the same job. The implication is that NPs and PAs will replace many physician jobs in the future.

Repairing broken physicians. In a meeting I was recently attending, a question was asked whether we have different standards for terminating physicians with behavioral problems or substance abuse than we do for terminating other health care workers for the same problems. The reality is that I think we probably do and part of this is because of the enormous societal investment in those physicians. To create an analogy, if you have a broken handle on a screw driver that cost $2, you buy a new screw driver and don’t pay the cost of repairing it. On the other hand, if you have a broken handle on an airplane that costs $1.2 million, you repair the handle rather than throwing out the entire plane. If society invests $1.2 million to create a physician who then develops alcoholism, one can make the argument that hospitals have a societal obligation to first attempt to cure the physician and return him or her to practice when/if safe to do so rather than permanently end that physician’s career. Like it or not, hospitals will often put broken physicians on leave and attempt to rehabilitate them for infractions that would result in an unskilled employee being terminated – it is not necessarily fair but it is an economic reality. On the other hand, if an airplane has a critical mechanical flaw that puts it in continuous danger of crashing, you decommission that airplane – physicians with critical flaws should similarly be decommissioned.

Discussions about the cost of training physicians usually center around the cost to the individual physician and often stop at the average debt of a graduating medical student. But beyond medical student debt, there is a much larger cost that is not paid directly by the doctor but is paid more broadly by the institutions that provide scholarships, by the citizens who pay state and federal taxes, by direct salary costs of residents who cannot bill for their services, and by the indirect costs to hospitals to train residents.

July 11, 2019

Categories
Medical Economics Medical Education

Predicting The Future Of Medicine In 2035

I was asked to give a talk to the new internal medicine interns this week and it gave me a chance to think about what it is that we are training them for. Wayne Gretzky famously said “I skate to where the puck is going to be, not where it has been.” If we are going to be effective teachers of medicine, we need to train our interns and residents for the way medicine will be, not how it was in the past or even how it is now. So, what will medicine look like 16 years from now in 2035? The Accreditation Council for Graduate Medical Education (ACGME) has created a vision for medicine in 2035 to help residency programs prepare tomorrow’s practicing physicians. I agree with a lot of what the document concludes and I’ve added some of my own projections about what medicine will be like in 2035:

It is going to be more complex. As we learn more about the causes of disease and as we develop more specifically targeted treatments for disease, the complexity of medicine will increase exponentially. Take the example of oncology: 20 years ago, a physician would specialize in hematology & oncology and that was pretty much the end of the story. As knowledge and treatments increased, the discipline split so that physicians either became a hematologist or an oncologist. Now, oncology has split further so that a physician becomes a breast cancer oncologist, or a lung cancer oncologist, or a gastrointestinal cancer oncologist. In the past, lung cancer was either small cell or non-small cell lung cancer; now non-small cell lung cancer is subdivided into many different varieties based on specific driver mutations and each of these varieties are treated differently. As we further subdivide diseases into different groups based on biochemical or genetic differences, we get newer and more complicated drugs to treat them with. Last year, the FDA approved 59 new drugs; at that pace, there will be nearly 1,000 new drugs on the market in 2035 that do not exist today.

Medical information will become more transparent. In the past, medical information was locked away in a paper chart stored on a shelf in a hospital medical records department storeroom. Now, the finest details of patients’ medical history, lab test results, and x-rays are available to just about any physician in the country who is involved in the care of that patient. In minutes, I can have radiographic images appear on my computer screen from a chest CT scan a patient had in California earlier that morning. Patients can view all of their test results and even their doctor’s progress notes real-time. Information transparency shows no sign of letting up and more people will be able to access more health information than ever before. Not only will patient medical information become more transparent, but the way we take care of patients will become more transparent. Already, you can see what any given hospital’s readmission rate, emergency department waiting time in minutes, and surgical complication rate is with a quick trip the the Medicare website.

Commoditization of medicine will increase. Health care in the United States is a business. Already, hospitals are buying and selling physician practices, healthcare systems are acquiring hospitals, and health insurance companies are merging with drug store chains. Hospitals are now federally mandated to publicly post the prices for all of their services. There is pressure to reduce costs by using the least expensive employees to provide care. Non-traditional healthcare locations are being used where profit can be made. You don’t need to look any further than your local pharmacy where medications are dispensed based on a patient’s insurance formulary, the pharmacists will administer vaccinations directly to patients, and a nurse practitioner will manage common acute illnesses in a “minute clinic” – all of which were decisions previously made by and services previously provided by physicians. Americans are entrepreneurial to the core and the business of medicine will increasingly mimic the business of other commodities.

Advanced practice providers will increase. 2013 was the last year that there were more MD degrees awarded in the United States than CNP degrees. The certified nurse practitioner workforce is increasing exponentially. 20 years ago, nurse practitioners worked for physicians as so-called “physician extenders” and did not prescribe medications. Now, NPs work independently and have prescriptive authority. It makes sense – it takes 2 years of education after a bachelor’s degree to become an NP but it takes 7 years of education after a bachelor’s degree to become a family physician. In addition, the typical NP salary is less than half that of a family physician. So, if an NP can do the same thing as a primary care physician at half the cost and with 28% of the training, the commoditization of medicine will encourage hospitals and clinics to hire NPs into roles that they would previously have hired physicians. In the U.S. graduation class of 2017, there were 26,000 NP graduates, 19,259 MD graduates, and 8,336 PA graduates. In the near future, it is likely that the annual number of physician assistant graduates will also exceed the number of physician graduates, just like nurse practitioners already do. Medicine will increasingly be a team sport with physician playing a more smaller role in the team than in the past

Artificial intelligence will proliferate. IBM’s Watson is just the first, rudimentary foray into the use of computers in disease diagnosis and management. Already, I have patients who type 4 or 5 of their symptoms into Google and come to the office asking if they could have whatever disease appears on their Google search. And why shouldn’t it be this way? Physicians are forever missing diagnoses, overlooking test results, and choosing the wrong drug. For years, the mantra of hospital quality departments has been to standardize care and no one can standardize better than a computer.

The patients will be older. The U.S. demographic is changing and in 2035, the number of older Americans will exceed the number of young Americans. This will increase the demand for physicians who provide care to the elderly, such as geriatricians and orthopedic surgeons. As the percentage of Americans over age 65 increases, so will the influence of Medicare on American healthcare as Medicare assumes a more dominant role in U.S. health insurance.

Many of today’s skills will become obsolete. As an intern in 1984, I was required to offer to do a rigid sigmoidoscopy to every patient over age 60 who was admitted to the hospital; I did a lot of rigid sigmoidoscopes that year. Bronchoscopy was not readily available so we would do transtracheal aspirates using an angiocath and a syringe if we needed a sputum sample in a patient who couldn’t cough it up. If I did a lumbar puncture in the middle of the night, I was expected to do a diff quick stain, a gram stain, an India ink prep, and an acid fast stain of the spinal fluid in the residents’ lab down the hall from the ICU.  And if a patient had unexplained thrombocytopenia, it was the intern’s job to get a bone marrow biopsy tray, do a bone marrow aspirate, and then stain that aspirate before rounding with the attending physician. As interns, we did all of the blood cultures and the EKGs. Today, no intern or resident is required to do any of these things; in fact, we don’t even let our residents do their own specimen stains due to CLIA restrictions. In 2035, new interns will chuckle when they hear about the “bad old days” in 2019 when doctors did all sorts of procedures that were replaced by better ways of doing things.

A lot of today’s knowledge will turn out to be wrong. Perhaps the most visible manifestation of this is in advanced cardiac life support (ACLS). As a critical care physician, I’m required to re-certify in ACLS every 2 years and since I first took it in medical school, I’ve taken the ACLS course 18 times. Each time, the guidelines are a little different and the correct answers to the questions on the test you have to take are different. It turns out that many of the drugs we used didn’t actually work and the best way to “run a code” turns out to be completely different than what we thought it was. In my first year of medical school, one of the professors told us that 50% of everything we were about to learn will turn out to be wrong… and he was right. The only unchangeable thing about medicine is change itself.

Doctors will be paid differently. In 1965, Medicare was invented and this led to standardization of physician fees… doctors thought it was the end of the world. In the 1970’s DRGs (diagnostic related groups) were rolled out to standardize the way that hospitals got paid for a particular diagnosis or surgical procedure… doctors thought it was the end of the world. In the 1990’s RVUs (relative value units) were created to standardize the way doctors got paid for specific services or procedures… doctors thought it was the end of the world. Now, we are basing physician compensation on value metrics… doctors again think it is the end of the world. Our problem is that healthcare is so expensive. In 2017, the healthcare costs for the average American was $10,224, nearly double the cost per person in economically similar countries. As a percent of GDP, we pay more than any other country for healthcare and that gap is increasing every year. Although we can’t predict what physician compensation model will be in place in 2035, it is clear that our past models of healthcare financing are unsustainable.

The solo practitioner will become extinct. Physician employment models have changed unfathomably fast in the past decade. In just 6 years, the percentage of physicians who are hospital-employed increased from 26% to 44% nationwide. However, there are substantial regional differences such that in the Midwestern United States, 55% of physicians are now employed by a hospital. The solo practitioner or even the small physician group cannot negotiate for favorable payment rates from health insurance companies – only very large groups and larger health systems have the clout to negotiate high payments for physician services from insurance companies. Furthermore, as medicine has become more regulated, it it harder and harder to be sure that you are practicing according to the rules: physicians have to have sufficient support staff to be sure that billing is compliant, HIPAA laws are not violated, and the electronic medical record network is regularly updated – it takes a lot more staff than a solo practitioner can afford to hire. The solo practitioner is not a viable business model for the future.

Results of the 2019 fellowship match

There will be more international medical graduates. American doctors make more money than doctors in any other country. So, naturally, doctors in other countries like to come to America because they can make a better living. It works out well for the U.S. healthcare system as well – medical school in other countries is generally either heavily subsidized or completely paid for by the governments of those countries so in the end, some other country is paying to train doctors who end up practicing in the U.S. Currently, 24.3% of physicians in the U.S. are international medical graduates but there are significant differences by specialty. For example, 38.6% of internists are international medical graduates as are 50.7% of geriatricians. As I pointed out in a previous post, more nephrology fellowship positions were filled by international medical graduates than U.S. medical graduates this year.

Is there anything that won’t change? The good news is, yes, and no one said it better than Francis Peabody who wrote in his 1927 article in the Journal of the American Medical Association: “... the secret of the care of the patient is caring for the patient.” That tenet held true in 1927, still holds true today, and will hold equally true in 2035. No matter how much we come to depend on artificial intelligence to help us diagnose and manage disease, no matter how many more NPs and PAs are trained, and no matter how commoditized medicine becomes, one quality of being a physician that won’t change is in caring for the patient. Humanism is that one unchangeable thing.

July 4, 2019

Categories
Medical Economics Medical Education

What The 2019 Fellowship Match Tells Us About The Future Of American Medicine

Last week, the National Resident Match Program released its annual data report on the most recent fellowship match for positions to begin in July 2019. The fellowship matches take place between May 2018 and January 2019, with different match days for different specialties. The NRMP releases a summary of all of the specialty match results in February each year. By analyzing the data, you can learn a lot about which specialties are attracting new physicians and which ones are not attracting new physicians. And projecting forward, you can predict which specialties are going to have shortages of practitioners in future years. The 2019 year had the most positions ever offered in the U.S. (10,936), the most fellowship programs ever in existence in the U.S. (4,750), and the most residents who matched into a fellowship program in the U.S. (9,378).

Because the hospital I practice in primarily has internal medicine specialists, I am particularly interested in the outcome of the various internal medicine specialty fellowship matches. This table in blue shows the number of internal medicine fellowship positions by specialty. They vary widely from a low of adult congenital heart disease (9) to a high of cardiology (951). Oncology-only fellowships and hematology-only fellowships generally have very small numbers of available positions because most physicians tend to go into combined hematology and oncology fellowships. Similarly, there are few pulmonary-only fellowships because most candidates go into a combined pulmonary and critical care fellowship.

The NRMP also reports the percentage of available positions that fill with U.S. allopathic (MD degree) medical school graduates, as shown in this table in red. Eliminating oncology, hematology, and pulmonary from the analysis because most doctors interested in those fields do a combined fellowship, it becomes clear that the most popular specialties are hematology & oncology, gastroenterology, and palliative medicine (adult congenital heart disease, interventional pulmonary, and cardiac electrophysiology are only done after a doctor has already completed a pulmonary or cardiology fellowship and are thus sub-specialty fellowships). The least popular fellowships are nephrology, geriatrics, and endocrinology.

Next, lets look at the how all of the various specialties filled when including not only U.S. allopathic graduates but also U.S. osteopathic (DO) graduates, U.S. citizens who attended foreign medical schools (most frequently Caribbean medical schools), Canadian medical school graduates, and foreign medical school graduates. Here, in the table in brown, we see that most fellowships eventually filled. However, nephrology and geriatrics are notable exceptions.

So, why are certain specialties so unpopular? One factor may be salary. Using the 2018 Medscape Physician Compensation Survey data, the internal medicine specialties with the highest salaries also had the highest percentage of available fellowship positions filled with U.S. allopathic medical school graduates (cardiology, gastroenterology, and hematology/oncology). Endocrinology is notable because the annual salary of an endocrinologist is less than a general internist, meaning that for the personal cost of doing 2 additional years of fellowship training in endocrinology compared with a general internist, you get to make $18,000 less than a general internist – not surprisingly, relatively few of the endocrinology fellowship positions were filled by U.S. allopathic medical school graduates.

Another way of analyzing salary and work effort is from the annual MGMA Physician Compensation Report. The 2018 report is the most recent and it reflects 2017 data. There are important differences between the MGMA compensation data and the Medscape compensation data. The MGMA report only includes large group practices, is reported by practice managers, and reflects total compensation. The MGMA report has data on private practice physicians (who make more) separate from academic physicians (who make less). On the other hand, the Medscape report includes any physician, is self-reported by the physician, and represents salary (which may not be the same as total compensation). The Medscape report includes both academic and private practice physicians. The MGMA data is probably more accurate but represents a skewed population of doctors. The Medscape data is probably less accurate but in theory is more representative of the average doctor (or at least those who are willing to take the time to fill out the survey). This table reflects just the MGMA private practice data. From the MGMA report, it is apparent that based on median wRVUs, nephrologists work very hard, in fact, harder than any other specialists except cardiologists. However, they make $140,000 less than cardiologists. When the MGMA data is expressed as total compensation per wRVU, it appears that nephrologists make the second lowest amount of money per wRVU compared to other specialists (note that the MGMA total compensation per wRVU is calculated with a complicated equation and that not all practices report both total compensation plus wRVUs so the reported values will be different than if you simply divide the mean total compensation by the median wRVUs for any given specialty).

There is a pretty sharp demarcation between the lowest paid specialties (geriatrics, endocrinology, rheumatology, infectious disease, and nephrology) and the highest paid specialties. The lowest paid specialties had the lowest percentage of fellowship positions filled with U.S. allopathic medical graduates. The one exception to this is palliative medicine but palliative is unique in that palliative physicians make about twice as much income per wRVU at $110.57 than the other specialties.

Another reason why newly trained residents may choose one specialty over another is how happy the physicians are in a given specialty. The 2018 Medscape Physician Compensation Report also has information on job satisfaction of physicians, including a survey question of “Would I choose the same specialty again?”. Once again, there is a relationship between job satisfaction and the percentage of residents who choose that specialty. The least happy internal medicine specialists are nephrologists (in fact, per the Medscape survey, they are the least happy specialty of all physicians, not just internal medicine specialties). Nephrology is also the specialty that filled the least of available positions with U.S. allopathic medical school graduates. So, if you choose to do 2 additional years of training compared to a general internist, you are rewarded by being 30% less happy with your job than a general internist. On the other hand, the three specialties with the most satisfied physicians are also the 3 specialties with the highest percentage of fellowship positions filled with U.S. allopathic medical school graduates (hematology/oncology, cardiology, and gastroenterology).

As we project the results of this year’s fellowship match into the future, we should anticipate future physician shortages in nephrology, geriatrics, infectious disease, and palliative medicine. Additionally, we should anticipate that there will be more nephrologists who are foreign medical school graduates than U.S. allopathic medical school graduates in the future based on the total number of U.S. versus foreign medical school graduates filling fellowship positions this year. Endocrinology and geriatric medicine are not far behind and in the future, your endocrinologist and geriatrician will probably be more likely to be an immigrant from another country than a graduate of a U.S. medical school.

If American medicine was an entirely free market economy, then as the supply of nephrologists, geriatric physicians, infectious disease physicians, and palliative medicine physicians goes down, then their salaries should go up. But physician supply and demand is complex and since it can take many years to train enough physicians to fill a specialty with a physician shortage, we may be looking at a medical economy with too few nephrologists, geriatric physicians, infectious disease physicians, and palliative medicine physicians for years to come.

An alternative explanation is that we have too many fellowship positions open in these specialties and that academic medicine is out of alignment with the needs of American medicine. Academic medical centers tend to create fellowship positions based on the needs of the individual divisions and departments within a given medical center and not necessarily based on the needs of the medical economy as a whole. This can also contribute to a misalignment of specialist supply and demand.

One thing seems certain, however. American nephrologists are less happy with their job, work harder in terms of wRVUs, and are compensated less per wRVU than other physicians. I believe that these are the reasons why so few physicians are entering the nephrology fellowship match and why so few nephrology fellowship positions filled in this year’s fellowship match. To insure that our patients’ medical needs are met in the future, hospitals will need to be sure that their nephrologists are happy and are compensated appropriately for the work that they do. On the other hand, gastroenterologists, hematology/oncologists, and cardiologists are the happiest and most highly compensated and this may explain why these three specialties filled so well in this year’s match.

February 26, 2019

Categories
Medical Education

ABIM Maintenance Of Certification Points

This post falls under the general category of shameless self-promotion. The American Board of Internal Medicine keeps changing the requirements for maintaining board certification. When I completed my internal medicine residency, it was easy – you took a board examination and then you were board certified for life. But after 1989, everything changed and the ABIM required re-taking a board examination every 10 years to maintain board certification. Since I first took pulmonary boards in 1990 and critical care boards in 1991, I was required to do those exams once a decade. Next came the maintenance of certification program that required us to do on-line ABIM MOC learning modules that included “open-book” exams every year plus do the 10-year formal board examination. Most recently, the ABIM has done away with their own MOC modules and now require 100 MOC points to be earned every 5 years (in addition to the every 10-year formal board examination).

This has left physicians scrambling to try to get enough MOC points by December 31st in order to maintain their board certification. Since physicians can no longer go to the ABIM’s website to get those MOC points, they must be earned through other activities, usually coupled with continuing medical education credits. Some of these are pretty easy – for example, I can generally get 18-22 MOC points by just attending the annual American College of Chest Physicians meeting. But attending the ACCP meeting costs me more than $2,000 and it seems like we inevitably come up a few MOC points short by the end of the year.

One way of finding activities that you can do to earn MOC points is by going to the Accreditation Council for Continuing Medical Education’s website that allows you to search for different CME activities. One of these is where the shameless self-promotion comes in:

OSU MedNet

21 years ago, I started moderating a weekly CME television program called OMEN-TV (Ohio Medical Education Network- TV). This was born out of an audio CME program called OMEN that began in 1962. The original OMEN was broadcast from an audio studio on campus at the Ohio State University and went out over a telephone speaker system to hospitals throughout the country that would be pre-mailed 35 mm slide sets. OMEN evolved into OMEN-TV in the 1980’s and was broadcast from a television studio at OSU over a satellite TV system every Friday at noon and was targeted to subscribing hospitals that used the programs as the equivalent of a grand rounds for their medical staff. In 2002, OMEN-TV evolved into a webcast and was renamed OSU MedNet in order to reflect the internet broadcast.

I’m still moderating the program and currently, we produce 40 OSU MedNet programs every year and we leave them up on the internet for 3 years with the result that we have 120 hours of medical education programming available at any given time. Anyone can view the programs for free. To get either CME credits or MOC points, physicians either have to be on the medical staff at a subscribing hospital, be on the faculty of the Ohio State University, or pay at the end to take a post-test to get their credits.

The great thing about using OSU MedNet for your MOC points is that it is simple and you can learn a lot. Here is how you do it:

  1. Go to the OSU Center for Continuing Medical Education website and open up an account. Remember, this is all free if you are at a subscribing hospital or if you are employed by Ohio State University.
  2. Log into your account and then go to the OSU MedNet website. Click on any of the 120 programs that are relevant to your practice (all programs since September 2016 are approved for MOC points).
  3. At the bottom of the webpage for that particular program, click on the “Take Pre-Test” button. This will pull up a short quiz to test your knowledge of the topic before you view the webcast.
  4. After you submit your pre-test, view the program over the internet. Each program is 55-60 minutes long (43 minute if you watch at 1.4 speed or 37 minutes if you watch at 1.6 speed). You can also listen to the programs as an audio podcast if you prefer. You can download a PDF file of the PowerPoint slides from the webcast in either 2 slides per page or 4 slides per page format to help you with your learning.
  5. After you view the program, click on the “Take Post-Test” button and you will take the same short quiz that you took for the pre-test. If you need to refer back to the materials to help with any of the questions, you can refer to the PDF files of the PowerPoint slides.
  6. Once you submit your answers to the post-test and pass the test, you will have an MOC point (and a category 1 CME credit). Your total MOC points will appear on your account. The MOC points are uploaded to the ABIM at the end of each month and you will get an email from the ABIM letting you know how many MOC points you have earned.

With my Amazon Prime account and my Netfix account, I’ve been binging on everything from “Jack Ryan” to “The Great British Baking Show”. Now you can spend your weekend binging on MOC from the comfort of your own home. You don’t need to buy airfare or a hotel room to attend a conference and at $25 per MedNet program ($800 for a 40-program season), it is less expensive than the meeting registration to attend national conferences.

The ABIM is the organization that internists used to love to hate. But you don’t have to hate any longer because with OSU MedNet, keeping up with your MOC points is easier than ever before and you can chose the particular MedNet programs you want to use based on your own unique clinical practice needs.

November 1, 2018

Categories
Medical Education

2017 ACGME Resident Duty Hours 33 Years After Libby Zion

The Accreditation Council for Graduate Medical Education (ACGME) has released new resident duty hour restrictions that will go into effect July 1, 2017. Resident work hour restrictions all started with the case of Libby Zion.

In March 1984, Libby Zion was admitted to New York Hospital with a flu-like illness, fever to 103.5 F, and tremors. She was evaluated by an emergency room physician and then worked up by an intern and a second year internal medicine resident. She had a history of depression and was taking the MAO inhibitor, Nardil. The housestaff discussed her case with Ms. Zion’s attending physician and prescribed Demerol for the tremors. She became agitated during the night, so the intern prescribed Haldol. She then developed higher fever with a body temperature of 107 F followed by a cardiac arrest and died within 8 hours of admission. Tests revealed traces of cocaine. The ultimate conclusion was that the cause of death was serotonin syndrome triggered by the combination of Nardil plus Demerol. Ms. Zion’s father, Sidney Zion, was a trial attorney and contributor to the New York Times who had previously been fired for publicly releasing Daniel Ellsberg’s identity as the source for the Pentagon Papers. Mr. Zion was enraged at the medical system and said that his daughter was murdered by the hospital and the doctors. He focused on the fact that the intern was working a 36-hour shift and attributed his daughter’s death to the over-worked intern. He filed a medical malpractice claim and convinced the district attorney to have a grand jury consider murder charges against the intern and resident – although the grand jury declined to indict them for murder, they did charge them with 38 counts of gross negligence because of the prescription of Demerol. Ultimately, they paid $375,000 to the family for pain and suffering compensation.

Because of this case, the New York State Health Commissioner put together a commission headed by Dr. Bertrand Bell. The “Bell Commission” recommended that residents should not work more than 80 hours per week, no more than 24 consecutive hours, and that the attending physician needed to be physically present in the hospital at all times. In 2003, the ACGME adopted the 80-hour resident work restriction. Of note, Dr. Bell had been a life-long critic of residency training, having coined the mantra: “see one, do one, teach one, kill one” and was later dismissed from his administrative role by the Dean of the Albert Einstein College of Medicine. Later in his life, he acknowledged that he did not arrive at the 80-hour limit by scientific analysis, instead, he and a friend came up with the number during a conversation on his porch one day.

The problem with the Libby Zion case is that her death really had nothing to do with resident work hours, despite the allegations raised by her father. She died of a very rare condition (serotonin syndrome) that was a rare side effects of the Demerol that she was prescribed. Prior to this case, the overwhelming majority of physicians in the United States had never heard of serotonin syndrome resulting from the combination of Nardil and Demerol (I certainly had not) and very few physicians had ever seen a case of serotonin syndrome (I’ve seen 2 cases in the ICU in my 30 years in critical care). The intern would likely have prescribed the Demerol whether it was the middle of the night or whether it was his first hour back after a week-long vacation. Unless you are a savant, it is just not humanly possible to memorize every drug-drug interaction that can occur. If Libby Zion was admitted to a hospital today, she would probably live – not because the interns and residents are better rested, but because we now have electronic medical record order entry that automatically alert physicians when they prescribe medications that can interact with other medications.

So, that brings us to the new ACGME rules that continue to limit residents to less than 80 clinical work and education hours per week but now specify that these work hours not only include time spent in the office, the hospital, and the library,  but also time spent with home-call. This has residency and fellowship programs in a quandary because now they have to have some way of accounting for calls that residents and fellows take at night. Should they use resident self-reported hours? Should they require residents to submit cell phone call logs? Do they audit the amount of time residents spends in the electronic medical record at night?

Although there is abundant sleep medicine literature to support that sleep deprivation impairs cognitive performance, a 2016 study in the New England Journal of Medicine showed that residents who were subject to an 80-hour work restriction did not perform any differently than those who were not subject to duty hour restrictions. Furthermore, attending physicians do have to work more than 80 hours during some weeks and my own personal opinion is that doctors are better prepared to work those occasional very long hours if they have been trained in how to do it. As an attending pulmonary/critical care physician, I do occasionally work more than 80 hours per week, particularly on the weeks that I cover the hospital on weekends (about once a month).

However, given the legal precedent of the Libby Zion case and the ACGME’s strong stance on duty hour restrictions, it is unlikely that future doctors will experience 80 work weeks until after they complete their training. Many older physicians who trained in an era of every-other-night call during internship currently work long days and nights, because it is what they always have done. Tomorrow’s doctors will probably be less willing to work 80-hour weeks because they never did it during training. That means that hospitals will need more physicians to provide the same amount of 7-day per week on-call coverage and this will cost more money. And that means that in the future, physicians will either earn less or consumers health care costs will go up.

80-hour work/education weeks do improve resident satisfaction and may lessen physician burnout. And I think that keeping residents from regularly spending more than 80 hours a week in clinical care and education activities is a good thing. But the genesis of the 80-hour duty restriction was based on anger and zeal, not on scientific evidence. It is one of those “right outcome for the wrong reasons” phenomenon. For me, 90-100 hour work weeks during my internship in 1984 (the same year Libby Zion died) allowed me to succeed – my greatest strength was not my IQ but my endurance and in that era, endurance was a trait that made a good doctor a better doctor. Success in anything is a match between the unique characteristics of an individual and the unique demands of the environment at a unique time. And in the future, endurance will no longer be a trait that makes one a better doctor and someone like me will less likely to be successful in medicine.

For now, it looks like residents are going to have to start logging those calls they take at night from patients who need medication refills and text pages they get from hospital nurses letting them know they have a consult for the next morning.

May 23, 2017

Categories
Hospital Finances Medical Education Physician Finances

The Conundrum Of Academic Release Time

It is that time of the year when department chairs and division directors come to the hospital administration asking for financial support for the upcoming year. Few specialties can be self-sufficient in an academic medical center so the hospital has to provide some amount of money to ensure that there is adequate physician staffing. Inherent in being an academic physician is the premise that you are not going to be seeing as many patients or doing as many surgeries as your colleagues in private practice because you are going to be spending part of your time doing academic activities: teaching, writing papers, developing a focused area of clinical expertise, and doing research. You also commit to directing part of your income to the college of medicine (“dean’s tax”) and the department/division (“academic expense”). For this, you are willing to make a little less than your private practice counterpart, but not too much less. Thus, the need for the subsidies from the hospital.

But the hospital wants to know that there is some value in the these subsidies. By and large, the funds are ultimately used for “academic release time”, that is the time that the physician spends doing those activities that are important to the academic mission of the medical center but are otherwise unfunded. Back in the 1980’s, unfunded academic release time was typically about 40% for a newly hired physician: the physician would do 6 months of inpatient service and see patients for a half-day in the clinic. By the 2000’s, that had dropped to about 20% and now 10-15% is more common for new physicians.

The problem with academic release time, is that if everyone gets it, it can become an entitlement and then it becomes next to impossible to take away without organizational disruption. So, our challenge is to find a way to ensure that physicians are accountable for that otherwise unfunded academic time that they have. In order to figure out how we can do that, lets start with a look at how several specialties in our medical center deal with unfunded academic time. For the purposes of simplicity, I am going to use “department” to mean either department or division.

Department #1. All physicians start at 100% clinical full time and then after they are practicing for months or years, they come up with specific proposals to acquire academic release time. These could include doing a hospital quality project, chairing a hospital/college committee, doing a clinical research study, taking on an administrative position, etc. The physician continues to get that academic release time as long as he/she continues to perform that particular non-clinical activity.

  • The problem: many of these physicians never have the initial time investment to get any kind of academic activities off the ground and so after several years, they often move to private practice jobs since there is nothing tethering them to the university.

Department #2. All physicians get some percentage of academic release time that is negotiated individually at the time of their initial appointment. The percentage varies from 10% to 20%. The purpose is to teach and obtain research funding. At this time, however, none of the physicians except the chair have research grants.

  • The problem: there is a lot of “release time envy” by those physicians who only negotiated 10% release time versus those with 15% or 20% release time since those with more release time are seen as having to work less but getting paid the same as those who have less release time.

Department #3. All physicians get 20% academic release time and that is maintained in perpetuity, regardless of what they do during that time. There is an annual review process with the chair and those physicians who lack any academic productivity are directed by the chair to do more.

  • The problem: in theory, this academic productivity would be tied to physician bonuses but the department has not had any money to give bonuses for 15 years. Therefore, there is little incentive for the physicians to do anything productive for 20% of their time.

Department #4. All physicians get 10% academic release time at the time of their initial appointment. If they don’t have any academic output to show for after 3-4 years, then their release time is eliminated and they become 100% clinical.

  • The problem: once you go 100% clinical, you can never go back. Eventually, a private practice job across town that will pay you more for the same amount of work looks pretty inviting.

Department #5. All physicians get 20% academic release time but they are expected to produce work RVUs at the 75th percentile of national benchmark during the 80% of their time that they are doing clinical activities. In this way, the physicians self-fund their own 20% academic release time.

  • The problem: you are really deceiving yourself by making yourself be way more productive than the average physician 4 days of the week so that you can have the 5th day to do academic stuff. The reality is that most physicians work at a pace of average productivity so inevitably, they end up doing clinical work on that 5th day to catch up. In other words, the physicians coast for 1 day to make up for sprinting the other 4 days. What you are in reality doing is asking the physicians to have average productivity 100% of the time; you are just wrapping it up differently.

Department #6. All physicians get 20% academic time. If a physician gets a paid administrative or teaching position, that 20% of time is eliminated.

  • The problem: you reward those physicians who do not take on administrative or teaching roles. Those physicians who do take on a paid administrative role have to do more work than everyone else and get paid the same. You discourage anyone from volunteering to take on paid teaching and administrative roles and you encourage your doctors to not do anything that might ultimately improve care within the hospital or bring academic notoriety to the college of medicine.

So what is the answer? Ultimately, what the academic medical center wants are those activities that bring research grant dollars, result in journal articles with the institution’s name on them, create teachers who attract the best medical students & residents, generate clinical expertise that attracts patient referrals, create an environment of high-quality clinical care, and result in efficient clinical care with a positive financial margin. What the doctors want is enough time to do academically creative things that will help them achieve whatever they define as an academically success for themselves. Here are two proposals:

Model #1:

This is essentially what department #1 does above. Namely, all new physicians start out at 100% clinical and then submit specific proposals to “buy down” academic release time. The goal would be for most physicians to buy down 15% academic release time by their 4th year of practice. Because there is not enough money in the system to pay for every single physician to have 15% non-clinical time, there would have to be some way of adjudicating the proposals to cull out those that do not provide institutional value or that have a low chance of success. This model works best for physicians who do shift work where it is relatively easy for them to flex up or down in the number of shifts that they do since they are relatively interchangeable with one another. Examples include hospitalists, anesthesiologists, and emergency medicine physicians.

Model #2:

This is a variation on the “ramp up” period that many surgeons have in their initial contract with the assumption that as they build experience and a build a referral base in their first 5 years of practice, they are more able to support their own salary so that they need a lot of hospital support their first year in practice but need progressively less each subsequent year. So, in model #2, a typical clinical-track physician faculty member would get 20% unfunded academic time in their first 2 years, 15% unfunded academic time in their third and fourth years, and then 10% unfunded academic time in their fifth and sixth year. The physician could maintain their 20% unfunded academic time after their second year by demonstrating that they have been good steward of that time by producing publications, obtaining grants, doing a lot of unpaid teaching activities, etc. After year six, a physician who has no academic output would be moved to a 100% clinical role. This model works best for physicians who are office-based or who rely on an individual referral base since increasing non-clinical release time after they have become established can be disruptive to patients by transferring his/her patients to other physicians in order to reduce the physician’s outpatient patient panel or by refusing some patients referred specifically to that physician. Examples include primary care physicians, surgical sub-specialists, and outpatient consultative specialists.

Ultimately, unfunded academic time should be used as an investment in junior physicians with the potential to become academically productive and to support those physicians who are doing academic or clinically unique activities that are vital to the success of the institution but that are otherwise unfunded. It is up to us to ensure that this unfunded time does not simply become an entitlement that allows the physicians to leave work at 2:00 on Friday afternoons or do fewer surgeries per week, just because they have an academic title in front of their name.

April 9, 2017

Categories
Medical Education

Paying Doctors To Teach

I am on a committee to provide recommendations to our Dean on how to compensate physicians for teaching. This turns out to be a lot more complicated than it might first appear. One way of approaching it is to calculate the cost to a physician for teaching – from there you can work back to what the physician should be paid for teaching.

Where does the money come from for medical education?

Medical students. Money to teach students comes from the College of Medicine that in turn gets money from several sources: tuition, endowments, “Dean’s tax” on clinical revenues, and government subsidies. In nearly all medical schools, the money from all of these sources is insufficient to pay for all of the hours of teaching by the attending physicians, at least compared to what those physicians could make in their clinical practice for those same hours. Fortunately, the intangible rewards of teaching plus the prestige of being a professor are great enough for many physicians to accept a lower income in order to be a medical school educator… up to a point.

Residents. Money to pay residents’ salaries comes from the hospitals that in turn gets money from federal funds to support GME (graduate medical education) as well as from hospital clinical income and endowments. There are additionally funds from the federal government that come in to support the teaching of residents and these funds can be used to support the teaching efforts of the attending physicians.

Fellows. There is not enough federal GME money to pay the salaries for fellows nor to pay attending physicians to teach fellows. There are 2 types of fellowships: ACGME accredited and non-ACGME accredited. The ACGME accredited fellowships are the standard specialty fellowships, for example, pulmonary fellowship. The non-ACGME accredited fellowships are in highly specialized areas, for example, an interventional pulmonary fellowship (done after a physician has already completed a basic pulmonary fellowship). The funding for ACGME accredited fellowships varies from hospital to hospital – at our medical center, half of the fellows’ salaries for ACGME-accredited fellowships are paid by the hospital and half is paid by the attending physicians in that particular specialty. In turn, the attending physicians get their funding from their own clinical income. Fellows in non-ACGME accredited fellowships are paid entirely by the attending physicians’ clinical income. Fellows in ACGME accredited fellowships cannot bill patients but fellows in non-ACGME accredited fellowships can bill patients and generate at least some clinical income on their own to help support their salaries.

Continuing medical education (CME). This is education for attending physicians who have completed their training but need to stay current in their field. In the past, this was supported by grants and sponsorships from pharmaceutical companies, medical supply companies, and medical device companies. Conflict of interest regulations now limit how much these entities pay for CME. Now, CME is paid for primarily by the individual attending physician being educated or by the hospital. Most of the time, physicians do not get paid to be a CME educator except in situations when they are getting paid an honorarium to give a talk; even then the amount of the honorarium rarely covers all of the teaching physician’s time involved in preparation, travel, etc. The intangible reward for being a CME educator is prestige and local/regional recognition as well as building a referral base.

What is the cost of teaching?

There are 3 major costs to consider in medical education: salary costs of the trainee (for residents and fellows), time costs of the attending physician teaching those trainees, and infrastructure costs for the space and other hospital resources required for teaching trainees. Lets examine each of these further:

  1. Salary costs. Medical students do not cost anything since they are taking out loans in order to pay to be there. Residents make about $52,000 their first year and this increases by about $2,000 for each additional year of training. So if we assume a 3 year residency for salary plus 25% benefits, an average cost of a resident is about $67,500 per year. However, the resident’s salary is going to ultimately be supported by federal GME funds so the attending physicians do not have to cover it. The average ACGME fellow salary + benefits in a 3-year fellowship will be about $75,000 and half of that ($37,500) is paid by the attending physicians, at least at most academic medical centers. The average non-ACGME fellow salary + benefits will be about $80,000 and this will be paid entirely by the attending physicians (plus whatever the non-ACGME fellow can bill for independently).
  2. Time costs. To determine time costs, you have to look at what the physician could have done from a clinical billing standpoint if they were providing patient care by themselves rather than engaging in a particular teaching activity. The most expensive education time cost is in classroom teaching (e.g., pre-clinical medical student classes or resident didactic lectures) because the attending physician is removed entirely from billable patient care during the time that they are lecturing or preparing a lecture. CME education also falls into this category. For attending physicians who are doing clinical education (in the office, hospital, or OR), the time cost varies depending on the level of the trainee. A third year medical student will slow you down the most since the student will need to see the patient independently and then present his/her findings to you before you see the patient. The attending physician will then need to take some time to teach the student about the patient’s disease. Because of Medicare rules on what students are not allowed to document (for billing purposes), the attending physician must then see the patient and re-do most of the history, all of the physical exam, and most of the progress note documentation. Although Medicare does permit a medical student to document the past medical/social/family history, in an era of electronic medical records, this is usually already in the electronic note. A junior resident is generally a break-even as far as the attending physician’s time – they have more experience than a medical student and Medicare permits the attending physician to use most of their progress note documentation for billing purposes. A senior resident or fellow generally adds billing productivity to the attending physician since these trainees can function more independently and at the attending physician has to spend less time with the patient and preparing the progress note on a per billable patient standpoint.
  3. Infrastructure costs. There are two general types of infrastructure costs: office practice costs and hospital costs.
    1. In the office, a typical allocation of examination rooms per doctor is 2 per attending physician/provider. This allows the doctor to be seeing one patient while the nursing staff is rooming the next patient. In certain types of practice, this may increase to 3 or even 4 exam rooms per physician but for the purpose of this analysis, lets assume it is 2 rooms per physician. To maintain clinic efficiency, you have to have additional rooms for trainees since the patients will need to spend more time in each exam room so that the trainee can see the patient first, before the attending physician. Medical students increase the infrastructure cost since they are less efficient in history taking and spend more time with the patient; however, they see relatively few patients so the number of exam rooms taken out of commission by the medical student is relatively few – usually 1. A senior resident or fellow is more efficient but also sees more patients per day and so they may need 2 additional exam rooms. If the physician owns or leases the office, this infrastructure cost goes to the physician; if the hospital owns and operates the office, then the hospital bears the infrastructure cost.
    2. In the hospital, you don’t need to have extra exam rooms or nurses for trainees since each inpatient already has their own room. However, trainees can have addition infrastructure costs in certain areas, particularly the operating room and to a lesser extent, the emergency department. In these areas, trainees add extra time to patient encounters and that extra time adds additional costs. For example, in the operating room, an experienced surgeon may be able to do a cholecystectomy in 30 minutes if he/she is doing it solo with an experienced surgical assistant. But if that surgeon is teaching a resident to do the same procedure, it might take 40 minutes. This adds 10 minutes to the surgeon’s per case time and 10 minutes to the operating room cost (including the cost of the nursing and OR personnel plus the cost of not being able to start another case in that operating room earlier). The surgeon may be able to make that time up by stepping out of the OR while the resident closes the wound and does the operative note dictation but the cost to the hospital of having a teaching OR (as opposed to a non-teaching OR) remains. ACGME fellows are a break-even for the hospital because they have less effect on operative time and permit the attending surgeon to start a second case in a second room sooner. Non-ACGME fellows may actually improve the hospital margin by permitting the attending surgeon to operate in 2 rooms simultaneously, thus increasing the surgical volume.

So, lets put all of this together to see what the net cost of various trainees is to the physician and to the hospital. In the table below, attending physician productivity (RVUs per hour) are reduced with classroom teaching and medical students but increased with residents and fellows. On the other hand, fellows have a cost to the attending physician since the attending physician has to pay part or all of the fellow’s salary. All trainees add additional outpatient infrastructure cost and the more experienced the trainee, the greater the cost because of the number of exam rooms they can cover (thus requiring both more rooms and more office staff). For hospitalized patients, there is no significant infrastructure cost except in the operating room, where these costs are largely borne by the hospital and not the physician.

 

 

 

So, if we look at the net costs of being an educator, we see that it varies depending on whether the trainees are in the physician’s office or in the hospital. Classroom teaching and medical student clinical teaching are the most expensive overall with resident and fellow clinical teaching being close to break-even in the outpatient setting but a net benefit to the attending physician in the inpatient setting.

Obviously, these are generalities and each specialty and each clinical setting will be a little different. Nevertheless, this analysis does demonstrate that there are both productivity costs and productivity gains in medical education.

March 9, 2017

 

Categories
Medical Economics Medical Education

The Hidden Time Cost Of Being A Doctor

It takes a lot of time to become a doctor. And once you become a doctor it takes a lot of time to keep being a doctor. The amount of regulatory requirements per year are staggering. These add up to time costs and every doctor has to pay these time costs, regardless of the number of patients that you see. As you will see in this post, these costs add up quickly and result in those doctors who do a lot of teaching, research, or administration spending a disproportionate amount of their time meeting these requirements.

Protected time (for research, administration, or teaching) is highly sought and highly prized in academic medicine. It has to be – the only way to get promoted and get a salary increase is to do something other than clinical care of patients. There is the obvious cost of these activities: they don’t pay very well so if a physician is going to make anywhere close to a full-time clinician’s salary, then someone else has to contribute money. But there are hidden costs – those that no one ever talks about but that can eat away at your physicians’ productivity and suck the life out of an academic department.

They’re the fixed time costs that we all pay in order to do our regular jobs. Whether you are a 100% clinical FTE (i.e., a physician who only takes care of patients) or a 25% clinical FTE (i.e., someone who only spends 1 out of 4 working hours taking care of patients), you have to do these regular activities in order to maintain licensure and medical staff privileges. And they can add up… a lot. Let’s take a look at some of the more common of these:

  1. Continuing medical education. In Ohio, we have to do 50 hours per year of CME to maintain our medical license.
  2. ACLS (Advanced Cardiac Life Support). Required for many specialties; for others, ATLS (Advanced Trauma Life Support), or PALS (Pediatric Advanced Life Support) may be required. Preparation and classwork is about 10 hours every 2 years.
  3. CITI (Collaborative Institutional Training initiative). This is required for any physician who is involved in human subject research. Because this includes enrollment in trials and not just being a funded researcher, many/most academic physicians have to keep their CITI certificate up to date just to be able to assist clinical researchers by referring patients into clinical trials. It takes about 12 hours to do the program and it has to be renewed every 3 years.
  4. Department faculty meetings. At our University, these are mandatory and held quarterly – 4 hours per year.
  5. Division faculty meetings. In our division, these are mandatory and held monthly – 12 hours per year.
  6. Electronic medical record training. Initially, this takes about 10-20 hours. However, once you are facile with it, you just need to get trained on the periodic software updates – about 1 hour per year.
  7. Compliance training. At our hospital, we have a mandatory 2 hours per year for billing/coding compliance training to ensure that we are documenting our services and billing correctly.
  8. Hospital training. At Ohio State, these fall under “CBL” (Computer Based Learning) modules. These cover everything from what to do in a fire, to how to read a hazardous materials label, to the hospital’s sexual harassment policy. They vary from year to year but typically, it is about 10 hours per year.
  9. Hospital committees. I attend an enormous number of committee meetings but I get paid to attend them as a medical director. However, no one fully escapes committees and most physicians find themselves on a couple. I’ll estimate 15 hours a year.
  10. “Justify your existence forms”. These are part of the annual review that every academic physician has to fill out to document their annual clinical/research/publication/teaching/administrative productivity and describe how they have spent all of their time over the past year. Included in this category is the “promotion and tenure dossier” that all academic physicians have to complete periodically as they move toward promotion to associate professor to full professor. In our institution, if a physician is in the so-called clinical track, even full professors have to fill these out every 2-5 years in order to have their university contracts renewed. If you include the required face-to-face meeting with the division director or department chairman, the process requires about 6 hours per year.
  11. Emails. I get 50-100 a day – most physicians don’t get quite this many. Many of these are mass emails to all physicians. Some are worthy of reading (like weekly hospital news briefs) but a lot are garbage (like people who hit the “respond to all” button on every congratulatory email sent by a chairman to recognize a notable achievement by one of the faculty members). You have to at least open all of them and skim the first few sentences to see if you need to read the rest or if you can just click the delete button on your email program. Probably about 50 hours per year on average.
  12. Licensure forms. Medical license, DEA license, etc. Plan on 1 hour a year on average to fill these out.
  13. Surveys. We get surveyed constantly – from the College, from the hospital, from the department, from outside agencies. Most physicians don’t answer most of them because there are just too many. But some are inescapable – figure 2 hours per year.
  14. Board certification maintenance of certification. This includes required “MOC modules” that some boards require physicians to do every year and also includes the renewal board examination test (every 8-10 years depending on the specific board) as well as studying in order to pass the board exam. Although some of these activities can double for continuing medical education requirements, some can’t so figure an overall average is about 5 hours per year that can’t be included in CME.
  15. Employee health. This includes the time it takes to get your annual flu shot and the time it takes to do the annual infection control learning module, among other employee health & epidemiology requirements. Overall, 2 hours per year.

So, add all of this up and you get approximately 169 hours per year that every physician has to spend doing required activities just to be able to see a single patient or to see a thousand patients. Given that most physicians work about 56 hours per week, this equates to 3 weeks of time over the course of a year. Let’s assume a physician works 48 weeks a year (off 3 weeks for vacation and 1 week for the sum of all holidays for a year). A 100% clinical FTE would need to spend 3 weeks doing all of their required activities resulting in 45 weeks of patient care per year. A 25% clinical FTE (for example, someone who spends 75% of their time doing research or administration) would have 36 weeks per year doing research/administration leaving 12 weeks per year left over to do clinical activities. However, because that physician would need to spend 3 weeks of time on all of the above activities, they would only really be seeing patients for 9 weeks per year.

The reality is that most of us end up doing most of these activities during the evening or on weekends. But they still represent a huge fixed time cost to any academic physician. As a result, you can potentially get more clinical work from one 100% clinical FTE than you do from four 25% clinical FTEs.

February 1, 2017

Categories
Medical Education

The Anachronism Of Tenure

Tenure [ten-yer] noun:  Guaranteed permanent employment, especially as a teacher or lecturer, after a probationary period.

In academic medicine, the ultimate professional achievement is tenure. But what, exactly, is tenure? Historically, it meant that if you proved yourself, you got tenured and you were given academic freedom to do whatever research you wanted and the freedom to express your own opinions as an educator. And then, you would be protected from being fired.

The history of tenure in the United States.

In the 1800’s, professors served at the discretion of university’s boards of trustees who hired and fired them. But by the turn of the century, there was concern that this system led to influential donors dictating what professors could and could not research and teach. In 1915, the American Association of University Professors (AAUP) created a declaration of principles for academic freedom and tenure:

  • Trustees raise faculty salaries, but not bind faculty with restrictions.
  • Only committees of other faculty members can judge a member of the faculty.
  • Faculty appointments be made by other faculty and chairpersons, with three elements:
    1. Clear employment contracts
    2. Formal academic tenure, and
    3. Clearly stated grounds for dismissal.

In 1940, the AAUP recommended that the probationary period before granting tenure should be 7 years. But the AAUP’s declarations did not provide academic freedom protection. In the McCarthy era, professors suspected of being communists could be fired and in the 1960’s, twenty states passed laws that professors who voiced anti-war sentiments could be fired from public colleges. Legal cases in the 1970’s helped to create protection from dismissal of tenured professors leading to the system that we have today, where tenured faculty are insulated (although not completely immune) from job termination and censorship.

Tenure track versus clinical track.

The problem with this is that it has created a caste system in academic medicine where physicians are either in the “tenure track” or the “clinical track”. If you are in the tenure track, you are promoted from “Assistant Professor” to “Associate Professor” and ultimately to “Professor”. When you are promoted to Associate Professor, you become “tenured”. However, if you are in the clinical track, you are promoted from “Assistant Professor, Clinical” to “Associate Professor, Clinical” and ultimately to “Professor, Clinical”. The clinical track faculty do not have the same rights as the tenure track faculty. You cannot be tenured in the clinical track and your contract is year-to-year rather than an indefinite duration.

Each department has a promotions and tenure committee that then reports to the college promotion and tenure committee that then reports to the university board of trustees. At each level, a faculty member who is up for promotion is voted on whether or not to be promoted.

But there is a problem with two academic tracks.

At the promotion and tenure committee levels, committee members who are in the tenure track vote on whether or not to promote both tenure track candidates and clinical track candidates. However, committee members who are in the clinical track can only vote on clinical track candidates. Inherent in this system is the assumption that tenure track faculty can judge the qualifications of clinical track faculty but clinical track faculty are incapable of judging whether tenure track faculty are qualified.

As a result, the criteria for promotion in the clinical track ends up looking a lot like the criteria for promotion in the tenure track. Being the best diagnostician or surgeon in the university does not get you promoted. Similarly, being the best teacher in the university won’t get you promoted. Even in the clinical track, you have to write articles about diagnoses and surgeries or write articles about teaching to get promoted. The clinical track in academic medicine has become in essence, the junior varsity track with the tenure track becoming the varsity track.

Last year, my son was doing campus visits as a high school senior when deciding where to go for college. At one university, which by all of the college ranking lists was among the top universities in the country for chemistry, the upper classmen that we met with told him that he should take his freshman chemistry courses at the 2-year community college on the other side of town and then transfer the credit because the professors that taught freshman chemistry were not as good of educators and were largely unavailable since their primary focus was their research rather than teaching undergraduates.

Our academic promotion values are out of synch with the needs of academic medicine.

The only way to get grants and write manuscripts is to have time during the week to do it. This has resulted in the concept of “protected time”, that is, time that you are not required to be seeing patients. The more protected time you are able to negotiate in your employment contract, the better your chances of being promoted, either in the tenure track or in the clinical track. One of the problems is that someone else has to pay for the cost of your salary during that protected time and that someone is often the physicians seeing patients full-time.

But to survive in the future, academic medical centers will not maintain financial viability purely by populating themselves with as many famous physicians as possible. Academic medical centers are increasingly in a vicious competition with private hospital systems for their very survival. If the academic medical center is not seeing enough patients, then it doesn’t have enough clinical income. And if it doesn’t have enough clinical income, it goes broke. So we are now in the difficult position of rewarding our academic physicians to to see fewer patients while we need our academic physicians to see more patients to stay in business. Our need priorities and our reward priorities are out of alignment.

So what do we do with tenure?

  1. Promote academic physicians for excellence in teaching. This seems so intuitive, so why don’t we do it? As an analogy, if you were hiring a contractor to remodel your kitchen, would you want the contractor who has the reputation as the best remodeler in the community or the contractor who writes a lot of articles in The Journal of Home Remodeling but had all negative reviews on Angie’s List? If our business is teaching medical students, why wouldn’t we value the best teachers?
  2. Promote academic physicians for excellence in clinical care. One of the best clinicians I have ever known spent 33 years as an Assistant Professor before retiring (as an Assistant Professor). He was known at Ohio State as “the doctor’s doctor” because all of the doctors who knew him wanted him as their doctor. If our business is taking care of patients, why wouldn’t we value the doctors who do the best job taking care of patients?
  3. Eliminate the caste system of tenure versus clinical tracks for promotion. Promotion and tenure committees should either be comprised of both tenure track and clinical track faculty who all vote on all candidates who are up for promotion or we need to have two entirely separate promotion systems: one comprised only of tenure track faculty who vote on exclusively tenure track promotion candidates and one comprised only of clinical track faculty who vote exclusively on clinical track promotion candidates.
  4. Eliminate the word “Professor” for academic physicians who are not in a tenure track. In some health systems, the physicians have other titles that better reflect their commitment and achievement in patient care. So maybe we’d be better off using consultant: “Assistant Consultant”, Associate Consultant”, and “Senior Consultant”. Or maybe clinician: “Associate Clinician”, “Senior Clinician”, and “Master Clinician”.

What did I do?

In 1997, I became tenured when I was promoted from Assistant Professor to Associate Professor in the tenure track. However, rather than feeling like I had academic freedom to do what I was passionate about, I felt constrained because in this track, I would not be able to do what I really enjoyed: teaching medicine, taking care of patients, and taking on administrative leadership roles in the hospital. Instead, the tenure track had me locked into a future of submitting research grants and writing journal articles. Don’t get me wrong, these are noble and valued activities and I had a lot of passion for them. Its just that I had even more passion about teaching and patient care. So in 2002, I resigned my tenure which meant that I actually had to resign from my job at Ohio State, and then was immediately re-hired as a “Professor – Clinical”, no tenure. And now, I have the best job in the medical center.

The whole idea of tenure was to protect university faculty from being fired because of their opinions and to give them the freedom to study the things that they were passionate about. But the unintended consequence of tenure is that in today’s academic medicine environment, the tenure process discriminates against those academic physicians whose passions are teaching and clinical care.

December 31, 2016