There is one constant in regulations and policies... unintended consequences. Presently, Medicare seeks to improve quality of care delivered in hospitals by rewarding those hospitals that have lower mortality rates...
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:
- Continuing medical education. In Ohio, we have to do 50 hours per year of CME to maintain our medical license.
- 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.
- 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.
- Department faculty meetings. At our University, these are mandatory and held quarterly – 4 hours per year.
- Division faculty meetings. In our division, these are mandatory and held monthly – 12 hours per year.
- 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.
- 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.
- 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.
- 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.
- “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.
- 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.
- Licensure forms. Medical license, DEA license, etc. Plan on 1 hour a year on average to fill these out.
- 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.
- 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.
- 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