In 1994 the Josiah Macy, Jr. Foundation sponsored a conference on the financing of medical schools in an era of healthcare reform and concluded that “the rapid expansion in medical schools’ revenues over the past 30 years is at an end, and medical schools can no longer depend on the continued growth of past sources of income, especially the highly specialized practices of their faculties.?1 While previous excesses from clinical practice were adequate to cross subsidize the educational mission, the current mismatch between core mission and core business is now an unacceptable mismatch because of poor margin. These emerging fiscal constraints have prompted re-evaluation of the methods for distributing limited resources both at the medical school level and within departments. At the departmental level, the teaching mission has suffered the greatest under these economic pressures since it is perceived as non-income producing and seldom a major factor in promotion and tenure decisions. In light of these new restraints, this paper describes an effort/quality based program designed for a surgical clerkship to assure that the educational mission is kept intact with a fair and equitable educational contribution by all faculty members and a basis for rewards for those whose contributions are significant in both amount and quality.
METHODS -THE EFFORT/QUALITY BASED PROGRAM
The program was designed to provide both quantitative and qualitative evaluation of faculty contribution. During a faculty retreat all faculty teaching activities were identified that would allow achievement of the surgical clerkship goals and objectives. Presentation of a one hour student core curriculum case based session was assigned the relative value of one teaching credit. Through faculty consensus, appropriate teaching credits were agreed on for all of the other activities noted in Table 1. All components were clearly defined. In addition, instruments were developed to provide ongoing qualitative evaluation of faculty teaching with forms completed by students at the end of each core curriculum session, and at the end of the Clerkship providing an overall evaluation of teaching effectiveness as well as an evaluation for all faculty serving as student mentors for a group of four students throughout the six week Clerkship.
Over the subsequent five years, faculty received an annual report for the quantity and quality of their teaching contribution to the Clerkship Program. This report was generated using social security numbers so that faculty could identify their ranking relative to peers with regard to quantity and quality of teaching. This information was annually provided to the Department Chair for discussion during annual evaluation for salary negotiation and promotion and tenure planning. The generated data was readily available and used by the Clerkship Director to provide teaching support letters for all faculty being considered for promotion and/or tenure. It should be noted that a very similar program for quantitative and qualitative evaluation was implemented simultaneously for teaching in the residency training program.
Over the five year interval there was a high level of satisfaction by both department leadership and faculty with the effort/quality based program. At each annual faculty retreat faculty were identified that ranked highest for quantity of teaching in the Clerkship. At the beginning of each academic year a surgical education grand rounds was devoted to honoring faculty with teaching awards based on data accumulated in this program over the previous twelve months.
The traditional economic model for U.S. Medical Schools has been described by Reinhardt as a black box with financial resources entering the system with the three outputs of education, research and patient care.2 Utilizing surpluses in clinical practice income, most medical schools have managed to maintain excellence in the three missions over past decades. However, new economic pressures threaten this balance with education suffering the impact because of its poor reimbursement and perceived minor role in promotion and tenure decisions. Furthermore, healthcare insurers have been reluctant to allow healthcare premiums to reimburse any activity3 other than direct patient care.In an effort to counter this trend, the 1992 ACME Tri report recommended that ?. . . deans and department chairmen should elevate the status of the general profession education of medical students to assure faculty members that their contributions to this endeavor will receive appropriate recognition.?4 However, only six of the 55 responding schools reported using educational accomplishments in tenure decisions, five used educational dossiers to document teaching and only five utilized rewards for educational accomplishments.
A number of medical schools have sought to define a rational distribution of limited resources by unbundling income and expenditures in programmatic budgeting. With a goal of developing a revenue allocation system for the sole purpose of supporting teaching, the Yale School of Medicine created a system with both a quantitative and qualitative component.5 Cumulative totals for each department were used to calculate percentages reflecting teaching commitment, which was then used to determine appropriate allocation of tuition dollars. Similarly Dalhousie University has developed a model of “desired academic outputs” using contact hours for the first two years of medical school and the number of students for clerkships and senior electives.6 All of these programs enhance the educational mission by support of an effort based system that defines faculty teaching expectations, provides program and faculty evaluation incentives, and assures accountability for tuition dollars.
The departmental model described in this paper seeks to maintain accountability to the educational mission at the third year student clerkship level. The quantitative component considers all contributions to achieving the educational goals and assigns them a relative value. The qualitative component assures clerkship leadership that faculty are effective in their assigned or selected teaching roles. Such a system can assume a baseline level of faculty involvement in teaching activities regardless of clinical practice volume or basic science research commitment. For those who make educational activities the major focus of their scholarly work, this system provides for public recognition and reward. The system allows for added incentive to activities of greatest value to the educational mission such as faculty development and supervising student research. The annual ranking of faculty by quantity and quality of teaching compared to peers appeals to the competitive nature of physicians and virtually eliminated the need for the Clerkship Director to coerce faculty to participate in student teaching activities. More frequently, faculty made requests for additional teaching assignments, particularly after the annual distribution of ranking. Such a system, particularly when paired with a similar arrangement in a departments’ residency training program, assures that all faculty are provided with opportunities to contribute to the educational mission according to their perceived teaching abilities. For example, the faculty member who is reluctant to participate as a lecturer in a student core curriculum with documented poor teaching evaluations may find that she is uniquely effective in the setting of one on one student mentoring. Finally, although this system was not linked directly to faculty reimbursement, the system provides such an opportunity if desired.
The current mismatch between core mission and core business is a major problem facing medical school leadership as well as clinical department leadership. Systems such as the effort/quality-based program we have described assure continued focus and accountability for the core mission. Similar systems designed for accountability in research may help to provide further balance between the core business of clinical practice and the educational and research mission.
- Ebert, R.H. (ed). The Financing of Medical Schools in an Era of Health Care Reform. New York: Josiah Macy, Jr. Foundation, p. 51, 1995.
- Reinhardt, U. Planning the Nation’s Health Workforce: Let the Market In. Inquiry 31:250-263, 1994.
- Reiser, J.R. Linking Excellence in Teaching to Departments’ Budgets. Academic Medicine 70:272-275, 1995.
- Association of American Medical Colleges. Educating Medical Students: The ACME-TRI Report. 1992.
- Johnston, M.C. and Grifford, R.H. A Model for Distributing Teaching Funds to Faculty. Academic Medicine 71: 138-140, 1996
- MacDougall, B. and Ruedy, J. Linking Budgets to Desired Academic Outputs at Dalhousie University. Academic Medicine 70:349-354, 1995.