Academic health centers that utilize a mission-based management system often employ metrics of faculty contributions to inform revenue distribution. These relative value unit (RVU) metrics generally omit the concept of value added to the education interaction by the faculty member’s preparation and redaction. These RVU-based systems tend to incentivize functions that are part of the revenue stream at the expense of critical functions such as service to the institution on committees. Such functions go under-supported handicapping the academic environment and educational enterprise at large. Unless carefully designed, RVU systems can undervalue and inhibit collaborative interdisciplinary teaching. A larger view of duty to teaching and to the institution is advocated.
The poet T. S. Eliot wrote the following lines for Archbishop Thomas Becket in the poem Murder in the Cathedral
“The last temptation is the greatest treason
To do the right deed for the wrong reason.”
Faculty members in academic health centers (AHCs) are faced with increasing pressures on their time. The recent financial downturns have increased pressure on these institutions to match expenditures to revenue sources and attain the best value for each cost center. In such analyses, it follows that faculty are considered cost centers. Thus, value is often considered in terms of financial cost and choices are made for reason of cost rather than institutional goals.
On the other hand, faculty members are well aware of institutional financial pressures and likewise make choices within their degrees of freedom. Such choices include “valued,” that is to say financially rewarded, activities over those that do not appear to be valued because they are not financially rewarded. The result is that many faculty functions within the AHC go under-supported. The value framework within which faculty members function needs to be reaffirmed and reset. We examine these issues in the following discussion of the value of teaching.
What is “value added” in an instructional interaction?
The concept of “value added” appears in many constructs ranging from manufacturing and processing to tax levies. To take the last as an example, the value-added tax allows the assessment of tax levies at each stage of the manufacturing process; e.g., from ore to ingot, from ingot to refined metal, from metal to instrument. Each stage of the process has made the product more able to be used as starting material for the next step and therefore more valuable and thus worthy of additional taxation.
This concept of value added also applies in the interaction that takes place between student and teacher and in the preparation that the teacher does for that interaction. Value is added to that interaction in several stages, most of which precedes the actual teacher-student interaction. We will designate these stages or phases as digestion, selection and prioritization, organization, and communication. In the digestion phase the full range of topics to be covered in a learning activity (lecture, problem-based or team-based learning session, laboratory, bed-side teaching, etc.) is digested by the teacher/facilitator. Just as the physiological digestion process means breaking down complex macromolecules to their monomeric or base units so that those units can be reassembled into appropriate structures for the body, so also the digestion phase for the teacher entails a breaking apart of the material for his/her own understanding and familiarity so that it can be presented to students in such a way as to facilitate learning. Following digestion of the material, the teacher then selects and prioritizes the content, identifying the foundational concepts that are essential for student understanding and application of the material and those that are derivative from the foundational concepts. This process permits an assessment of how much time and emphasis each component receives in order to enable the learner to reassemble the components into an ordered whole wherein each component is appropriate for both learning the material and using it in subsequent activities.
The next phase is organization. In this phase the teacher assembles the components into a framework or scaffold for the teaching interaction, ordering the material in such a way that best allows for effective presentation by the teacher so that the learner is able to acquire the information in a useful way. The teacher’s organization is present in syllabus, outline, and in manner of approach.
It is not until the completion of the digestion, selection and prioritization, and organization phases are complete that the apex of the teaching interaction takes place, the communication stage. In a problem-based learning (PBL) session, for example, how the faculty facilitator helps students formulate pertinent questions assists them in identifying learning issues that will lead to solving the session’s problem. In a lecture, the challenge is to enable the students to actively, rather than passively, learn the content. Thus, the use of examples, humor and analogy, as well as questions by the lecturer or learners, are critical aids in the teaching interaction in that each invites the learners’ action in digestion, weighting, organization and reassembly of components into their working knowledge base.
Each of these processes adds value to the teaching interaction. Each of these is a part of the process of teaching. Each is critical to the overall process and contributes uniquely to the value added to the teaching interaction through the teacher’s efforts to provide an environment in which the learners learn. The challenge, therefore, is to identify the relative value added at each stage and to assign correlative worth for each activity.
How is value added to the teaching interaction recognized?
The relative value unit (RVU) system was developed by Medicare as a guide to physician reimbursement.1,2 In this system, each clinical activity was assigned an RVU based on the complexity of the activity. At approximately the same time, the American Association of Medical Colleges (AAMC) began the Mission-based Management (MBM) Program to help deans and faculties of medical schools. The medical education panel of the MBM Program proposed a metric developed to create RVUs for education activities by faculty members in medical schools.3 This system has been adapted by some AHCs or departments in AHCs to allocate resources for the various activities that serve the institutional missions.3-6 Its use has been helpful in that it provides a method for evaluating activities and contributions from different sources and contributors. Successful use of an RVU system requires a careful analysis of the level of contribution in terms of degree of effort and relation to the overall institutional goals.
In an academic institution, three main areas of contribution are teaching, research/publication, and institutional service. In an AHC, these three areas are joined by a fourth, namely, clinical care. The utility of an RVU system depends on the ability of a system to evaluate appropriately the various contributions made across the different areas of expected (and therefore rewarded) activities and on the use of the system for all areas of activity. In AHCs, teaching takes place both outside of and within the clinical setting. Non-clinical teaching occurs during lectures and grand rounds, in laboratories, in small groups including problem-based learning, team-based learning and conference/recitation sessions, and while mentoring the research of students and trainees. Teaching occurs on clinical services during rounds, outpatient clinics, clinical conferences and case-based sessions, and in surgical or special clinical procedure rooms. How these differing teaching interactions are assigned RVUs is critically important to the reliability of the RVU-based system of accounting for faculty time and for its acceptability to the faculty.
While the AAMC suggested a mechanism for developing an RVU metrics system for teaching, the ways that various institutions or departments have calculated them are myriad. They range from a simple time-based system7 to a sophisticated metric that measures overall academic productivity by including publishing, teaching, administration and research.2 Most metrics start with the number of contact hours for each educational activity and include some factor for the complexity of the activity, which may include the number of students. Some systems may employ endpoint measures such as section test grades or student evaluations in the calculation. Such inclusions introduce variables into the calculation that are beyond the faculty members’ role. Moreover, questions arise as to how to equate different types of teaching. For example, how does preparing and presenting a lecture to a large classroom of 200 students compare to the bedside teaching given to 5 students during a 40-hour week clinical rotation? The product of hours times number of students is equivalent but 1 hour is far less than 40 hours in the weekly schedule. Is 3 hours of clinical bedside instruction for 5 students equivalent to 3 hours of “tankside” instruction in the gross anatomy laboratory? How are overlapping duties evaluated? For example, how much of clinical rounds is teaching vs. clinical care and how much of graduate student research training is research vs. teaching?
While these questions may seem to be fine points or details, they nonetheless markedly influence faculty satisfaction or dissatisfaction with an RVU-based system from the standpoint of the fairness of the system. The degree of dissatisfaction increases markedly when RVUs are utilized in the calculation for distribution of funds to individual departments. Dissatisfaction increases even more when RVUs are used to calculate individual salaries, particularly when these calculations lead to a decrease in remuneration. Faculty dissatisfaction with RVU systems is a significant cause for revisions of systems in order to address equivalencies.
Where RVU systems have greatest difficulty, however, seems to be in the area of universality of application. This difficulty arises from the well known observation that an institution or an individual will receive more of whatever behavior is incentivized. For the case in point, if more RVUs are available for teaching there will likely be a greater willingness to teach on the part of the faculty. Similarly, if incentives are offered for new grants, an increased number of applications will be sent to funding agencies. These are desirable results for an AHC, but if certain functions are not incentivized, the danger lies in the inability to retain active participants.
Unfortunately, adoption of the RVU system may lead to disincentivizing collaborative efforts. Instruction that involves the collaboration of faculty from different departments or disciplines can often result in disparate apportionment of RVUs, especially when RVUs are the basis for distributing educational funds to departments. Inequities can arise ranging from awarding RVUs only to the team leader/course director to too few RVUs for participant faculty whose role may be critical yet subordinate. Some departments award RVUs for departmental courses only to departmental faculty and not to faculty of other departments who teach in the course. Inequities such as these have led to some faculty members refusing to participate in interdepartmental courses because of inadequate amounts of RVU recognition in the face of their department chair’s demand for high RVU per unit time. In essence, the RVU system has incentivized these faculties to place their efforts elsewhere. Thus, lack of universality of awarding and/or recognizing RVUs for teaching is a multi-headed problem for AHCs.
In addition to teaching, research and clinical care, an AHC has critical responsibilities that require the efforts of faculty as committee members, task force leaders and coordinators. These “volunteer” efforts are necessary in the normal operation of the AHC in functions such as student admissions, faculty promotion and tenure reviews, internal review boards and animal welfare committees to name only a few. These “volunteer” efforts are also critical for periodic site visits and certification reviews such as those of the Liaison Committee on Medical Education (LCME), academic accreditation agencies, hospital certification reviews and others. This latter group of external reviews requires extra concentrated effort in preparation for the actual site visit ranging from 2 years prior to site visit in order to prepare the self studies and data bases required for the visit. These efforts are not recognized by RVUs in the vast majority of institutions, although they are institutional functions. These efforts have always been assumed to be part of the “other duties not specified but part of the faculty role” and recognized as not specifically delegated but required. This lack of universality of assigning RVUs to all functions seems to us to be greater than the disparities in distribution of teaching RVUs.
Did the concept of the RVU or the RVU system as employed cause the problems described above? The answer to this seems to us to be no. Neither the RVU concept nor the RVU system causes the problems; they just lay bare the underlying issues. The real question for AHCs, and for that matter universities and colleges, is what does it mean for an institution to have a teaching mission?
To help answer that question, we would like to introduce the concept of magisterium. While the word magisterium has ecclesial roots, specifically in the Roman Catholic Church and other liturgical traditions, it applies to academic institutions as well. Magisterium denotes both the authority to teach as well as the duty to teach. The magisterium resides in the institution as is illustrated by the fact that the right to award degrees is given to the academic institution by the state through various licensing and review processes. Teaching in the institution is authoritative in that it is accomplished by learned degree-holding faculty. Thus the authority exercised by the institution is a corporate authority dependent on the collected expertise of the whole faculty. Licensure and certification of academic institutions is also corporate in that these processes are dependent upon review by degree-holding academicians outside the institution.
The magisterium of the institution is authoritative (knowledge-based) but not authoritarian. Rather, it is inviting, challenging and encouraging of learning and contributing new ideas. Since the teaching authority lies in the faculty it follows that the duty to teach also lies in the faculty. This duty to teach includes responsibilities to students, the field of study and to the environment of the academic institution. Duty to students focuses on presenting the material in such fashions that students learn, recognizing that students learn in differing ways. Thus, the teacher repeatedly checks the progress of student learning through questions, conversations and tests. Duty to the field of study requires that the teacher keep current with both advances in the field and advances in teaching strategies and subsequently to adjust teaching strategies to meet the changing needs of the student population. It also requires that the faculty member contribute to the field in any of a variety of ways including publication, poster presentations, lectures, seminars on research topics, etc. Duty to the environment of the institution, it seems to us, includes by definition participation in collaborative interdepartmental/interdisciplinary teaching as well as committee work and faculty governance, which is required for the orderly functioning of the department, division, school, and institution. Since the teaching authority is corporate, faculty participation on committees and other ancillary functions is also necessary to the proper execution of the magisterium of the academic institution.
RVU systems that inform revenue distribution are accounting constructs that are useful for the maintenance of the university and for faculty remuneration. However, we suggest that RVU systems, if not well-designed or misapplied, challenge traditional values in teaching and the magisterium of the AHC. This is because RVU systems introduce a hierarchy of duties that is dependent on revenue streams. By their very nature, RVUs incentivize and prioritize duties that generate income for the institution, and therefore for the faculty member, to the detriment of those that do not.
Most academic institutions prepare budgets on the basis that every activity has an income stream. Faculty teaching effort is financed through institutional resources such as tuition, endowments, and state allocations for state institutions. Faculty research time is financed through grants, contracts, or endowment sources. For AHCs, faculty clinical time compensation is covered by clinical income. Since many of the responsibilities inherent in the magisterium of the AHC are not within the revenue stream (e.g., counseling or mentoring students or other faculty members, teaching in pre-matriculation courses, committee work, faculty governance, etc.), RVUs can be applied in such a way that faculty members are inhibited from properly executing those responsibilities.
We propose that if AHCs are going to utilize RVU systems to inform revenue distribution in a mission-based management plan, they carefully design and apply those systems in such a way that they recognize the importance of all the duties inherent in the magisterium. The faculty needs to be assured that the RVU system is equitable and reflects the importance of the faculty responsibilities to promote student education, their field of study, their patients, and the institution regardless of whether these duties are directly captured in a revenue stream.
However, it also seems to us that the privilege and duty of teaching transcends whatever construct is utilized by the institution for revenue distribution. Since the magisterium resides in the faculty, its members must take seriously their duties that come with being part of the magisterium. A faculty member’s decision about whether to participate in a course should be based on expertise, interest and available time, not on the number of RVUs awarded. Faculty members also have a responsibility to advocate for teaching, for students and for the various constituencies of the institution by participation in institutional committees and faculty governance. The voice of the faculty is critical to the well-being of the institution in matters of academic policy, procedures, and standards, as well as in implementation of current curricular content. Without the voice of the faculty, the institutional magisterium falters in its pursuit of excellence.
Likewise, the administration of AHCs also has duties derivative from the institutional magisterium. High in the rank of duties would be the duty to recognize and value the contributions of all constituencies of the AHC on whose efforts the success of the AHC depends. While this certainly includes providing appropriate remuneration for all the various contributions, it is especially critical that the AHC ensure that each contributor knows, believes and can articulate the role his/her contribution makes to the institution. In a sense, this effort gives ownership of the aims, goals and success of the institution to each constituent, such that each member of the AHC becomes a valued contributor rather than just a paid employee.
The authors gratefully acknowledge Jeffrey K. Actor, Ph.D., for reviewing this paper and providing valuable suggestions and insights.
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