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

Categories
Medical Education

13 People Years = 2 Dog Years = 1 Dean Year

The Ohio State University has new Dean of the College of Medicine, Dr. Craig Kent. We are very excited to have someone as esteemed to lead our college. But the occasion has caused me to look back on the medical school leaders at our university over my own career. I have had 8 deans or interim deans in the past 36 years since starting medical school. Each time there was a change, it seemed like it might be the end of the world as I knew it. But deans have a relatively short half-life as it turns out.

The median length of tenure of a medical school dean is 6 years nationwide. There an average of 12 new deans appointed each year in the U.S.  A key question to ask when a new dean starts is how will he or she define success during their tenure at your medical school. Some deans define success in terms of longevity: whoever lasts the longest wins. Other deans define success in terms of specific objectives that they have when taking the job.

Department chairs have a slightly shorter tenure. Their average time on the job was 5.7 years for a full chair and 1.3 years for an interim chair. At Ohio State, we’ve definitely been the exception: in the 32 years since I started residency, I’ve only had 2 chairmen (and one interim for a brief few months). The first, Dr. Ernie Mazzaferri, was on the job for 15 years and the second, Dr. Mike Grever, is now going on 17 years.

To put that in comparison, the average duration of office for the 44 U.S. president is 5.1 years.

One of the reasons that deans and department chairs hold their jobs for a relatively short time is that we hire them based on their past scholarly performance but then we fire them based on their business performance. Large numbers of grants and publications can make a search committee swoon but if it turns out that the new dean or chair can’t read a profit and loss statement or has no concept of strategic planning in a competitive clinical market, then he or she is not going to keep their job very long.

One of the perpetual challenges that we have in academic medicine is that when you distill what we do, we basically have 3 missions: research, teaching, and clinical care. For tenure, research is king – historically, a medical faculty member could not get promoted simply by being the best teacher or the best clinician – they had to write about teaching and write about clinical medicine. But regardless, given their 3-part mission, colleges of medicine that are doing well with 1 of those 3 missions always look to hire a new dean or chair who has the promise of elevating one of the other 2 missions. If your college of medicine is doing great as a teaching institution, you don’t hire your next leader to elevate your already thriving educational mission, you hire the leader who you think can elevate your lagging research or clinical mission. If the college of medicine is not careful, this can result in perpetually changing sense of institutional self-identity and priorities.

I’ve heard some chairs lament that their job is no longer fun because of a perceived shift from the job being one of promoting scholarship to being one of running a business. And it is true that colleges of medicine and departments of medicine rely more and more on clinicians and the clinical income that they generate in order to fund the colleges’ operations. But I think that as we have changed how we define success for a dean or department chair over the years that we have simply changed the job requirements for a dean or department chair.

October 4, 2016

Categories
Hospital Finances Medical Education

Financing American Colleges Of Medicine

IMG_0715Recently, the Association of American Medical Colleges (AAMC) released a report on how American colleges of medicine are funded and how this funding has changed over the past several decades.

As a hospital medical director, this has enormous implications for hospitals associated with medical schools and the report is pretty sobering. Let’s take a look at 2 years: 1980 (the year I started medical school) and 2015, thirty-five years later.

In 1980, the biggest source of income for colleges of medicine was state governments which accounted for 29% of the total funding. Support from federal research was next at 22%. Income from clinical practice (both from physicians and hospitals) was also 22%. Tuition accounted for 6%.1980 COM funding

Jump ahead to 2015 and there has been a huge shift in where the money comes from. Now state governments dropped to 6% of medical school funding. Federal research dropped to 14% of medical school funding. But clinical practice income now accounts for 60% of medical school funding. Of that 60%, 18% comes from hospital revenue and the other 42% comes from physician revenue. Tuition accounts for 4%.2015 COM funding

It is not that the state governments are paying less. Indeed, in 1980, the states contributed $1,639,000 to medical colleges whereas in 2015, the states’ contributions rose to $6,990,000. The problem is that the total cost of colleges of medicine has exploded, rising from $5,645,000 in 1980 to $112,978,000 in 2015. In order to support this exponential increase in costs, medical schools have had to depend more and more on clinical practice income, from both physicians and hospitals.

On the surface, this might seem that the colleges of medicine are like giant parasites feeding off of the toil of physicians and hospitals but the reality is more complex. In 1980, most academic physicians were in private practices, with a rather small portion of their income coming from colleges of medicine; the physician practice income went to the physicians and not to the colleges. By 2015, most academic physicians were no longer in private practice but rather were employed by either the teaching hospitals or by the college of medicine (and sometimes the hospital and the college are essentially the same thing). Therefore, with the changes in physician employment, the total cost of a college of medicine has had to go up since the college now has to pay physician salaries but the amount that the colleges receive from clinical practice income has also gone up since the college-employed physicians clinical practice income is now credited to the college instead of a private medical practice.

So what is the implication of all of this to the hospital medical director? First, if you are a medical director of an academic teaching hospital, you will have an increasing percentage of your physicians employed by the colleges and universities rather than being in separate private clinical practices. Second, with 15% of college of medicine revenues coming from the academic teaching hospitals, these teaching hospitals will have additional expenses not borne by non-teaching hospitals. Although academic teaching hospitals do have additional federal income that non-teaching hospitals do not have in the form of federal direct graduate medical education and indirect graduate medical education funding, these funding sources alone will not sustainably cover the hospitals’ contribution to colleges of medicine in the future.

So what can we do as hospital medical directors? We are and for the foreseeable future will be inextricably intertwined in a symbiotic relationship with our colleges of medicine and academic physicians. We will need to recognize that our hospitals will be obligated to help support activities that are not historically part of the hospital mission, such as pre-clinical medical education and medical research. We also need to be stewards of the hospital’s resources since the hospital administrative leaders will rely on our expertise to advise them on where money should appropriately be allocated. And as part of being stewards of those hospital resources, we will need to hold the colleges and the physicians accountable to ensure that hospital funding is being used wisely and for the purposes that it was intended.

I still firmly believe that being an academic physician is one of the highest career callings in healthcare. And being a medical director of an academic teaching hospital is for me the culmination of that career. As medical directors, we face the controversies, conflicts, and challenges posed by the dynamic relationships between the hospitals and the colleges but in the end, there is no better job on the planet.

July 27, 2016