Academic Medicine

Do We Really Still Need A Tenure Track In Academic Medicine?

Tenure is defined as: “guaranteed permanent employment, especially as a teacher or lecturer, after a probationary period“. Ohio Senate Bill 83 is currently being considered by Ohio’s legislative body and would change tenure in Ohio’s colleges and universities. In current practice, tenure is usually reserved for those faculty who have proven their value to a college based on the number of research grants they have received and number of research articles that they have published. But is tenure still relevant in our nation’s colleges of medicine?

Summary Points:

  • Universities want tenured professors who are successful obtaining research grants and writing papers
  • Academic hospitals want clinical professors who practice the highest quality and often highly specialized patient care
  • We treat these two classes of faculty differently
  • It’s time to level the playing field and treat tenure track and clinical track faculty the same
  • Ohio Senate Bill 83 includes provisions to reduce privileges traditionally afforded to tenured faculty


Fifty years ago, most medical school faculty were either tenured or in the tenure track awaiting advancement to tenure. Once they received tenure, they were given academic freedom to take their research and scholarly activities in whatever direction they chose and it was exceedingly difficult to fire a tenured faculty member.

As an example, 30 years ago, a tenured physician member of my division lost his medical license due to recurrent alcohol and drug use. Without a medical license, he could no longer be a member of our hospital’s medical staff. However, because he was a tenured professor, he could not be terminated from the university so he continued to receive a salary despite no longer seeing patients, teaching students, or performing research. Due to the structure of the university’s salary plan, the funds for his salary had to come from the clinical income of the division, meaning that we all had to forgo bonuses and raises in order to pay the salary of a tenured professor who was no longer even coming into the office. This was a (fortunately rare) example of tenure gone awry.

Beginning about 40 years ago, there emerged a second track for physician faculty at U.S. colleges of medicine, most commonly called the “clinical track”. Unlike tenure track faculty, these clinical track faculty members had fewer requirements for research metrics such as grants and journal article publication. Instead, clinical track faculty primarily focused on clinical care of patients. Over time, these clinical track faculty also assumed most of the responsibility for teaching medical students and residents. What emerged in the 1990’s was a caste system in our nation’s universities with the clinical track faculty perceived as second class citizens. For example, at the Ohio State University, tenure track faculty can vote on promotion of clinical track faculty, however clinical track faculty cannot vote on promotion of tenure track faculty. In the past, only tenure track faculty could vote in elections to the University Senate, the governing body of the university and only tenure track faculty could run for Senate office. Tenured faculty receive a university appointment for life but clinical track faculty are only hired for periods of 3-5 years, after which, they have to be reappointed to maintain their employment.

Tenure track faculty are still favored over clinical track faculty at most American universities. For example, at Ohio State University, the Board of Trustees Bylaws and Rules number 3335-7-03 states that “Unless an exception is approved by the university senate and the board of trustees, clinical/teaching/practice faculty may comprise no more than forty percent of the total faculty in each of the colleges of the health sciences.” The implication is that clinical track faculty are less desirable than tenure track faculty. But the demand for faculty who perform patient care vastly exceeds the supply of tenured physicians. Consequently, the overwhelming majority of faculty in clinical departments of the OSU College of Medicine are in one of the clinical tracks and not in the tenure track. This is similar to most medical schools in the United States. Despite this trend, nearly all medical school deans and clinical department chairs in the U.S. come from the tenure track and not the clinical track.

As academic medical centers have grown larger, so too has grown the number of physicians needed at these hospitals to see patients and generate clinical revenue. At most academic hospitals, physicians have to have an academic appointment in order to be on the hospital’s medical staff. This has led to a rapid expansion in clinical track faculty at most colleges of medicine in the United States. It has also led to conflicting values between the universities and their associated academic medical centers: the university leaders (such as the presidents and deans) value tenure track faculty more highly whereas the hospital leaders (such as the CEOs and CFOs) value the clinical track faculty more highly. The rapid increase in clinical track physician faculty has also led to more subdivisions of the clinical track. When I first joined the Ohio State University faculty in 1991, there were only two options: tenure track or clinical track. Now, the clinical track has been subdivided into clinical educator, clinical scholar, clinical excellence, teaching, and practice pathways. In addition, there is an adjunct clinical faculty track for unpaid community physicians who participate in medical student or resident education. At other colleges, adjunct faculty are those who are paid by the college but are part-time faculty; in many undergraduate colleges, these adjunct faculty teach the majority of classes.

The result is that U.S. colleges now have two parallel tracks for promotion and career advancement. First, there is academic rank consisting of (1) instructor, (2) assistant professor, (3) associate professor, and (4) professor. Academic rank is used for both tenure track and clinical track faculty. It is a measure of seniority and academic accomplishment. Second, there is tenure. Tenure is only granted for tenure track faculty, typically when they advance from assistant professor to associate professor. Tenure grants the privilege of choosing one’s own scholarly activities and grants one a job for life. At issue is whether we really need both tracks or can we eliminate tenure and replace it with academic rank?

I would argue that this two-class system of academic medicine is harmful to the future of academic medicine. An academic physician in the clinical track who is treated like a second class citizen at the university can leave to work in a community hospital where he or she will be treated like a first class physician. If we don’t start treating our clinical track physicians like other faculty, then our academic medical centers will continue hemorrhaging the best clinicians to private practice.

In full disclosure, I began my academic career in the tenure track and was granted tenure in 1997 when I was promoted to associate professor. However, my academic identity was as a teacher and clinician. So, in 2002, I resigned my tenure and switched to the clinical track since medical education, patient care, and clinical research were more appropriate activities for clinical track faculty. As a professor in the clinical track, I still was able to choose what classes I taught and choose what clinical research studies to participate in. In this sense, I had academic freedom. The main difference for me was that unlike the professors in the tenure track, I had to be reappointed to my job every 5 years.

So, should one class of faculty be more privileged than another class?

Ohio Senate Bill 83 is a proposed legislation that, among other things, would alter how Ohio’s colleges and universities use tenure. One provision of the bill is that it would require universities to annually assess tenured faculty on several criteria, including teaching. Furthermore, 50% of the teaching assessment must be based on student evaluations and mandates that students evaluate each faculty member based on the question: “Does the faculty member create a classroom atmosphere free of political, racial, gender, and religious bias?” The bill further requires tenured faculty to undergo a post-tenure review if they have evaluations of “does not meet performance expectations”. The implication is that it would be easier for universities to fire tenured faculty members who have below average student evaluations. It has engendered a lot of debate and some of the fiercest criticism has paradoxically come from conservative professors who fear that they could lose their jobs due to poor evaluations from students who have more liberal or centrist views on political and social issues.

Senate bill 83 has some other controversial provisions. It prohibits colleges from having mandatory diversity training for employees. It prohibits any Ohio state-funded college from having any academic relationships with any academic institutions in China. It requires all Ohio undergraduate students to take a history or political science course and specifies the required reading materials for those courses. It mandates an enormous amount of reports and paperwork to be regularly submitted to the Chancellor. It prohibits colleges from using gender identity or sex to segregate student for residential housing. It specifies that no employee of a state institution of higher education can strike; this includes nurses and essentially anyone who works at an academic medical center.

Make no mistake about my opinions regarding academic medicine – we need medical scientists to do research to improve our ability to understand and treat disease. But we also need expert clinicians to oversee the care of our patients at academic medical centers. And we need the best teachers for our medical students and residents. There was a time when a single tenured academic physician could do all three of these mission areas effectively, the so-called academic “triple threat”. But those days are gone and true triple threat academic physicians are exceedingly rare as grant funding has gotten more competitive, as clinical care has become more specialized, and while teaching has remained time-consuming. Increasingly, the tenure track is primarily used for those faculty who do research whereas the clinical track is used for those faculty who primarily teach and take care of patients.

If our colleges of medicine really want to meet their tripartite mission of teaching, research, and clinical care, then we need to start treating those faculty involved in each of these mission areas equally. If we hire tenured faculty for an indefinite duration then we should hire clinical faculty for an indefinite duration. On the other hand, if we only hire clinical faculty for 3-5 year periods before reappointment, then we should only hire tenured faculty for 3-5 year periods.

Seven years ago, I wrote a post entitled “The Anachronism Of Tenure” that implied that tenure is a hold-over from a previous era of American academia. Increasingly, tenured faculty are the minority of our country’s academic physicians and increasingly, tenure is reserved for only those academic physicians whose primarily role is research. Ohio Senate Bill 83 is an attempt to diminish the special privilege that tenured faculty have enjoyed but I think that it misses the target. The original idea of tenure was to ensure academic freedom for the tenured faculty member. With the growth in the number of faculty members who provide clinical care and the shift in medical education resulting in non-tenured faculty teaching the majority of health science courses, tenure has evolved to mean additional privilege and job security afforded to faculty who do funded research.

It is time to call tenure out for what it really has become. It was originally created to provide job security protection for academic faculty to pursue scholarly activities. It is now primarily reserved for faculty who have been awarded the most research grants and who have published the most journal articles. Other measures of scholarly activity, such as effectiveness of teaching and (in the case of academic physicians) improving community health, are no longer considered grounds for tenure and are now mostly relegated to clinical track faculty. The recipe to achieve tenure is: don’t volunteer for anything, protect your time at all costs, and focus exclusively on getting published. The advice given throughout the country to physician assistant professors in the tenure track is that in order to make tenure, you have to see fewer patients, avoid committee assignments, and teach fewer classes so that you can spend more time writing papers.

It is time to show that U.S. colleges of medicine value all three mission areas equally. We need to either grant tenure privileges to those academic physicians whose primary responsibility is teaching and clinical care or we need to eliminate tenure completely. Some specific tactics that could realign these mission areas include:

  • Ensure equal representation and authority of both tenure track and clinical track faculty on promotion and tenure committees.
  • Equate the annual review process for tenure track and clinical track faculty. For example, a 1-year probationary period followed by a 3-year subsequent appointment period for all assistant professors, a 4-year appointment period for all associate professors, and a 5-year appointment period for all professors (for both tenure track and clinical track faculty). Reappointment periods would be for similar periods of time for each academic rank.
  • Equal eligibility of both tenure track and clinical track faculty to serve on university governing bodies.
  • Increase the representation of clinical track faculty in dean and department chair positions in our colleges of medicine and clinical departments.
  • Consider eliminating tenure altogether and transferring some of the job protection and privileges of tenure to academic rank, such as the ranks of professor and/or associate professor.

In my opinion, Ohio Senate Bill 83 is simply bad legislation. It creates a new layer of bureaucracy and paperwork, it restricts or eliminates collective bargaining processes, it meddles in foreign affairs that should be the jurisdiction of the U.S. State Department, and it mandates undergraduate classes that are already required for graduation from Ohio’s high schools. But part of the bill targets tenure at Ohio’s colleges and universities. Clinical departments comprised of academic physicians are different than non-clinical departments comprised of PhDs and the need for a privileged class of tenured faculty in our clinical departments may be less than in non-clinical departments. If we don’t fix the tenure issue at our medical schools ourselves, then legislative bodies like the Ohio Senate are going to fix it for us… and we may not like the result.

April 30, 2023


Academic Medicine Medical Education

Results Of The 2022 Internal Medicine And Pediatric Subspecialty Fellowship Match

Yesterday, on November 30, 2022, the results of this year’s fellowship match for internal medicine and pediatric subspecialties was released. This is for fellowship positions that will begin in July 2023. Every specialty has its own fellowship match and the dates of the match results vary from as early as May the year before the start of fellowship (vascular surgery, thoracic surgery, pediatric surgery) to January the year of the start of fellowship (sports medicine, psychiatry). The internal medicine and pediatric match results are released at the end of November.

The results of all of the fellowship match results are made available in a report published by the National Resident Matching Program in March every year. Last year’s match showed that more physicians are subspecializing, fewer foreign medical graduates applied, certain subspecialties were very competitive (surgical and OB/GYN subspecialties) and certain subspecialties were less popular (most internal medicine and pediatric subspecialties).  Although we will not know the complete results of all subspecialty fellowship matches for several months, internal medicine and pediatrics represent the largest number of fellowship positions and so we can draw preliminary conclusions for yesterday’s match results in those subspecialties.

The terminology used in physician specialization can be confusing. As an example, internal medicine is a specialty and cardiology is a subspecialty within internal  medicine. This means that a cardiologist must first complete an internal medicine residency and then do further training in a cardiology fellowship. This post will focus on the recent subspecialty fellowship match results for the specialties of internal medicine and pediatrics.

Internal Medicine

Overall, there were 2,042 different programs participating in this year’s internal medicine subspecialty fellowship match and these programs offered a total of 5,779 fellowship positions. 82.1% of programs filled all of their positions and 89.5% of all positions in the country filled. These results are similar to last year. Of the physicians who did match, 46.8% were U.S. MD graduates, 13.5% were U.S. DO graduates, 12.8% were U.S. citizens who attended foreign medical schools, and 26.7% were foreign medical graduates. This is a slight decrease in the percent filled by U.S. MD graduates and a slight increase in foreign medical graduates compared to last year.

As in the past, certain internal medicine specialties were more competitive than others. Competitive programs are those that had a higher percentage of their total positions filled. The most competitive subspecialties were cardiology and interventional pulmonary that both filled 100% of their positions, followed by gastroenterology (99.8%) and hematology/oncology (99.7%). Three subspecialties filled fewer than 65% of positions: adult congenital heart disease (63.6%), transplant cardiology & heart failure (55.9%), and geriatrics (45.4%).

Two other subspecialties had relatively low fill percentages: infectious disease (74.4%) and nephrology (72.8%). These two subspecialties are concerning because their total number of fellowship positions is considerably higher than other low-performing subspecialties. There were 441 infectious disease fellowships offered and 493 nephrology fellowship positions offered compared to adult congenital heart disease (22 fellowship positions offered) and transplant cardiology & heart failure (127 positions offered). The implication of these results is that our country will face a much larger shortfall in the number of internal medicine infectious disease specialists and nephrologists in the future compared to other subspecialties.

A second way of determining the competitiveness of a subspecialty is by the percentage of positions filled by U.S. medical school graduates (MD). In general, most subspecialty fellowships are affiliated with medical schools offering MD degrees (as opposed to DO, or osteopathic, degrees). Historically, U.S. MD graduates tend to have an advantage over U.S. DO graduates, U.S. citizens graduating from foreign medical schools, or foreign medical school graduates who are not U.S. citizens. Subspecialties with the highest percentage of U.S. MD graduates filling available fellowship positions were adult congenital heart disease, gastroenterology, hematology & oncology, and interventional pulmonary. Pulmonary medicine had a very low filling percentage by U.S. MD graduates but there were only 27 total positions offered in 2022 since most physicians instead choose to do a combined pulmonary & critical care medicine fellowship (748 positions offered).

Graduates of U.S. osteopathic (DO) schools were most likely to fill pulmonary medicine-only fellowships or critical care medicine-only fellowships. But again, these fellowships offer very few available positions since most available positions are in combined pulmonary & critical care medicine fellowships. Geriatrics, infectious disease, and nephrology all had high percentages of U.S. osteopathic graduates.

U.S. citizens attending foreign medical schools account for nearly as many filled subspecialty fellowship positions as U.S. osteopathic graduates and followed a similar trend with a high percentage in pulmonary-only and critical care medicine-only fellowships followed by nephrology, interventional pulmonary, geriatrics, and endocrinology.

The final group of physicians filling positions in the 2022 internal medicine subspecialty fellowship match was non-U.S. citizens who graduated from foreign medicine schools (foreign medical graduates). Subspecialties with the highest percentage of positions filled by foreign medical graduates were endocrinology, pulmonary-only, and nephrology.


Overall, there were 919 different pediatric subspecialty fellowship programs that together offered 1,814 fellowship positions in the 2022 match for fellowships to start in July 2023. 74.9% of the programs filled and 84.7% of all positions were filled. Pediatric subspecialty fellowship positions were most likely to be filled by U.S. MD graduates (61.6%) followed by foreign medical graduates (14.8%), U.S. DO graduates (14.7%), and U.S. citizen graduates of foreign medical schools (8.8%). These percentages were unchanged compared to the previous year’s match. Compared with internal medicine, more pediatric subspecialty fellowship positions fill with U.S. MD graduates.

The most competitive pediatric subspecialty fellowships were gastroenterology, emergency medicine, and cardiology which all filled more than 97% of available fellowship positions. Similar to internal medicine, the least competitive subspecialties were infectious disease (49%) and nephrology (54%), as well as endocrinology (61%).

The pediatric subspecialties most likely to fill with graduates of U.S. medical schools were adolescent medicine, hospital medicine, and infectious disease – all of which filled 73% of positions with U.S. MD graduates. The least likely were transplant hepatology and endocrinology, each of which filled 50% of available positions with U.S. MD graduates.

Subspecialties with the highest percentages of graduates of U.S. osteopathic schools were child abuse (31%), gastroenterology (19%), and hospital medicine (19%). Subspecialties with the lowest percentage of U.S. DO graduates were infectious disease (5%) and rheumatology (4%).

There were only 135 U.S. citizen graduates of foreign medical schools who matched into pediatric subspecialty fellowships with the highest percentages in developmental-behavioral medicine (16%) and endocrinology (14%).

Foreign medical graduates had the highest representation in rheumatology (30%) and transplant hepatology (33%). They had the lowest representation in hospital medicine (1%).

Implications of the match

The overall trends of the 2022 match (for fellowships to begin in July 2023) are similar to the 2021 match. For both internal medicine and pediatrics, two subspecialties continue to be unpopular and had a high percentage of unfilled positions:  nephrology and infectious disease. In both pediatrics and in internal medicine, physicians in these two subspecialties have lower annual incomes than other subspecialties due to the current U.S. physician billing and reimbursement model. For internal medicine, these 2 subspecialties are also those with the highest percentages of foreign medical graduates filling fellowship positions.

The results of the match suggest that the United States will see an increasing shortage of both adult and pediatric nephrologists and infectious disease specialists. Pediatric endocrinology and adult geriatrics will also face physician shortages In order to attract these subspecialists, hospitals will need to subsidize their salaries as they are not able to generate competitive incomes by professional revenues alone. As these shortages become more severe, the clinical services provided by these subspecialists will need to increasingly be provided by primary care physicians and advance practice providers.

December 1, 2022

Academic Medicine Physician Retirement Planning

Is Your Public Pension Safe? Check The Pension’s Vital Signs!

Physicians at academic medical centers often have an option to contribute to a state teacher’s pension plan. Although a pension can be an important component of a diversified retirement portfolio, some public pensions are currently in danger. How safe is your state’s public pension and should you contribute to it? The answer is in the pension’s vital signs.

Summary Points:

  • Most physicians employed by public universities can participate in their state’s public pension
  • Each state’s public pension is managed separately
  • Some public pensions are healthier than others
  • The funded ratio and the funding period are two important vital signs that indicate the health of a public pension


In Ohio, the State Teachers Retirement System (STRS) is our state’s public pension for academic physicians at state-funded universities (such as the Ohio State University). STRS is similar to Social Security or an annuity in that it gives university-employed physicians an option to participate in a defined benefit plan that will pay you a fixed amount of money every month that you are alive after you retire. There is also an option for survivor benefits so that your spouse can continue to receive a monthly payment after you die. The advantage of defined benefit plans, such as STRS, is that you never run out of money in retirement. The disadvantage is that as an investment, you may be able to come out ahead by investing the money yourself rather than contributing to the pension during your working years.

In the past, most American workers had access to employer-sponsored pensions but many private employers have abandoned pensions and replaced them with 401(k) plans. However, pensions are still quite common for employees of state and local governments. Everyone’s retirement portfolio should be diversified and contain several different types of investments, such as stocks, bonds, and real estate. A pension can be an important component of those investments, less risky than bonds but also having a low rate of return.

However, all types of investments have risk and a pension is no different. Social Security is generally considered to be very low-risk, as investments go. But even Social Security is in danger of running out of money in 2035, unless action is taken by the U.S. Congress in the future. Private company pensions occasionally run out of money, leaving retirees with reduced or no monthly pension payments. State public pensions are somewhere in-between Social Security and private company pensions with respect to investment risk.

In some states (such as Ohio), academic physicians have an option of either participating in the public pension (STRS) or self-directing payroll deduction retirement savings into investments of their own choice. In other states, participation in the public pension is mandatory and there is not an option to self-direct. When deciding whether or not to participate in a public pension or deciding whether or not to take a university job in a mandatory public pension state, you should look carefully at the state’s public pension. Some states’ public pensions are considerably safer than others. When researching a state’s public pension, there are two pension vital signs that are important: (1) the funded ratio and (2) the funding period. Understanding these two numbers is critical to understanding the health of a public pension.

The Funded Ratio

The funded ratio is the ratio of a pension’s assets to its current and future liabilities. In simple terms, the assets are all of the money that the pension currently has in cash and in investments. The liabilities are the total amount of money that the pension plan will pay out to retirees now and in the future plus the administrative cost of the pension. In an ideal world, the funded ratio should be 100% or higher. In other words, the pension plan should have enough money to pay for the pensions of all of its current participating members. A funded ratio below 100% can be cause for concern and a funded ratio below 80% can be a sign that the pension plan is in jeopardy. The Equitable Institute recently released its annual State of Pensions report for 2022 and there are some concerning findings. From the map below, it is apparent that some states’ public pensions have very strong funded ratios and others have very poor funded ratios.

Washington, Utah, South Dakota, Wisconsin, Tennessee, New York, the District of Columbia, and Delaware all have funded ratios greater than 90% (dark green). On the other hand, Illinois, Kentucky, South Carolina, New Jersey, Connecticut, Hawaii, and Rhode Island all have severely low funded ratios that are below 60% (dark red). In between these extremes are thirteen states that mildly low funded ratios between 80-90% (light green). Fourteen states have moderately low funded ratios between 70-80% (yellow). And nine states have moderate-severely low funded ratios between 60-70% (light red).

One of the main reasons that many states’ funded ratios have recently fallen is the downturn in the stock market in the past 7 months. Public pensions do not just keep all of their money in a checking account, they invest the money in order to keep up with inflation and to ensure that they have sufficient money to pay their retirees in the future. Most public pensions estimate that their investments will have an average 6.9% annual return. Last year, in 2021, the average pension plan’s rate of return was 25.3% – an extraordinarily high rate of return, primarily because stock markets had an exceptional year. So far in 2022, the average pension plan has had a -10.4% rate of return. In other words, instead of gaining 6.9% this year, the average pension has already lost 10.4%.

There are several reasons why a state might have a low funded ratio:

  1. Inadequate funding. Public pensions are funded by a combination of employee contributions (payroll deductions) plus employer contributions (usually as a fixed percentage of gross salary). If the contribution rates are set too low, then the public pension fund will not have sufficient funds to pay monthly retirement benefits. Currently, the average employee contribution is 8.07% of total salary, an increase from 7.06% in 2001. In addition to employee contributions to the public pension, there are also employer contributions to the pension and these currently average 29.8% of total payroll, an increase from 9.13% in 2001.
  2. Excessively high retirement benefits. Similarly, if the amount of money that retirees receive in their monthly pension payments is set too high, then the funded ratio will fall as the pension gradually runs out of money. The amount of the pension fund contributions and the amount of the pension fund distributions requires a very careful actuarial analysis and this in turn requires well-trained and highly skilled actuaries. Not every state has equally high-quality actuaries working for their public pensions. Public pensions should have periodic external audits to validate the conclusions and recommendations of the pensions internal actuaries. These audit reports should be available to pension participants and can be a valuable source of information about the pension’s health.
  3. Poor investment choices. Each state’s pension is managed differently – some by internal fund managers and some by external investment companies that employ their own fund managers. Inevitably, some fund managers will be better than others at selecting winning investments. However, as has been shown with managed mutual funds compared to index funds, most fund managers will not beat the overall stock market. This year, one of the particularly bad investment choices was in Russian investments. Prior to the Russian invasion of Ukraine, U.S. public pensions held approximately $5.8 billion in Russian market assets, securities, and real estate. These investments have lost enormous value since 2021. Over the past 15 years, there has been a growing trend to outsource investment decisions – currently 15% of public pension funds are managed by either a hedge fund or a private investment company.
  4. Unrealistic projected rates of return. The average annual rate of return on public pension fund investments is 6.9%. If a fund projects a higher rate of return, say 8.5%, then there is a high likelihood that their investments will not meet their projected rate of return, leading to lower than anticipated asset value. A pension fund’s rate of return on its investments will be largely determined by the ratio of stocks:bond:real estate in the fund’s investment portfolio. This ratio is in turn determined by the decisions made by the pension fund managers.
  5. The value of stocks and bonds fall. Some years, the stock and bond markets go up and some years they go down. Because public pension funds are mainly investing for the long-term, it is expected that the funded ratio will fall during short-term market downturns but then go up when the market recovers. 2021 and 2022 exemplify this perfectly with large losses in stock and bond values in 2022 but even larger gains in 2021. This resulted in a higher average funded ratio in 2021 that then fell in 2022 (graph below). It is more important to look at public pension fund investments over a several year period to determine how well the fund is doing.
  6. Inflation. If the public pension fund retiree distributions are tied to inflation, then there can be large cost of living increases in monthly pension payments during years that there is a high inflation rate. In these pensions, when inflation rises unexpectedly high (as in the previous 12 months), then the funded ratio can fall due to higher than expected monthly pension payments. Of 372 public pensions, 204 of them have automatic cost of living increase provisions with the majority of these linked to the inflation rate or the fund’s overall performance. Because of the danger of inflation eroding the funded ratio, other public pensions limit or do not give any regular cost of living increases in pension distributions.
  7. Increased life expectancy. This is often cited as a cause of a low funded ratio because if retirees live longer than expected, then the overall amount that the pension fund pays those retirees will be higher than expected. However, it turns out that annual increases in life expectancy have only a very small effect on funded ratios. It remains to be seen whether the opposite effect (shorter life expectancy) will improve funded ratios in the next few years since the majority of the more than 1 million U.S. COVID-19 deaths in 2020 and 2021 were in retirees.

The Funding Period

When a public pension’s funded ratio falls, or when actuarial analysis projects that it will fall in the future, there are a number of tactics that the pension can take to rectify the low funded ratio. For example, the pension managers can suspend cost of living increases in pension distributions. Or they can increase the contributions by increasing the percentage of employed pension members’ salaries going into the pension fund. Or they can increase the number of years a member must work before being eligible for full retirement benefits. When a public pension makes these corrective actions, it can take many years for the funded ratio to increase to 100%. The projected number of years that it will take to reach 100% is called the funding period.

Simply having a low funded ratio may not necessarily be bad as long as the public pension managers have taken corrective actions to improve the funded ratio. How effective these corrective actions are projected to be is measured by the length of the funding period. In general, the shorter the funding period, the better. In Ohio, the State Teachers Retirement System is required by state statute to have a funding period of less than 30 years. Funding periods in excess of 30 years are generally too long and can be a sign of an unhealthy public pension.

Many of the same variables that affect the funded ratio also affect the funding period. For example, the Ohio State Teachers Retirement System funding period dropped from 30 years to 8 years in 2021 due to the unusually large rate of investment return in 2021.

Public pensions with both a low funded ratio and a long funding period are in trouble. These pensions are in danger of being unable to meet future obligations. From a retirement portfolio standpoint, they are poor investments.

A Story Of 3 States

To illustrate the variability in public pension health, let’s examine three states: one that is in trouble, one that is in great shape, and one that was in trouble but has taken effective measures to improve.

Illinois. Illinois has 5 different state government public pension programs and all of them have a long history of being underfunded. At the end of 2021, these public pensions had an average funded ratio of only 46.5%, the highest ratio for the Illinois public pensions since 2008, before the great recession. Although improved, this is still among the lowest of all states’ public pension funded ratios. The state legislature has created a plan to increase the funded ratio to 90% by the year 2045. However, the state’s actuary and outside actuarial consultant have advised that a 90% funded ratio target in 23 years is insufficient and instead have advised a funding period to a 100% funded ratio of no more than 25 years. So far, no legislative action has been taken to improve the funding period. As a consequence, participation in the Illinois public pension is very risky compared to other states’ public pensions.

Wisconsin. The primary state public pension is the Wisconsin Retirement Benefit. It has a track record of being well-managed and as a consequence, it has a funded ratio that exceeds 100%. In fact, the funded ratio at the end of 2021 was 120.6%. That puts its funded ratio as the eighth highest out of 167 statewide public pensions in the country. Academic physicians can feel secure that their contributions to the Wisconsin public pension will be safe and that they can count on their monthly pension benefits in retirement.

Ohio. There are 5 statewide public pensions in Ohio. Academic physicians have the option of participating in one of them, the State Teachers Retirement System of Ohio.  In 2001, STRS was in good shape with a funded ratio of 91%. The great recession severely impacted STRS and by 2012, the funded ratio had fallen to 56%. By 2017, the funding period to reach a funded ratio of 100% had risen to 60 years, putting the entire pension in jeopardy. STRS enacted three corrective measures to stabilize the pension fund: (1) suspension of annual cost of living increases in retiree pension distributions, (2) a 2.91% increase in the employer contributions to the pension fund, and (3) an increase in the number of years of service to full retirement benefits from 30 years to 35 years. By the end of 2021, the pension’s funded ratio was 80.1% and the funding period was 8 years. STRS’s willingness and ability to make hard decisions to increase contributions and limit distributions has resulted in it once again becoming a safer retirement investment for participants.

Even healthy public pensions are vulnerable to forces that can destabilize them. For example, the next pension fund manager could make poor investment choices. The state legislature could enact statues that acquiesce to lobby pressure to increase retiree benefits or decrease employee/employer contributions. The next actuaries may make faulty life expectancy projections. For these reasons, it behooves all participants to periodically check the status of their public pension. At a minimum this should entail reviewing the current funded ratio and funding period of the pension. In this sense, a pension is an investment and should be monitored similarly to how one monitors their 401(k) or 403(b) fund.

“If you’ve seen one public pension, you’ve seen one public pension”

A strong and secure retirement investment portfolio is one that is diversified. Ideally, one’s portfolio should consist of a mixture of stocks, real estate, bonds, fixed income, and cash. For each of these types of investments, the potential long-term return is directly related to the short-term risk of the investment.

For most Americans, the fixed income component is Social Security. But academic physicians and other employees of state-funded universities usually do not participate in Social Security. The public pension substitutes for for Social Security and is thus the main component of the fixed income portion of academic physicians’ retirement portfolio.

Some financial pundits have argued that it is better to not participate in a public pension and instead take the money that would have gone into the pension fund from payroll deduction and invest that money into stocks. The argument is that in the long-term, the rate of return from stock investments will be greater than the return from pension distributions in retirement. However, a more accurate view of a public pension is that it forms a crucial low-risk/low-return component of a balanced retirement portfolio. By having a public pension in the portfolio, the academic physician can devote a larger percentage of other retirement investments (403b, 457, IRA, etc.) into higher risk stocks and real estate.

In addition to functioning as a fixed income retirement investment, public pensions have other features that can increase their value to the participant. Survivor benefits for one’s spouse and dependents can replace the need to purchase separate life insurance. Disability benefits can replace the need to purchase separate disability insurance. Access to group rates for health, dental, and vision insurance can result in insurance premiums that can be thousands of dollars less per year than equivalent insurance policies purchased individually. And access to financial counselors at the public pension can provide some elements of free financial planning advice.

But each state’s public pension has different degrees of risk as evidenced by their varying funded ratios and funding periods. Before committing to participating in a public pension, it is important to carefully examine the health of that particular state’s public pension. Do a routine vital sign check of the pension by following its funded ratio and funding period.

July 22, 2022

Academic Medicine Physician Retirement Planning

Retirement Planning For University Physicians

University-employed physicians (and all university faculty for that matter) have more retirement savings options than most physicians in private practice. Unfortunately, many of the decisions about these options have to be made at the time of hiring. This is a time in young physicians’ lives when they are least knowledgeable about personal finances and least equipped to make these decisions. This post will cover university faculty retirement planning with an emphasis on academic physicians at the beginning of their careers.

Summary Points:

  • Academic physicians have more retirement savings options than other physicians
  • Contribute the maximum amount into your 415(m)
  • Maximize 457 contributions before contributing to a 403(b)
  • 403(b), 457, and 415(m) plans offer hidden tax advantages
  • The decision about contributing to a state teacher’s retirement system versus an alternative 401(a) retirement plan is complex

The number of decisions that new university physicians have to make when they sign their employment contracts can be overwhelming. Will you be in the tenure track or clinical track? Who will be your mentor(s)? Which weeks do you want to block out for vacation over the next year? Where will your office be? What teaching assignments would you prefer? Fortunately, as months and years go by, you can change your mind about most of these decisions. But when it comes to retirement plan participation, some of the decisions you make initially are irrevocable and you cannot change your mind a few months later.

Understand your retirement options

Every university’s retirement plans are a little different and not all retirement savings options will be available to physicians at every institution. Here are the most common options:

  • Base retirement plans (401(a) plans). These are generally qualified retirement plans covered by section 401(a) of the Internal Revenue Code. Each state will have different specific plans – here in Ohio, university physicians can choose between the State Teacher’s Retirement System (STRS) or the Alternative Retirement Plan (ARP). In both plans, a fixed percentage of the physician’s salary is contributed pre-tax to the plan with a matching contribution from the university. When contributed to STRS, the plan can function essentially as a pension with a fixed amount of monthly income for life. When contributed to the ARP, the physician selects among a number of investment options (typically mutual funds) that are controlled by the physician with no guarantee of monthly income in retirement (very similar to a 403(b) plan). Both of these plans serve as a substitute for Social Security so physicians are ineligible for Social Security for their income earned from the university.
  • 403(b) plans. These are deferred income retirement plans for employees of non-profit organizations. Most universities are non-profit so 403(b) plans are available to most academic physicians. These are essentially the same as a 401(k) (deferred income retirement plan in a for-profit company). In 2022, you can put up to $20,500 per year into a 403(b) (up to $27,000 if over 50 years old). This is money taken out of your paycheck pre-tax and then you pay federal and state income tax on it when you take money out of the account in retirement.
  • 457 plans. These are deferred income retirement plans for government employees. Faculty at public universities are usually considered state government employees and are eligible to participate in 457 plans in addition to the university’s 403(b) plan. The contribution limits are the same: $20,500 per year if under age 50 and $27,000 per year if over age 50. By contributing to both a 457 and 403(b), physicians at state-supported universities can put away a combined amount of up to $41,000 per year ($54,000 if over age 50). Although fundamentally similar to 403(b) plans, there is one unique advantage of the 457 plan in that unlike the 403(b) plans, there is no tax penalty for early withdrawal before age 59 1/2 years old.
  • 415(m) plans. These are deferred income retirement plans for highly paid government employees earning more than $305,000/year in 2022 in salary and bonuses or with contributions more than $61,000 to the university’s base retirement 401(a) plan (STRS or ARP). Many physicians at public universities will fall into this category since physicians command relatively high salaries compared to other university faculty and compared to regular state government employees. Contributions to 415(m) plans can be made by the employee, the employer (i.e. the university), or both, depending on each university’s specific plan. In essence, the 415(m) plan allows physicians and other highly paid university employees to put away more for retirement after the annual base retirement 401(a) contribution limits have been reached.
  • Traditional and Roth IRAs. These are not sponsored by the university but anyone can contribute to a traditional IRA. Because the income limit to contribute pre-tax money into a traditional IRA is $144,000 per year if filing single in 2022 ($214,000 if filing jointly), most physicians are not eligible to contribute pre-tax dollars into a traditional IRA, nor are they able to contribute post-tax dollars directly into a Roth IRA. However, physicians can contribute post-tax money into a traditional IRA and then promptly convert it into a Roth IRA (‘backdoor’ Roth). As I have posted previously, I think that everyone should have a Roth IRA as part of a diversified retirement portfolio, even if it requires doing a backdoor Roth.

The tax advantages of deferred compensation options

A widely discussed advantage of deferred compensation retirement plans, such as the 403(b), 457, and 415(m) plans, is that you can defer paying income tax on the withdrawals until you are in retirement when you will likely have a lower income tax rate. Although that may be true, it is impossible to predict what the income tax rates will be 35 years from now when you are retired. They may be higher, lower, or the same as they currently are and therefore, depending on the amount that you are withdrawing each year, your federal income tax rate could be higher, lower, or the same as it currently is. If your income tax rate is the same, then the amount of take-home money that you have after taxes will be the same whether you pay income tax now and invest the money or contribute the money to a deferred income investment and pay income tax later. But there are two often-overlooked advantages to using a deferred income retirement plan:

  1. Reduce your income tax rate today. When you contribute to a deferred income retirement account, you effectively reduce your taxable income that year. Thus, you end up paying less tax on all of your take-home income. For example, assume you have an annual income of $250,000 and you are married, filing jointly. Your effective federal income tax rate for 2022 is 16.81%. If you contribute $20,500 to a 403(b), your taxable income drops to $229,500 and your effective federal income tax rate drops to 16.16%. The difference in effective tax rates is 0.65% and this results in you paying $1,492 less in taxes on the $229,500 than you would have at the higher tax rate. In other words, by contributing to a 403(b), 457, 401(a), or 415(m) plan, you have in essence given yourself a tax deduction!
  2. Avoid paying investment taxes twice. If you were to put the $20,500 into a regular post-tax investment (such as a mutual fund) instead of contributing to the 403(b), then not only do you pay income tax on that money this year but you will also pay capital gains tax when you eventually cash-out the post-tax investment AND you will also pay taxes on the annual dividends and interest from those investments every year that you hold those investments. You can avoid the capital gains, dividend, and interest taxes by contributing to a backdoor Roth IRA but the contribution limit is only $6,000 per year ($7,000 if over age 50). So, unless you put that retirement money in a Roth IRA, you will end up paying much more in taxes by putting retirement money in a regular post-tax investment than you will by putting that money in a deferred income plan.

Maximize 415(m) contributions

The decision about whether or not to participate in a university 415(m) plan is usually made at the time of initial employment and is irrevocable (meaning that you cannot change your mind later). At the Ohio State University, the choices are 0%, 4%, 8%, or 12%. If the 0% option is chosen, then you are electing to not participate in the 415(m) plan.

The 415(m) plan only kicks in when you have reached the annual contribution limit to your 401(a) base retirement plan ($61,000 in 2022) or retirement eligible earnings over $305,000. Therefore, you will only be contributing to the 415(m) plan for the portion of you income that exceeds the portion of your income subject to 401(a) contributions.

My advice is to take the maximum contribution to the 415(m). Even at the highest option (12% at OSU), it will still be less than your contribution to the university’s base retirement 401(a) plan (14% at OSU). Also, you can always increase or decrease contribution amounts to a 403(b) and/or 457 in order to allow you to meet annual expenses such as a new home purchase or student loan repayment. But once you commit to a percentage contribution to the 415(m) plan, you cannot increase it in the future.

Think very carefully about base retirement plan selection

A second irrevocable decision at the time of initial employment is which 401(a) base retirement plan to choose. Most universities will have something like a state teacher’s retirement system choice versus an alternative retirement plan choice. Both options have advantages and disadvantage and the choice that is best for one academic physician may not be the best choice for another academic physician.

Many financial advisors will tell you that you can get a higher rate of return by investing your retirement money yourself than you will get from a state teacher’s retirement system (STRS) pension. And they are right – you can, if you invest that money in a portfolio with a large percentage of stocks. But you should think of a pension as the non-volatile fixed income component of a balanced retirement portfolio. In this sense, it will substitute for the bond or annuity component of your portfolio had you not contributed to STRS. Therefore, by contributing to STRS, you will have the ability to safely put a higher percentage of your other retirement investments in more volatile investments with higher potential rates of return (such as stock and real estate mutual funds). Most academic physicians will contribute far more to their 403(b), 457, and 415(m) plans than they will to their base retirement 401(a) plans and these physicians can then afford to put more of their 403(b), 457, & 415(m) investments into stocks and real estate than they otherwise would have been able to.

Once retired, the predictable fixed income monthly pension income reduces the amount that you will need to keep in cash. The cash portion of your portfolio after you are retired serves to cover sudden, unexpected expenses and serves as a buffer to having to withdraw money from volatile accounts when the stock and bond markets fall. By keeping less money in cash, you can put more money into investments that over the long-term will result in greater wealth.

Every state will have different options for base retirement plans. In Ohio, it is either the State Teacher’s Retirement System of Ohio (STRS) or the Alternative Retirement Plan (ARP). Because most states have plans that are similar, I will use Ohio’s options of STRS versus ARP as examples. Some of the factors to consider when choosing between 401(a) base retirement options include:

  1. How long will you be employed by the university? In order to get the maximum annual pension, you have to contribute to STRS for 35 years. If you leave the university to go into private practice or if you take a job at a university in a different state, then you can either withdraw your STRS contributions plus a 3% annual interest rate or you can take a rather small pension when you eventually retire. Some states allow you to purchase credit for some of the years that you worked as an educator in other states making STRS contributions somewhat portable.  However, if there is a high likelihood that you will work at a university in your current state of residence for less than 35 years, then the ARP may be the wiser choice.
  2. Will you need health insurance? If you retire before you are eligible for Medicare (currently age 65), then you will need to purchase health insurance. If you purchase an individual insurance policy on the open market, it can be incredibly expensive. STRS participants have access to group health insurance with good coverage that is considerably less expensive. Once you are covered under Medicare, you will still need supplemental health insurance and once again, it will be less expensive to purchase though STRS. Dental and vision insurance for retirees is also available through STRS. The ability to purchase STRS health insurance can result in saving a considerable amount of money after retirement.
  3. How do you value other benefits? In addition to health insurance, participants in STRS have access to other benefits. If you become disabled, then you may be eligible for a monthly disability benefit. There are also options for monthly benefits for surviving beneficiaries (spouse or children). My father died when I was in college and his STRS plan helped support me while I was in medical school and 42 years after his death, my mother still receives a monthly STRS benefit.
  4. Your confidence in STRS. There is a reason that most corporations have eliminated pensions – they are expensive and have the potential to run out of money. Although most  teacher retirement systems are supported by their state governments, they are not immune to financial crisis. For example, the Illinois Teachers’ Retirement System is in danger of running out of money and not being able to pay its retirees. Each state’s system varies in terms of financial stability. My own opinion is that it is very unlikely that any state government will allow a teacher’s retirement system to default – if they do, that state will not be able to find new teachers willing to work there and the public education system would collapse. However, you should look at participation in an STRS plan as a type of investment and all investments have risk. For most states, that risk is equal or less than the risk of investing in bonds.
  5. You won’t have Social Security. At most public universities, physicians do not contribute to Social Security. The idea is that STRS substitutes for Social Security but even of you elect the alternative retirement plan (ARP) instead of STRS, you still do not contribute to Social Security. Therefore, when you are retired, you will not receive Social Security benefits. Even if you have contributions to Social Security from years that you worked for other employers or from outside consulting that you did while working at a university, your monthly Social Security payments in retirement will be considerably reduced. Therefore, if you elect the ARP instead of STRS, you will need to have a  higher percentage of your retirement savings in stable investments such as bonds, annuities, or certificates of deposit since you will not have the safety that a fixed income source brings to a diversified retirement portfolio.
  6. How old will you (and your spouse) live to be? Pension benefits are determined by actuaries who estimate how long the beneficiaries will live. If beneficiaries live a long time after retiring, then the monthly pension amounts have to be lower to be sure that the pension does not run out of money. On the other hand, if retirees die shortly after retiring, then the pension can afford to have higher monthly pension payments. Currently, a man who retires at age 65 can expect to live to age 83.2 years; a women retiring at age 65 can expect to live to age 85.8 years. If you anticipate dying younger than these ages, then the ARP may be better for you. If you anticipate living beyond these ages, then STRS becomes a better option. Factors to consider in estimating your longevity include any chronic diseases (diabetes, hypertension, etc.), personal or family history of cancer, age of death of your parents, your smoking history, whether you get regular vaccinations, your body mass index, etc.
  7. Your risk tolerance. Remember, a pension should be considered as the defined benefit component of a diversified retirement portfolio. As such, it is a low-risk component. Each person has a different risk tolerance. Those who have a higher risk tolerance will generally have a higher percentage of their retirement portfolio in higher risk stocks and real estate. Those with a lower risk tolerance will generally want to increase the percentage of their portfolio in low-risk bonds and fixed income. If you choose STRS, then the percentage of your overall retirement savings portfolio derived from your STRS pension should match your risk tolerance. If you find that contributing to STRS would make your overall portfolio diversification too conservative, then the ARP may be preferable.

What about the 403(b), 457, and Roth IRA?

The base retirement 401(a) plan will not be enough to fund your entire retirement portfolio. For most academic physicians, the largest component of their portfolio will be in their 403(b, 457, and 415(m) plans. As mentioned above, the 403(b) and 457 plans are very similar but the 457 plan’s lack of early withdrawal penalties gives it a slight advantage over the 403(b). For that reason, it is preferable to maximize annual contributions to a 457 plan before starting to contribute to a 403(b) plan. If you can afford it, ideally, you should be contributing to both.

Most universities will have options of directing contributions to different investment brokerages and to different mutual funds within each brokerage. It is within the 403(b) and 457 accounts that most people can create the proper risk diversification for their overall retirement portfolio by selecting funds that compliment fixed income sources such as STRS.

A Roth IRA is an essential component of a balanced and diversified retirement portfolio and everyone should have one. Ideally, one should contribute to all three options: a 403(b), a 457, and a Roth IRA. Maximizing annual contributions to all of these would add up to $47,000 per year and if you did that every year with an average annual rate of return of 8%, then after 35 years, you would have $8.7 million in retirement savings. However, $47,000 per year is beyond the reach of most people so I recommend doing an annual partial contribution to both a Roth IRA and a 457 initially. Once you reach the contribution limit of the 457, then increase your Roth IRA contribution to the IRS limit. Next, steadily increase your 403(b) contributions until you reach the IRS limit.

Academic physicians can save more

Physicians in private practice usually have access to a 401(k) or 403(b) plan… and that is about it. Physicians employed by public universities usually have access to a 401(a), 403(b), 457, and 415(m) plan. Moreover, most of the 401(a) plans include sizable employer matching contributions. Physicians in private practice will generally have a higher annual income than academic physicians. However, academic physicians can generally save more for retirement in deferred income plans with the tax advantages that come with those plans. For many academic physicians, these increased retirement savings can offset the lower annual income with the result that the decision between private practice versus academics can be based more on workplace preference and lifestyle rather than on economics.

May 12, 2022

Academic Medicine Medical Education

Lessons From The 2022 Fellowship Match

NOTE: This post is about the various fellowship matches that were held between May 2021 and January 2022 for various fellowships starting in July 2022. For a post about the internal medicine and pediatric subspecialty match released November 2022 for fellowships beginning in July 2023 click here

This month, the National Resident Matching Program (NRMP) released the results of this year’s match for fellowships that will begin in July 2022. Match day for most subspecialty fellowships was in December 2021 although some subspecialties had their match day earlier in the year. The new report summarizes the results of these match days.

The process for physician training begins with medical school graduates entering a residency in a specific specialty such as internal medicine, pediatrics, obstetrics & gynecology, or surgery. After completing residency, physicians can do further subspecialty training in fellowships. For example, cardiology is a subspecialty of the specialty of internal medicine. Therefore, to become a cardiologist, a physician first completes an internal medicine residency and then completes a cardiology subspecialty fellowship. Some subspecialties have their own subspecialties. For example, a physician completing a cardiology subspecialty fellowship can go on to do an even more specialized subspecialty fellowship in cardiac electrophysiology.

In the match, physicians who are either in their final year of residency or have already completed residency apply to fellowship training programs. The physician applicants then rank the training programs in order of their preference and the fellowship training programs also rank the applicants in their order of preference. The NRMP computers then assign each applicant to a specific training program using an algorithm that matches the applicant’s preferences with the training programs’ preferences. Overall, the process works and ensures that the applicants get into their most preferred training program that will accept them.

Every spring, the NRMP releases an annual report of the data from the match and by examining the data, there is a wealth of conclusions about the current state of the various subspecialties.

More physicians are specializing

From 1995 to 2000, the number of fellowship positions as well as the number of physicians applying to fellowships fell. However, since 2000, there has been a steady increase in both the available fellowship positions as well as the number of applicants for those positions. This year, 13,586 physicians applied for 12,571 fellowship positions. The majority of applicants were U.S. MD degree graduates (7,141), followed by non-U.S. citizen graduates of international medical schools (2,619), U.S. DO degree graduates (1,991), and U.S. citizen graduates of international medical schools (1,791).

The number of fellowship positions has been increasing faster than the number of resident positions. Over the past 2 decades, resident positions have increased by 74% from approximately 20,200 in 2000 to 35,194 in 2021. During that same time period, fellowship positions have increased by 558%, from approximately 1,900 in 2000 to 12,571 in 2022. In other words, resident positions have not quite doubled in the past twenty years whereas fellowship positions have increased by 5.5-fold.

Internal medicine subspecialties account for the largest number of fellowship positions. 49% of the 12,571 fellowship positions were in internal medicine subspecialties, followed by pediatrics (14%), surgery (7%), and radiology (7%). The penetration of subspecialty fellowships varies between different specialties. For example, there were 1,137 resident positions offered in radiology in 2021 (the most recent year resident data is available) and 869 fellowship positions offered in radiology in 2022. Therefore, there were 0.76 radiology fellowship positions for every 1 radiology resident positions. If all resident and fellow positions were filled, then this would imply that 76% of radiology residents go on to do radiology subspecialty fellowships. Similarly, this analysis would estimate that 69% of internal medicine residents do fellowships whereas only 13% of physical medicine & rehabilitation residents do fellowships.

The number of foreign medical school graduate applicants fell

In recent years, the number of all types of applicants for subspecialty fellowships have been increasing. For the 2022 year, the number of non-U.S. citizens graduating from international medical schools (foreign medical graduates) decreased for the first time from 2,332 in 2021 to 2,280 in 2022. All other types of fellowship applicants increased in number in 2022. One of the main reasons for the decrease in foreign medical graduates was the COVID pandemic that resulted in immigration and travel restrictions that prevented many foreign applicants from coming to the U.S. for medical training.

Non-U.S. citizens who graduated from international medical schools make up a minority of physicians who match in most subspecialties. However, in subspecialties that are less popular with U.S. MD degree graduates, foreign medical graduates comprise the largest percentage of matched positions. Four subspecialties had more foreign medical graduates than U.S. MD degree graduates filling fellowship positions: adult endocrinology (40.4%), adult nephrology (35.8%), adult pulmonary (26.1%; note that there are relatively few positions available for adult pulmonary-alone fellowships and most positions are for combined pulmonary & critical care medicine), and medical genetics (52.2%).

U.S. DO degree graduates (osteopathic school graduates) have historically comprised the smallest number of subspecialty fellowship applicants but now exceed the number of applicants who are U.S. citizen graduates of foreign medical schools. Because of the traditional emphasis on musculoskeletal elements of disease and rehabilitation, osteopathic graduates tend to gravitate to certain subspecialties. Those with more than 20% of filled positions going to U.S. DO degree graduates include: pain medicine (21.5%), emergency medicine services (27.2%), global emergency medicine (22.7%), hospice & palliative medicine (20.7%), brain injury medicine (27.3%), spinal cord injury medicine (35.3%), and sports medicine (36.6%).

Highly competitive subspecialties

The more applicants (particularly U.S. MD degree graduates) there are per subspecialty fellowship position is a marker of how competitive that subspecialty is. Those subspecialties with more applicants than available fellowship positions are highly competitive whereas the subspecialties with more fellowship positions than applicants are less competitive. The 2022 NRMP fellowship match report reveals that some subspecialties are for more competitive than others. Overall, the average subspecialty fellowship filled with 51% U.S. MD degree graduates. The results listed below are the subspecialty fellowship positions that filled with more than 70% U.S. MD degree graduates:

  • Obstetrics & Gynecology. Overall, the subspecialties of OB-GYN are the most competitive of all major specialties: complex family planning (100%) filled all available positions with U.S. MD degree graduates followed by gynecologic oncology (94%), reproductive endocrinology (90%), maternal-fetal medicine (88%), pelvic & reconstructive surgery (79%), and minimally invasive gynecologic surgery (73%).
  • Surgery. Highly competitive subspecialties include: pediatric surgery (95%), hand surgery (85%), colon & rectal surgery (80%), and thoracic surgery (71%).
  • Pediatrics. Three of the 17 pediatric subspecialties were highly competitive: adolescent medicine (77%), child abuse (70%), and pediatric hospital medicine (70%).
  • Internal Medicine. Only hematology (85%) was highly competitive. However, relatively few physicians do a hematology-only fellowship (14 positions) and the vast majority do a combined hematology/oncology fellowship (663 positions).
  • Emergency Medicine. Medical toxicology (74%).

A second marker of competitiveness is the percentage of available fellowship positions in each subspecialty that fill with any applicant, including U.S. MD degree graduates, U.S. DO degree graduates, U.S. citizens graduating from international medical schools, and foreign medical graduates. Below are the subspecialties that filled more than 90% of their available fellowship positions:

Unpopular subspecialties

As in past years, some subspecialties are less popular. Those that filled with fewer than 40% U.S. MD degree graduates were mostly subspecialties of internal medicine and pediatrics:

  • Internal Medicine. The least competitive subspecialty was pulmonary disease (16%). However, relatively few physicians do a pulmonary-only fellowship (25 positions) and the vast majority do a combined pulmonary & critical care medicine fellowship (721 positions). Other unpopular subspecialties included nephrology (20%), geriatric medicine (20%), heart failure & heart transplant (27%), endocrinology (32%), infectious disease (38%), interventional pulmonary (38%), and oncology (38%). However, like hematology-only fellowships, there are relatively few positions in oncology-only fellowships (8) and most positions are in combined hematology & oncology (663) which was a considerably more popular subspecialty.
  • Pediatrics. The least popular pediatric subspecialty was infectious disease (20%) followed by developmental & behavioral pediatrics (29%), endocrinology (30%), and nephrology (32%).
  • Physical Medicine & Rehabilitation. Spinal cord injury medicine (32%).

Below are the subspecialties that filled fewer than 90% of there available positions with any applicant including U.S. MD degree graduates, U.S. DO degree graduates, U.S. citizens graduating from international medical schools, and foreign medical graduates:

Nephrology, endocrinology, and infectious disease remain unpopular

In both internal medicine and pediatrics, nephrology, endocrinology, and infectious disease are among the least popular subspecialties. One of the reasons that infectious disease and endocrinology remain unpopular is salary. According to the 2021 Medscape Physician Compensation Survey, the average general internal medicine physician had an income of $248,000 last year. However, despite requiring two additional years of subspecialty fellowship training after internal medicine residency, adult endocrinologists and infectious disease physicians made less than general internists at $245,000 for both subspecialties. It is difficult to justify investing two additional years into training in order to make less money than if you had gone straight into clinical practice after completing residency. A second physician salary survey is done by Doximity. Like the Medscape survey, Doximity also found that endocrinologists and infectious disease specialists have incomes less than general internists. In addition, the Doximity survey reports salaries for pediatric subspecialties and like their adult counterparts, pediatric endocrinologists and pediatric infectious disease specialists have a lower income than general pediatricians.

The Medscape survey also asks physicians if they feel they are adequately compensated – infectious disease physicians and endocrinologists are the least satisfied with their compensation at 44% and 50% of survey respondents satisfied respectively. The salary disparity has been particularly acute for infectious disease physicians who over the past two years of the COVID pandemic have been among the most over-worked physicians of any specialty. In other words, the message that internal medicine and pediatric residents hear is to go into infectious disease is to train longer, work harder, and get paid less.

The reasons for nephrology continuing to be unpopular are less clear. Nephrologists have a higher annual income than general internal medicine physicians with an average of $311,000 per year. However, this is less than other procedural internal medicine subspecialties such as pulmonary medicine, critical care medicine, cardiology, and gastroenterology. One of the primary clinical activities of nephrologists is overseeing dialysis. Most patients with end-stage renal disease receive hemodialysis three days per week, either Monday-Wednesday-Friday or Tuesday-Thursday- Saturday. Because of this schedule, nephrologists typically have a 6-day workweek to cover dialysis with a 1-day weekend (Sunday) whereas other subspecialties typically have a 5-day workweek with a 2-day weekend. It is possible that the longer workweek attendant to nephrology could be discouraging physicians from entering the subspecialty.

Geriatrics continues to be an unpopular subspecialty. Unlike many of the other fellowships, a physician can do either an internal medicine or a family medicine residency prior to a geriatric medicine fellowship. Salary is one of the barriers to applicants. Geriatric medicine requires a 1-year fellowship and most geriatricians practice primary care medicine for people over age 65. There is no additional compensation in terms of RVUs for caring for older patients and many of these patients have multiple concurrent medical problems as well as cognitive impairment. As a result, it can take a geriatrician longer for an outpatient visit while getting paid the same amount that a primary care internist or family physician would be paid for an office visit for a younger, less medically complex patient. Thus, the economics of geriatric medicine discourages family physicians and internists from entering the subspecialty.

So, what does all of this mean?

As fewer physicians go into specific subspecialties, there will likely be shortages of those subspecialists in the future. The pediatric subspecialties of endocrinology, infectious disease, and nephrology had a lowest percentage of available fellowship positions fill and will therefore face physician shortages in the near future. However, I believe that the most serious future shortage will be in adult nephrology. Pediatric subspecialists are relatively small in numbers and almost always located in large referral pediatric hospitals. On the other hand, adult nephrologists are needed in most community hospitals and any town large enough to have an outpatient dialysis center.

The number of unfilled subspecialty fellowship positions is even larger for geriatrics. However, general internal medicine physicians and family physicians can more easily fill in for shortages in geriatricians. Therefore, shortages of physicians trained in geriatrics will not be felt as severely by most communities.

For capitalism to work in medicine, supply and demand have to be unconstrained so that when the supply of a subspecialty falls, demand for that subspecialty can bring the supply back up through free market forces that increase the pay for those subspecialists. The U.S. system for paying physicians has led to an uncoupling of supply and demand. Unless health policy changes the way that subspecialists such as endocrinologists, infectious disease specialists, and nephrologists are compensated, we will be facing an increasing shortage of these physicians in the future. In the meantime, if your hospital has one of these subspecialists who is a high-performer, treat him or her well – they are becoming a very rare breed.

March 30, 2022

Academic Medicine Medical Economics

Why Are There So Many Asian Physicians In The U.S.?

People of Asian descent comprise 5.6% of the American population but Asian Americans comprise 19.8% of all U.S. physicians. Two things happened this week that led me to think about this statistic and why Asian Americans are so disproportionately represented in American medicine. First, I listened to the America’s Test Kitchen podcast, Proof, about why there are so many Chinese restaurants in the U.S. (quite fascinating and worth a listen). Second, I listened to this week’s MedNet webcast on Racism and Racial Bias in Medicine that included an exploration of why African Americans are under-represented in U.S. medicine. Part of my interest is because of my own Chinese heritage (albeit only 1/8th).

Several years ago, there was a lawsuit against Harvard University by a group of Asian students who were denied college admission and claimed that the University discriminated against Asian applicants who had superior admission test scores and grades than applicants of other races. The allegation was that Harvard made it harder for Asian applicants in order to keep the percentage of Harvard students who were Asian from becoming too high. The press surmised that Asian American students have a culturally-driven higher study ethic than students of other races. But I think that the reason for the high percentage of Asian students at elite U.S. universities and the high percentage of U.S. physicians who are Asian American has a deeper and darker cause that has its roots in immigration laws that paradoxically were created to keep Asians out of America. As the law of unintended consequences dictates, those laws ultimately resulted in Asian Americans being more academically successful and more overly-represented in American professions such as medicine.

The Naturalization Act of 1790

One of the first laws of the new U.S. government was the Naturalization Act of 1790 that limited naturalization to “free white person[s] … of good character“, thus excluding Asians (as well as anyone else who was not from Europe). This law essentially banned Chinese from immigrating to the United States but this was in many ways a moot point since travel by ship to the Eastern seaboard of the country from China via the Atlantic Ocean was very difficult and expensive. Not until the country’s westward expansion opened California to development did travel from China to the U.S. via the Pacific Ocean become feasible.

The next major event that affected immigration and naturalization of Asians occurred in 1868. That year, the first section of the 14th amendment to the U.S. Constitution stated: “All persons born or naturalized in the United States, and subject to the jurisdiction thereof, are citizens of the United States and of the State wherein they reside.” The implication was that even if a non-white immigrant to the U.S. could not obtain citizenship himself or herself, their children could become citizens if born in U.S.

The Chinese Exclusion Act of 1882

The California gold rush attracted many Chinese to the west coast of the U.S. where they worked in mines and then when the mines played out, they worked in railroad construction. But soon, these laborers were competing with American citizens for labor jobs and often accepting much lower wages thus making it harder for white Americans to find work. This created a lot of hostility by many Americans toward Chinese immigrants. Notably, 140 years later, that same hostility would be directed against Latin American immigrants who are perceived as “stealing” jobs from other Americans.

The Chinese Exclusion Act of 1882 was enacted to appease this hostility. The act barred Chinese laborers from immigrating to the U.S. and also made Chinese immigrants ineligible for citizenship. The only exceptions were for Chinese merchants and teachers. At the time, Chinese were subject to racial discrimination equal in many situations to Blacks. In fact, in in 1896 Supreme Court case, Plessy v. Ferguson,  Justice John Marshall Harlan wrote in his dissent: “…the Chinese race is a race so different from our own that we do not permit those belonging to it to become citizens of the United States.”.

Because the Chinese Exclusion Act limited immigration to merchants and teachers, the act essentially barred Chinese women from immigration since at the time, the vast majority of merchants and teachers were men. Indeed, by the end of the 19th century, Chinese men in the U.S. outnumbered Chinese women 27 to 1. Many of these Chinese store owners and teachers married white women since there were so few Chinese women in the country. One of those men was my great-grandfather, who came to the United States from China in 1873, opened a Chinese laundry, married a white woman (my great-grandmother), and ultimately became the president of the Chinese Merchant’s Association of America (but that is another story).

The unintended consequence of the Chinese Exclusion Act was that it selected out only educated Chinese men from immigrating to the U.S. And when these men married and had families, they instilled the importance of education into their children. The unwritten message was that if you were Chinese in America, you had to have an education to economically survive. Racism against Chinese created a more educated and middle class Chinese population in the U.S. In contrast, racism against Blacks in the U.S. resulted in Africans being brought to America as slaves and education of their children was suppressed in order to maintain a population of unskilled enslaved laborers.

Many of these Chinese merchants opened restaurants. Chinese restaurants proliferated because their owners had to sell better food at a lower cost than other American restaurants since they had no other employment options than to be a merchant, even if it meant making a lower income by selling inexpensive food.

The Immigration and Nationality Act of 1965

After World War II, the Chinese Exclusion Act was repealed, in part because China had been a U.S. ally during the war. However, immigration from China was limited to only 105 Chinese immigrants per year. The Immigration and Nationality Act of 1965 eliminated national origin, race, and ancestry as basis for immigration. Importantly, it created a “special immigrant” category that was not subject to quotas – included in this category were foreign medical graduates. The implication was that if you wanted to immigrate to the United States, you had to go to medical school first.

Currently, 25% of U.S. physicians are foreign medical graduates. The more medical schools a given country has, the more physician immigrants that country can send to the U.S. There are 348 medical schools in India offering an MBBS degree. There are 154 medical schools in China that offer an MBBS degree and 50 of these teach in English. In contrast, there are only 160 medical schools in the total of the 48 countries in Sub-Saharan Africa; consequently, India and China are capable of producing more medical graduates that can then immigrate to the United States than other countries can.

One of the best predictors of whether or not a person will become a doctor is whether their mother or father was a physician. In the United States, 20% of doctors have a parent who was also a doctor. I’m a perfect example, a third-generation doctor, with my physician-father a descendent of one of the Chinese immigrants affected by the Chinese Exclusion Act. Medicine is the family business.

The counter productivity of Chinese racism

For a century after the inception of the United States of America, Chinese were usually disdained and immigration from China prohibited. For the second century of our country, some Chinese were tolerated, but only those who were well-educated and entrepreneurial. As a result of policies and laws to keep Asians out of the U.S., we now have a disproportionately high percentage of Chinese and other Asians occupying the ranks of physicians. And given the propensity for children of doctors to become doctors, the percentage of doctors who are Asian American will likely grow in future decades.

Racism is always morally wrong. And racism is always bad policy. There can be unanticipated consequences of racism that result in exactly the opposite of what racism intended… your doctor is likely going to be someone like me, a son of a son of a daughter of a Chinese immigrant.

October 30, 2020

Academic Medicine Physician Finances

Optimizing RVU Production In An Academic Medicine Practice

The work RVU is the current medium of exchange in clinical practice for all physicians, both private and academic. And as the numbers of physicians employed by academic medical centers swells at the same time as the percentage of these physicians’ time dedicated to clinical practice grows, academic physicians in particular are under increasing pressure to maximize their RVU output. Consequently, many academic physicians find themselves struggling to produce their required numbers of RVUs. Historically, private practices were built around efficient RVU productivity but academic practices were not and consequently, the academic inpatient and outpatient practice environment and practice culture is not conducive to RVU maximization. Failure to meet annual RVU targets can result in loss of bonuses, salary reduction, career disillusionment, and general unhappiness. On the other hand, consistently meeting or exceeding RVU targets can provide job security and the freedom to chart one’s own career path in academic medicine. Here are some of the ways that academic physicians can optimize their RVU production.

In The Inpatient Setting:

  1. Don’t forget to submit your bill for your clinical services. This seems so simple but a few years ago, I did an analysis at our own hospital and found that 7% of inpatient services and procedures that were documented in the electronic medical record went unbilled. This was not because of a conspiracy by the physicians, it was simply because they forgot to enter a charge for a given day’s clinical work. It is easy to forget to submit a bill (often called the “charge capture” application in an electronic medical record). If you are busy trying to save a patient’s life, the lowest priority in your day is to put in a bill for that service. I consider myself pretty compulsive when it comes to billing and even I found times when I forgot to enter a bill for a consult, a return hospital visit, or a bedside procedure. Two strategies can help minimize forgotten charges: (1) work with your electronic medical record to create charge entry prompts when completing progress notes or procedure notes to make entering those charges easier and (2) develop a personal strategy to ensure that all services are billed each day – I print out a rounding list of all of my patients each day and note my E/M service & procedure charge on each patient as I enter charges; at the end of the day, I can take a quick look at the printout to confirm that every patient had a charge entered.
  2. Don’t avoid submitting a bill for your service. A number of years ago, one of our very best clinical educators stopped signing resident inpatient notes and inpatient charges. The excuse was that there just wasn’t enough time in the work day and it got in the way of bedside teaching. No note meant no bill for service. No bill meant no income. No income meant no job.
  3. Don’t under bill. Most large academic medical practices do billing audits by billing compliance personnel. These audits are largely defensive, designed to prevent over billing. This is because large medical practices (and particularly academic practices) are subject to billing audits by Medicare or other insurance companies. The bias from compliance audits is that it is better to err on the side of under billing than over billing. Over billing jeopardizes the organization but under billing jeopardizes the individual physician by making him/her do more work than is necessary to meet annual wRVU targets.
  4. In academic medicine, RVU production is like running a series of sprints but in private practice RVU production is like running a marathon. The academic physician has weeks of being really busy interspersed with weeks of “academic time” with relatively little clinical activity. This is particularly true for internal medicine specialties that provide inpatient care where inpatient service blocks can pack a lot of RVUs into a short period of time. In private practice, RVU productivity is more consistent from one week to the next. Over the course of a year, the total wRVUs by an academic physician will be close to or slightly less than a private practice physician in the same specialty. The academic physician has to prepare for the fact that on the weeks that he/she is on service, he/she is likely going to be generating more wRVUs than a private practice physician but when off service, the wRVUs will drop.
  5. Maintain an adequate consult census size. In order to generate a typical academic internal medicine specialty wRVU target, the physician has to have enough patients on the consult census to generate those wRVUs. The inpatient consult service will have a mixture of new patient consults and return visits and this typically works out to about 1.75 wRVUs per daily encounter. If that physician works every day of the week for 46 weeks a year and does 1 weekend coverage per month, then the physician needs to keep an average daily consult census of about 13 patients. However, if (as is more often the case), that physician has some academic time when he/she is writing papers, teaching classes, preparing lectures, and doing research, then when covering an inpatient consult service, he/she has to have a considerably higher daily consult census in order to generate the proper target of wRVUs to make up for the lack of wRVUs during academic time. So, if the physician wants 5 months of academic time (“release time”) per year, then when on the consult service, that physician needs to maintain a daily census of about 25 patients. There is a limit to how many inpatients a consultant can see per day – there will be times when, by necessity, the consult census gets up to around 35-40. This size of inpatient census cannot be sustained for very long because after a few days of this high of a census, it is too easy to start missing things like key changes in patients’ physical exams, key lab tests, conversion of IV to PO medications, etc.
  6. A consult is a gift. Historically, academic physicians often tried to keep their inpatient census down as low as possible and often tried to dissuade primary services from getting consults. The successful consultant will express gratitude for all consults, regardless of when they come in. So, if you get a 4:00 PM consult, you should not be throwing a tantrum, you should be sending the referring physician a fruit basket at Christmas. Actively avoiding consults results in career death by wRVU deficiency.
  7. There should be no such thing as a curbside consult. The curbside consult is when an admitting physician (or more likely a resident) asks an “off-the-record” clinical question of a consultant. There is no entry into the medical record by the consultant and there is no bill generated. If a consultant’s expert opinion is sought, that consultant should be paid for it. I was once an expert witness in defense of a university medical center. One of the residents had called a pathologist to ask an opinion about an inpatient case and made the mistake of documenting that conversation (and the pathologist’s name) in the medical record. The pathologist was named as a co-defendant in the malpractice suit. Even an off the record opinion can result in legal liability so you should bill for your expertise and opinion.
  8. Don’t sign-off too quickly. For many consulting physicians in academic practice, a major goal of the workday is getting the consult census list shortened as much as possible. Consult follow-up visits are beneficial to patient and the primary service because the consultant’s expertise can be applied to new test results and changes in the patient’s condition. This can reduce inpatient hospital length of stay. Those follow up inpatient encounters do not pay as much as initial consult encounters but they often take very little time and on a per-hour basis can generate more RVUs per hour than initial consults. Most initial inpatient consults require at least 2-3 follow-up visits and many will require daily follow-up visits until the patient is discharged. In academic practice, there is a strong tradition of being a “one and done” when it comes to consults. For a consultant, those follow-up visits take far less time than a follow-up visit by the admitting service (hospitalist, etc.) so you can perform a lot of follow-up visits in an hour. I believe that this is the #1 low-hanging fruit in academic medicine for increased wRVU generation.
  9. Your goal should be to generate an yearly average of > 2.5 work RVUs per hour. For a pulmonologist, such as myself, in order to generate your salary, you should spend 24 minutes or less per work RVU, when averaged over the course of a full year (assuming a 55 hour work week and working 46 weeks a year). In reality, no physician does 55 straight hours a week of purely clinical care, especially in academic practice. Therefore, during the time that you are actually taking care of patients, you need to generate more like 4-5 wRVUs per hour. If it is taking you an hour to place a central line (1.75 wRVUs), then you are losing money.
  10. Mundane tasks generate a lot of wRVUs but can melt your brain. EKGs and pulmonary function tests are commonly performed in large medical centers. On an individual basis, neither generates very many work RVUs. However, they take very little time to interpret and document and consequently, the cardiologist or pulmonologist can generate huge numbers of wRVUs very quickly. The problem is that reading PFTs and EKGs is boring and are often seen as an unpleasant necessity of specialty practice. My brain would melt if the only thing I did all day was read PFTs but by reading them for an hour or two a week, I can generate enough wRVUs to free me up to do the uncompensated things that I really like to do.
  11. You can often generate more RVUs on a weekend than you can on a weekday. Weekdays in the hospital are full of non-clinical stuff: meetings, phone calls, emails, grand rounds, etc. On the weekend, those non-clinical activities largely do not exist, leaving more hours in the workday to see patients on a consult service. For many physicians, the goal for a Saturday or Sunday is to get out of the hospital as early as possible, preferably before noon. As a consequence, there is a different level of care provided on weekends: patients are often not seen as regularly and tests/procedures are often put off until Monday. This is often reflected in the “weekend checkout list” when the doctor covering on the weekday hands off the consult service to the doctor covering on the weekend. I have my own translation of the weekend checkout list.
  12. Make your EMR work for you. Investing a little time developing disease-specific note templates, order sets, and order preference lists can pay enormous long-term benefits by creating time-saving shortcuts in your electronic medical record charting. I have different new consult templates for the inpatient conditions that I most commonly encounter: COPD exacerbations, pneumonia, asthma exacerbations, abnormal chest x-ray, pulmonary embolism, etc. I incorporate my own self-designed “smart lists” into the physical exam portion of my notes that default to the expected findings; for example, for an asthma consult note, the lung exam smart list defaults to “diffuse wheezing” whereas the pulmonary embolism consult lung exam smart list defaults to “normal breath sounds bilaterally”. This allows me to rapidly click through the physical exam and saves me precious keystrokes when creating my consult note. Copying and pasting can also shorten your documentation time but it can be hazardous if you are copying too much data from a previous day’s progress note because of the danger of importing out-of-date information (like vital signs, lab results, NPO status, etc.). By using templates for notes that automatically import new data into the daily note, you can avoid this. I limit my copying/pasting to just my “impression and plan” list so that I can remember what problems I am actively following and what my previous day’s recommendations were – I then edit the impression and plan as appropriate.
  13. Medicare’s gift to pulmonologists is CPT code 94003. As a pulmonologist making inpatient rounds, particularly in a long-term acute care hospital (LTACH), I often see 5-10 patients a day who are on a ventilator and my primary role is ventilator management. CPT code 99003 saves me many minutes of unnecessary documentation keystrokes every day. The advantage of the ventilator management codes is that they require very little documentation – just the current ventilator settings and your plan for any ventilator changes. They are not regular E/M codes but instead are procedure codes; therefore, there is no requirement for a certain number of physical exam points, history elements or complexity of decision-making. Normally, when seeing a new ventilator management patient, for me the decision is between billing an initial day ventilator management code (99002) or a level 2 or 3 new inpatient E/M code. In this situation, it is usually better to bill the E/M code and pay the time cost of the additional documentation. However, for the subsequent visit ventilator management charge, it is generally a decision about whether to bill a level 1 or level 2 subsequent visit E/M or the 94003 ventilator management charge. Because the wRVUs associated with a level 2 subsequent inpatient visit E/M and a subsequent ventilator management code are about the same, you are better off using the ventilator management code and reducing your progress note from one page to one or two sentences.
  14. Organize your rounding strategically. As a pulmonologist, I start off my morning looking at any new x-rays and chest CT scans to see which patients need a bronchoscopy. That way, I can get the bronchoscopy team mobilized early and ensure that the patient is made NPO before the breakfast trays arrive. For a cardiologist, that might be checking to see which chest pain admissions need a stress test or which heart failure admissions need a cardiac echo. For an infectious disease consultant, it may mean checking to see which patients need a new CT scan or MRI to guide therapy. I will pre-chart the outline of my progress note before I see a patient so that I know what new information I need to know about when I am talking to that patient and what problems I am actively following. I then try to complete the inpatient encounter note as soon after I see the patient as possible so that I don’t forget about important data. 
  15. You will get more efficient producing RVUs with age. There is a Starling curve of physician productivity. It takes about 7 years after finishing residency or fellowship to get proficient in getting clinical work done. Not only do physicians continue to learn new knowledge but they get more efficient in getting their daily work done with everything from history taking to progress note writing. For most physicians, productivity peaks in their mid-50’s. After that, they often start dialing back the amount of time they spend in clinical practice.

In The Outpatient Setting:

  1. Pre-chart your patient encounters. Each outpatient encounter will require a certain amount of time in the patient exam room and a certain amount of time outside of the exam room. You can either finish your charting at the end of the day, after the patient leaves or you can do that additional charting before the patient arrives in the clinic. Either way, it will be the same amount of time – either before clinic or after clinic. But by pre-charting and preparing for the patient’s visit, you can often shorten the amount of time spent during actual clinic hours – this can free you up to spend more time communicating with individual patients and allow you to see more patients in a given period of time.
  2. Utilize CPT code 99358. This code is for “prolonged service without patient contact”. It requires documentation that you spent at least 31 minutes doing the service and I primarily use it (1) when reviewing a lot of medical records in advance of a new outpatient consult or (2) after an initial consult when I receive a lot of requested records and radiographic images. In my own practice, most new outpatients come with lots of chest x-ray & CT images that I need to review and interpret, office notes that I need to review, lab results I need to review, and pulmonary function tests that I need to review and interpret. About half of my new patients have > 31 minutes of records to be reviewed and documented. This CPT code is worth 2.10 wRVUs and when combined with a level 5 new outpatient visit (3.17 wRVUs), you can generate a whopping 5.27 wRVUs (7.91 total RVUs) for that visit. I use this code 2-3 times a week. Also, if that new patient does not show up, I still am able to generate some wRVUs for my efforts.
  3. Utilize the other CPT codes that you forgot to bill. The common ones are 99497 (advanced care planning, 30 minutes: 1.50 wRVUs), 99406 (smoking cessation 3-10 minutes: 0.24 wRVUs), 99495 (transition care management, moderate complexity: 2.11 wRVUs), and 99354 (prolonged services > 30 minutes: 2.33 wRVUs). I wrote about these and other often-overlooked CPT codes in a previous post.
  4. Cultivate a referral base. For specialists, new patients can come from self-referrals, emergency department referrals, or physician referrals. Self-referrals and ER referrals are notorious for being no-shows and for having no insurance (or having Medicaid). You are better off filling your schedule with referrals from primary care providers and other specialists because those patients are more likely to show up for their scheduled appointment and generally constitute a better payer mix. The best way to cultivate those referrals is by human contact, either introducing yourself in person or by the occasional phone call. Those referral physicians will remember your name the next time they need a consult if they have shaken your hand or heard your voice. This is especially true for nurse practitioner or physician assistant primary care practices – NPs and PAs don’t have the same opportunities to network with specialists at medical staff meetings, the hospital’s physician lounge, or CME events. A phone call to a primary care NP can endear you to him/her for life. Referral letters are also a good way to cultivate referrals. Each referral letter is an advertisement opportunity for your practice: a poorly constructed letter that consists of 4 pages of electronic medical record documentation will create animosity but a 1-paragraph readable note in prose form will create goodwill.
  5. Make the outpatient EMR work for you. Reducing keystrokes saves you time that you can spend seeing more patients and generating more wRVUs. Just as in the inpatient setting, by creating note templates for common conditions that you use, you can reduce your documentation time; in my pulmonary practice, I have different templates for COPD, interstitial lung disease, asthma, abnormal x-ray, and bronchiectasis office notes. Pre-designed order preferences and smart lists can streamline your practice. Outpatient EMR optimization is a huge topic and I’ll devote a post just to this in the future.
  6. Schedule your patients strategically. I see many academic physicians schedule 20 or 30 minute return visits. By pre-charting those visits, you should be able to cut that return visit time down. I schedule my return visits every 15 minutes. In the long run, this can increase your wRVU output by 33% compared to 20 minute return visits. The increase in net revenue can be even greater because the overhead expense of 4 patients per hour is not very different than 3 patients per hour and that means that after you pay off the base clinic overhead (rent, nurse salaries, etc.), the physician ends up keeping more of the total revenue for his/her own salary.
  7. Convert patient phone calls into wRVUs. There are two ways to do this: get the patient into the office or use the new CPT code for telephone/EMR encounters. CPT code G2012 is for phone or EMR patient encounters that last 5-10 minutes for patients that are not seen for 7 days before or 24 hours after the phone/EMR encounter. It pays 0.25 wRVUs. The other strategy is to get those patients into the office – either at the end of the day or to fill in holes in the office schedule created by late cancelations. Alternatively, keep a open 15 or 30 minutes at the end of the day for add-on sick visits. I prescribe way too much steroids/antibiotics over the phone for COPD exacerbations, etc. that could at least be billed as a G2012.
  8. Be sure that you have the right number of exam rooms. Exam room space in most academic practices is both costly and scarce. Often, a physician will get 2 exam rooms so that the nurses can be rooming one patient while the physician is doing the encounter in the other room. But some specialties need 3 or 4 rooms per physician to create optimal efficiency. Getting the right number of exam rooms to generate the most RVUs without creating too much overhead clinic expense can be challenging and needs to be individualized to each physician based on their specialty, efficiency, extent of point of care testing, etc.
  9. Use the entire day.  I often see physicians start their morning schedule at 9:00 even though the nurses and registration staff all arrive at 7:30. Similarly, I see physicians schedule their last patient at 3:30 or 4:00 even though the staff are paid to be there until 5:30. Time = wRVUs. Be sure to fill the entire day’s clinic time with patients.
  10. Double book strategically. In my practice, there are almost always late cancelations and no-shows. By double booking a couple of slots in expectation of those cancelations and no-shows, you can ensure that the schedule stays full. I often see physicians double book at the beginning of their schedule – I think this is hazardous because if both patients show up, then the physician is behind the schedule for hours, creating exasperation for the physician and dissatisfaction for the patients. I think you are better off double booking a slot in the middle of the morning (or afternoon) and at the end of the day. this is because there are inevitably patients who show up 30 or 45 minutes early for their appointments so if there is a late cancelation, you can slip an early arriver into that slot, thus creating an opening in the middle of the afternoon (or morning) or at the end of the day that the double booked patient can fill.
  11. Make up canceled clinics. There should not be an expectation for making up clinics canceled for vacations and scheduled CME time off. However, in academic practice, there are always things that come up that conflict with the regular clinic times: academic retreats, medical staff meetings, visiting lecturers, new faculty candidate interviews, medical student lectures, etc. These activities fall under “academic time” (release time) and when those conflict with regular clinic time, necessitating canceling that afternoon’s clinic, then a make-up clinic should be scheduled. If your academic time temporarily displaces your usual clinic time then you should have an equal displacement of your usual academic time by make-up clinic time in order to keep your total weekly academic:clinic time ratio constant.
  12. Do point of care testing. For me, this means having an office spirometer (0.17 wRVUs per test). For others, it may mean an INR machine, an EKG machine, or a hemoglobin A1C machine.  In order to determine if you need a piece of equipment to do point of care outpatient testing, you have to do a pro forma that compares the cost of the equipment to the estimated income generated by that piece of equipment. It takes about 44 spirometry tests to pay for the cost of a spirometer, after that, all of the income generated by spirometry is profit.
  13. Partner with advanced practice providers. Everyone wants an NP/PA/LISW/pharmacist in order to make their practice more efficient and generate more wRVUs. But everyone also wants someone else to pay for that NP/PA/LISW/pharmacist. In a healthy clinical environment, the physician should work synergistically with advanced practice providers so that the total RVU productivity is greater than the sum of what that physician & advanced practice provider could generate operating individually. Examples are a physician assistant who does the post-op office visits so that the surgeon can do more surgeries or a nurse practitioner who sees routine follow-up heart failure visits so that the cardiologist can see more new patient consults that in turn lead to more cardiac stress tests and echos.

June 8, 2019

Academic Medicine

How To Interview For A Medical Leadership Position

In academic medical centers, deans, department chairs, and division directors are almost always filled by doing a national search. Even if there is an inside candidate at the institution that is the heir-apparent for the job, a search is done to adhere to preserve the integrity of the hiring process. Sometimes, the medical center will hire a professional search firm to seek out and vet candidates (often at a high expense) and sometimes the medical center will perform the search with internal resources. The first step is generally the establishment of a search committee which will consist of a diverse number of physicians and administrative leaders both from within and outside of the particular specialty of the person being sought. Candidate names are compiled from responses to advertisements in professional journals, requests for nominations sent to deans, department chairs, and division directors at other medical centers, and first hand knowledge of candidates by search committee members. Candidates are asked to submit a CV and usually asked to submit a letter of interest in the position. There is an initial screening of candidates by the search committee with elimination of those candidates that clearly do not fit the position’s requirements. The search committee chair (or the search firm or the dean/department chair)  will then have a phone conversation with each candidate to discuss the position in more detail and assess their level of interest.

When the candidate list is down to 6-10 people, the so-called “airport interviews” are done. During airport interviews, 3-5 candidates are brought in per day, one after another, for a group interview with the search committee and often a second interview with the dean or department chair. These are called airport interviews because they are typically held at a hotel close to an airport so that candidates can fly in and fly out on the same day. At this point in the interview process, the candidate names are kept confidential; this is one of the reasons for not having these interviews done on-site at the institution. Most of these candidates do not want their own institution to know that they are out interviewing, otherwise, it could hurt their career at their current institution if they do not get the job. The confidentiality is to protect the candidates, not to create a shroud of secrecy for the medical center that is looking for a new leader.

The search committee will then narrow the list down to 4-5 candidates who are brought for a second interview. This second interview is a much longer interview – typically lasting 2 days or more – and the names of the applicants then become more public knowledge. Each candidate is asked to give a lecture, there are interviews with many different physicians and administrative leaders, there is typically a lunch and a dinner with members of the faculty. For many second interviews, spouses are also bought along for dinner, meetings with real estate agents, etc. After the second interviews, the search committee will generally meet a final time to recommend finalists to the university president, dean or department chair. Importantly, the search committee does not choose the final candidate – that is the job of the university president, dean or department chair. The search committee’s job is only to present a final slate of candidates to the individual who will make the final decision.

At this point, a job offer will be extended by the president, dean or department chair to the top candidate and there will be negotiations about resources (start-up packages, office/lab space, administrative structure promises, etc.) as well as salary. If terms cannot be agreed upon, then the president, dean or department chair will go to the next candidate on his/her list.

Over the years, I’ve been on dozens of search committees and have chaired several. I think I’ve seen every mistake a candidate can make and have seen candidates who excelled and knew how to hit the interview process out of the park. Here are some of the points I’ve learned. First, about the initial submission of your CV and letter of interest:

  1. Read the RFA (request for application) carefully and be sure that you send in the materials requested. If the RFA asks potential applicants to send in a CV and a letter of interest, then don’t just send in a CV without a cover letter.
  2. In the letter of interest, check your grammar and spelling 3 times. The search committee members are mostly going to be people outside of your specialty and most of them are not going to know anything about you. So, the first impression you make on them will be the letter of interest. If the search committee members find spelling or grammar mistakes, then they are going to judge you as sloppy, no matter how many awards you have obtained, grants you have received, and papers you have published.
  3. Make the right impression in your letter of interest. The letter should not just state why you want to be a leader (dean, department chair, chief medical officer, division director, etc.) but it should clearly state why you want to be a leader at that particular institution. That will require a little bit of research about the institution. If you have ties to the region or the institution make sure that those ties come through in your letter.
  4. Organize your CV. Many academic medical centers will require faculty to use an institutionally-approved CV template. These are often terrible and generate CVs that look fine in the CV template computer program that they are generated in but are a mess when they are printed up. Make your CV easy to read and organize it logically. If you have grants, separate them into current active grants (that are actively funded) versus submitted grants, versus completed grants. If you have publications, number them and separate them into categories of peer-reviewed articles, non-peer-reviewed articles, book chapters, and abstracts. If you have national/international presentations, organize them by date. Do not editorialize about yourself in your CV – it should just be the facts.

The airport interview is the next big step in the process. This can be a high-stress time because the candidate will typically be surrounded by a dozen strangers who will be asking all sorts of questions.

  1. The best preparation to do an airport interview is to have previously been on a search committee. Many physicians avoid being on search committees because they can be very time-intensive and it can seem like a lot of work for very little reward. But the education you get from being on a search committee will give you insight into the process that you just can’t get in any other way. You will also get a first-hand look at how successful candidates present themselves. So, if you are a junior faculty member, let your division director, dean, or department chair know that you’d like to participate on a search committee to familiarize yourself with the process.
  2. The second best preparation to do an airport interview is a good night’s sleep. Think of doing the interview the way you would think of taking a board examination. You are going to need to think on your feet and be as mentally sharp as possible. Being well rested is critical. If your interview is on the east coast early in the morning, taking a red-eye flight from California to arrive that morning is a really bad idea.
  3. Do your homework. Learn as much as you can about the institution before the interview. Draw from on-line sources, colleagues with first-hand knowledge, and alumni. But be careful in the interview – you don’t want to come across as bragging about how much you know but you do want to avoid sounding like a dummy when you are asked questions about institutional organizational philosophy, etc.
  4. Google search committee members. You may or may not get a list of the search committee members before the airport interview. But if you do, then do your research on them. There is nothing worse than to make a joke disparaging endocrinologists, when unbeknownst to you, one of the search committee members is an endocrinologist. The interview room may be set up with the committee members’ names on name tags but if they are not, there is no way you are going to remember everyone during a brief introduction so if you know their names/faces/backgrounds ahead of time, you can personalize your comments to them.
  5. Dress the part. If in doubt, over-dress rather than under-dress and be relatively conservative. You should be at least as well-dressed as the most-dressed search committee member – if only one other person in the room is wearing a tie, you need to be wearing a tie. Avoid flamboyant or provocative – all it takes is offending one search committee member and your prospects for the job are dead. You won’t know ahead of time if you are going to be seated at a large table or at an open desk so if you are a woman, avoid wearing too short of a skirt and if you are a man, leave your socks with pink bunnies on them at home.
  6. Expresso, not coffee. The interview may only be for an hour or hour and a half but you are already going to have an adrenalin-fueled diuresis going on and the last thing your bladder needs is to be hit by the effects of a 16 ounce double mocha vanilla latte half way into the interview. Expresso will give you the caffeine you need without the fluid volume. Also, remember that the last thing you do before you go into the room is to make a trip to the bathroom. A wise man once said that you should always start a lecture, a presidential debate, a rush hour commute, or an airport interview on an empty bladder.
  7. Everyone is either Dr., Ms., or Mr. Even if 9 committee members introduce themselves by their first name and 1 introduces themselves as Dr. so-and-so, address everyone equally and like clothing, it is better to be formal than risk being too informal. This is particularly true when it comes to gender. If you address all of the men as Dr. or Mr. and then address one of the women by their first name (or gender vice versa), then you have created a perception of gender discrimination that you likely will never get away from.
  8. Make eye contact. Every search committee member is evaluating you on your communication skills. When one member of the search committee asks you a question, make direct and continuous eye contact with that specific individual for at least 20 seconds. If you look at the floor or the ceiling, the person asking the question will think you are aloof and if you look at someone else, they will think you don’t like them. If possible, try to work the questioner’s name into your answer to them so that you can make your response more personal.
  9. Use your hands strategically. There are certain things you should never do with your hands during an interview: sit on them, drum your fingers with them, twirl your pen with them. Avoid crossing your arms or your posture will appear closed and defensive. Most of the time, keep you hands loosely folded on the table. But your hands can be great adjectives to emphasize key points you want to make. You don’t want to point or project your arm with the palm down. When you do want to use your hands for emphasis, position them as if you were holding an imaginary basketball in front of your chest.
  10. There are certain questions you are always going to be asked. What attracted you to this job? What is your leadership style? What is your approach to improving diversity? What would others say about you? Tell me about a time that you failed at something? Tell me about a time you dealt with a disruptive physician? At many airport interviews, the questions will have been pre-scripted ahead of time so that each candidate is asked the same questions (often by the same person) in order to better compare one candidate to another. Think about these ahead of time – you don’t want your answers to sound rehearsed but you don’t want to have uncomfortable pauses while you think of something to say.
  11. Be willing to acknowledge your shortcomings. There are a lot of pathways to becoming an effective leader – a successful researcher, a prolific publisher, an award-winning educator, a profit-generating administrator, an outstanding clinician. But few people, if any, are ever excellent at all of these. However, if you don’t have an RO1 grant, do make it clear that you value research and will be supportive of those who do research.
  12. Skype effectively. Some of the initial interviews are done by Skype. I think in many ways, these are more challenging than an in-person interview. When Skyping, your tendency is to look at the video picture of the other people on your computer monitor and not at the camera. As a consequence, the people interviewing you never have eye contact with you. In other words, you think you are looking at them but they see you looking away at something else. Resist the temptation to look at the other people on the monitor and instead look directly into the camera. Also, be sure that the back-drop is appropriate, tidy bookshelves or walls with artwork work well. Think of yourself as an actor and everything behind you is the stage that you are setting. When you are Skyping, your movements are going to seem amplified so don’t sway or rock back and forth. Also, position yourself appropriately in front of the camera – too close and your nose will look fat and your head will appear weirdly shaped. The best thing to do is to practice with a family member so that you can get feedback on your appearance and camera presence and you can also have your family member in front of the computer you will be using so you will know the best way to position yourself and the room background for effect.
  13. Avoid saying stupid things. A couple of examples from candidates I’ve seen in the past: “I like critical care because it is like internal medicine on crack.” Or, “As division director, can I put my name on the author list of all of the manuscripts that come out of the division?”. Or, “I’m debating on whether to retire or take on a new leadership job.”
  14. Don’t be a potty mouth. Most people swear (with varying degrees of intensity of vocabulary) but during an airport interview, your swear words should be limited to “gosh”, “gee”, and “wow”. The only thing that will blow up when an F-bomb is dropped is your chances for getting the job.
  15. Humanize yourself without self-aggrandizing. When asked about yourself, don’t come across as pompous or boastful but do present yourself as an interesting and well-rounded person.
  16. Pace your answers. Limiting answers to just “yes” and “no” is ideal for giving court testimony but you will want to expound a bit more than one word answers during the interview. On the other hand, you do not want to make your answers so lengthy that some of the search committee members feel cheated if there is no time for them to ask their questions.
  17. Project emotional intelligence. EI is all the buzzword these days in academic medicine. It turns out that this is a very difficult thing to teach or to prep for but it seems like some people naturally have it and others don’t. In an airport interview, questions that probe emotional intelligence often are grouped as questions that ask how you handle yourself and how you handle relationships with others. Examples are how you handle disputes, how you manage conflict, how you identify and overcome weaknesses in yourself and in others, how you handled a setback, and how you interact with others.
  18. Shake everyone’s hands… at least once. The handshake often seems like a formality of social etiquette but the human touch can help establish a connection between 2 people that words cannot. But there is an art to the handshake – it should neither be too limp nor too firm. For search committee members who use their hands for a living (surgeons, gastroenterologists, anesthesiologists, etc.), an excessively firm handshake is a direct threat since even a small injury to the hand can derail their professional career. On the other hand, a flaccid handshake can make you come across as timid and a pushover. Use the same amount of force that it takes to pick up a glass of water with your hand.
  19. Don’t clean out the hotel minibar. The institution will usually be paying the hotel bill if you stay overnight and that includes everything that you take from the minibar. Once, we had a candidate take everything from the minibar as she left the hotel, leaving the bill to the hospital. Needless to say, she was not asked back for a follow-up visit. What you take out of the minibar can reflect on your personality so if the institution gets a bill for 2 Snickers bars and 3 Budweisers, that is going to say a lot about you. If you order the lobster Thermidor with beluga caviar sauce and a bottle of champagne for a midnight snack from room service, that also tells a lot about you. If you want a beer the night before your interview, go downstairs to the hotel bar and pay for it in cash.
  20. Send a follow up email. I get these all of the time, from medical students interviewing for internships, from physicians interviewing for jobs, and from leaders doing airport interviews. Most of the time, I ignore them but I do think that a follow-up email can sometimes make an impression. The ones that impress me the most are those that incorporate some personalized information. For example, a reference to something that we discussed or a reference to something unique about me or my career. In other words, avoid sending the same generic “Thank you for interviewing me” email to all of the committee members.

Once finalist candidates are selected from the initial airport interviews, there is a whole new strategy involved for the next round of interviews. I will write more about that in a future post.

April 19, 2019

Academic Medicine Inpatient Practice

Setting Achievable Hospital Quality Goals

All across the country, hospital quality departments set goals for the upcoming year. For academic medical centers, that fiscal year is starts July 1st. And every year, at every hospital, those goals are set a little higher and hospital leaders get frustrated when a year from now, those goals are not met. The tactic that should be used to avoid all of this frustration is setting realistic goals.

In an academic medical center, there are all sorts of goals that are set for the physicians to achieve:

  1. Quality goals set by the hospital quality department
  2. Productivity goals set by the practice administrators
  3. Educational goals set by the medical school
  4. Efficiency goals set by the hospital finance department
  5. Research goals set by the department chairmen
  6. Citizenship goals set by the medical directors

For the physician with relatively limited time and emotional energy, all of these various goals compete with each other. The hospital finance department gets frustrated when the physician’s efficiency measured by getting all of the hospital discharges completed by mid-morning is affected by the physician doing too much teaching on rounds. The department chairman gets frustrated when the physician’s research output is affected by the physician spending too much time in the hospital trying to meet RVU targets. And the quality department gets frustrated when the physician is spending too much time in citizenship activities such as attending committee meetings and not focusing on spending more time with individual patients in order to improve patient satisfaction scores.

For the physician who is faced with the expectation of achieving a 75th or 90th percentile for all of these various goals, it is overwhelming and not realistically achievable. It is human nature to direct one’s limited time and energy to those goals that are achievable and then effectively ignore those that are not achievable.

As an example, lets say the quality department sets a quality goal that all physicians will do bedside rounds on every patient 3 times a day and the practice administrator sets a productivity goal of 4,000 wRVUs per year. If a physician currently rounds on every patient once a day and had a productivity of 3,500 wRVUs last year, then to both increase the number of daily visits by 2 additional visits with each patient each day AND increase the wRVUs by 500 in the next year, the only way to achieve both goals is for the physician to work more hours every day (the physician has to bill the patient the same amount whether he/she sees that patient 3 times a day or just once a day). From the physician’s standpoint, he/she will have to choose between meeting the quality department’s goal by increasing the number of daily encounters with each patient by 200% or meeting the practice administrator’s productivity goal by increasing the number of patients that the physician sees by 14%. Given these competing demands, most physicians will choose to go after the wRVU goal and ignore the quality goal because the wRVU goal is more achievable.

So, how should we set quality goals?

  1.  Recognize that most physicians cannot be above average in everything. The physician who wins all of the teaching awards get them because he/she is spending a lot of time doing bedside teaching rather than trying to knock the wRVU targets out of the park.
  2. Expect small annual incremental improvements and evelop long-term, aspirational goals. My favorite NFL team, the Cleveland Browns were winless last season at 0-16. Next year, I’m not expecting them to go to the Super Bowl but I’d be happy with 2 wins next season, 5 the following season, and then make the playoffs in 3 years. Setting long-term goals with incremental increases every year over a several year period is more realistic.
  3. Realize that the physicians can’t go it alone. Increasing productivity may require investing in more outpatient exam rooms per doctor, or geographically locating all of a hospitalist’s patients to one nursing station, or staffing up the case management department to facilitate discharge planning. Achieving higher goals requires giving the physicians the tools they need to meet those goals.
  4. Get the right benchmarks. For example, if you are tracking hospital mortality and are at a large tertiary care medical center that has a high percentage of complex, critically ill patients, then using a crude mortality rate will not be useful because your patients are sicker and have a higher expected death rate than those at a smaller community hospital. In this situation, using the mortality index would be a more appropriate way of comparing how well your hospital is doing in patient mortality. The mortality index adjusts the crude mortality rate by the severity of patient illness. For the tertiary care hospital to achieve the same crude mortality rate as a small community hospital or an orthopedic specialty hospital is unrealistic.
  5. The best theoretic result is not always the best achievable result. In an ideal world, there should be zero hospital-acquired central venous catheter infections. However, that is not going to happen, the bacteria always finds a way in the sickest patients and central lines are mainly used in the sickest patients. Therefore, setting a hospital goal of zero central line associated blood stream infections is not realistically achievable and if every year the doctors and nurses feel demoralized because they could not achieve a goal of zero, staff morale will suffer.
  6. Don’t create a storm of goals. There are 300 different merit-based incentive payment system (MIPS) measures. If you hold your physicians responsible for achieving all of these, their heads will be spinning and they will likely just give up. Focus efforts on a limited number of goals that are of highest priority for the hospital. Five or six goals for each physicians is a good target.
  7. Publicize next year’s goals before the start of next year. This seems so common-sense but many hospitals procrastinate on getting goals finalized and then getting those goals publicized to the physicians on time. A hospital that disseminates the annual quality goals 3 months into the year is doomed to failure since by the time the physicians and hospital staff know what their annual goals are, 25% of the year has already gone by. It would be kind of like a head football coach not telling the other coaches and the players what the game plan is until after the first quarter.
  8. Provide timely regular feedback. If one of the hospital’s quality goals is to reduce readmissions for heart failure patients, then report the 30-day readmission rate on a monthly basis, as soon as the data is available. People usually can’t remember what they did differently 6 months ago, let alone a year ago. Regular and timely feedback allows physicians and hospital staff to determine in real time what is working and what is not working and then adjust behavior and practices accordingly.
  9. Achieving a ranking is not achieving a quality goal. I’m probably going to get into trouble for this one because every hospital focuses on the U.S. News and World Report annual ranking of hospitals. Boards of Trustees, CEOs, Deans, and medical directors all define success as “moving up in the ranking”. It is true that in many situations, a higher national ranking by rating groups such as  U.S. News, Leapfrog, etc. do incorporate quality in the determination of ranking. However, the goal of the hospital should be to get the quality right and not just to get the ranking. Medicine is not like NCAA football where the highest ranked team at the end of the season wins. We win when our patients get the best care for their condition possible. The rankings and awards can come later.
  10. But… set goals that are achievable but not too achievable. To be successful in getting NIH research grants, research scientists know that they have to have half of the work already done before they submit a grant so that achieving the goals of the grant (and continuation of funding) is assured. Similarly, it is human nature for hospital leaders to choose goals that they know that they can achieve so that they are assured of looking good at the end of the year. For example, if I, as a medical director, set a quality goal of reducing Clostridium difficile infections by 20% next year and I know that the hospital just purchased an expensive ultraviolet light C diff decontamination system that the literature says reduces C diff rates by 50%, then at the end of the year, my quality goal scorecard is going to look great – it is like benefitting by insider trading.

The hospitals’ ultimate goal is to match the healthcare resources of the hospital to the healthcare needs of the community in a way that maximally benefits the patients. In most situations, a hospital cannot change overnight to perfectly match these needs and the alignment of hospital resources with community healthcare needs is a long-term journey. Setting achievable quality goals is a critical part of this journey.

July 11, 2018


Academic Medicine

How To dismantle Your Legacy As A Physician

Brett Favre was one of the greatest quarterbacks in NFL history. As physicians, we can learn a lot about the legacy we leave and about how we will be remembered from Brett Favre. After a rookie year with the Atlanta Falcons, Favre joined the Green Bay Packers where he spent the next 16 seasons amassing one football record after another. In Wisconsin, he was a hero: parents named their new-born sons Brett, Green Bay jerseys with #4 quickly sold out, and he was awarded the NFL’s most valuable player three years in a row. On March 4, 2008, he announced his retirement but then a few months later, he changed his mind about retirement and asked to be traded so he went to the New York Jets for a year and then announced his retirement (again). A few months later, he signed with the Minnesota Vikings, the arch rivals of the Green Bay Packers. And Brett Favre went from being the most beloved man in Wisconsin to being the most hated man in Wisconsin.

So, what does this have to do with physicians? We do not have the fame of a Brett Favre, but we do build up a reputation in our hospitals, our communities, and our medical schools. If you look around at medical centers and colleges of medicine, buildings are named after those locally famous doctors who stayed at their institution for years or decades and then retired from that institution. They don’t name buildings after doctors that practice at a hospital for 25 year and then leave to go practice somewhere else.

It is because our brains are wired to dislike someone more if we initially thought that they liked us but then later disliked us. As an example, think about the last ugly divorce that a neighbor, co-worker, or family member went through and how the former spouses now see each other. It also works the other way: we like someone more who we initially thought disliked us but then later liked us. As an example, think about every military sergeant and every high school coach that ever existed.

When a senior colleague, a mentor, a department chairman, or a division director leaves for a similar job elsewhere, they become a persona non grata. We perceive that the physician is leaving because he or she no longer likes us. Consequently, we no longer like him or her. Institutional history is always written by those who remain and not by those that leave and so those physicians who leave are remembered by institutional history not for all of the good that they did while they were here, but rather remembered just for leaving.

There are exceptions. For example, for a bona fide promotion, such as a division director who leaves to become a department chairman elsewhere else. Or for family reasons, such as a physician who moves to a different city because his/her spouse’s job got transferred. Or for internal transfers, such as a physician in a large multi-hospital medical system who is asked by the corporate leadership to transfer to fill a clinical void at one of the other hospitals.

But it is the physicians who depart for seemingly lateral moves who we perceive as rejecting us and thus we in turn reject. And the longer a physician has been at one hospital before leaving for another, the more strongly we reject him/her. We tend to erase and forget all of their accomplishments. We find other physicians to elevate to the level of celebrity to replace those who left. The students, residents, fellows, and junior physicians who came to the institution because of them feel as if they were lied to. The physician’s patients feel betrayed. To all, the departing physician becomes a pariah.

You can measure the qualifications of a physician by how he/she is recruited for a job. You can measure the integrity of a physician by how he/she leaves a job. It is better to leave an institution after only a few years than to leave after a few decades when you have become the face of that institution.

I want to be remembered not like Brett Favre but like Cal Ripken. He was born in Maryland and played every one of his 21 seasons with the Baltimore Orioles. His player number was retired by the Orioles in 2001 and the in the state where he was beloved as a player, he is still beloved.

July 2, 2018