Margaret M. Grimes, M.D., M.Ed.
Department of Pathology

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“Despite its fundamental importance, the educational mission of most medical schools receives far less recognition and support than do the missions of research and patient care.”
Irby DM et al. Acad Med 2004;79:729-36

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Medical schools are faced with greater reliance on clinical revenue and increasing competition for research funding
Respond by recruiting faculty dedicated primarily to patient care and education
Thomas PA et al. Acad Med 2004;79:258-264
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“The growing emphasis on delivery of clinical services and the concomitant decrease in time for tenured and clinical-educator faculty to teach and do scholarly work jeopardizes both the potential for continued discovery and the education of the next generation of medical scholars..”
Barchi et al Acad Med 2000;75:899-905

Martin GJ et al. EVUs: Development and implementation at two different institutions. www.im.org/.../
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“Most faculty want to teach- but think twice when it reduces their income
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Increasingly difficult to find faculty for resident interviews, physical diagnosis, clerkship lectures, etc.
Same faculty always volunteer, leading to decreased diversity in teaching programs
Decreased faculty enthusiasm about teaching impacts student career choices
Faculty held accountable to meet (clinical) productivity targets; faculty no longer want to teach because it will cost them in…salary.”

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Research funding declining
Departments place increased value on clinical dollars
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Faculty hired for clinical service (and teaching)
Educational funding variable/not clearly linked
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Clinical time trumps education time
Faculty members who teach outside of their departments return relatively little in direct benefits to the department regardless of benefit to the school
Traditional promotion and tenure favors scholarship
Faculty expected to teach without necessarily knowing how

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(personal)
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(departmental/personal)

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Clinician-educator faculty are increasing in numbers but their advancement is slower than that of research faculty
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Lower rank at hire
Limited time available for scholarly effort
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Limited resources
Thomas PA et al. Acad Med 2004;79:258-264

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AAMC Group on Educational Affairs
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Re-affirmed 5 education activity categories:
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Teaching
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Curriculum
Advising/mentoring
Leadership/administration
Learner assessment
“The establishment of documentation standards for education activities provides the foundation for academic recognition of educators.”
Simpson et al. Med Educ 2007;41:1002-9

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Scholarly approach = demonstrating evidence of drawing from and building on the work of others
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Scholarship = contributing work through public display, peer review and dissemination
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Engagement with the education community
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“Educators’ contributions to their institutions must be visible to be valued.”
Simpson et al. Med Educ 2007;41:1002-9

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Problems:
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Elitism
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Expectations may constrain initiative
Scholarship and national recognition still expected

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Other forms of recognition…
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Schindler et al: Recognizing clinical faculty’s contributions in education. Acad Med 2002; 77:940-1
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Faculty productivity profile system to recognize administrative, educational and research activities
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Excel document sent to faculty once a year. Committee identified all possible opportunities as educators (lectures, participating in faculty development, mentoring, interviewing, administrative, attending conferences/journal clubs)
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Point scale for each activity 0-25. Faculty fill in number of times – multiplied by points to give weighted score
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Awards/dinner given for outstanding contributions

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Still left with the problem of

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Irby et al. The Academy Movement (Acad Med 2004) argues that reform requires fundamental organizational change. Academies are:
 dedicated to education
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 independent but supportive of existing departments positioned to offer incentives and support, promote the scholarship of teaching, and encourage curriculum innovation have dedicated resources that fund mission-related initiatives do not compromise departments’ ability to succeed in research or patient care
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“Academies serve as powerful symbols of the importance and centrality of education.”

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State appropriation
Tuition
Grants and contracts
PRACTICE PLANS
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Federal: CMS
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Direct
Indirect
State (in Virginia, only for Family Medicine)

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Six broad rationales:
Mallon and Jones. Acad Med 2002;77:115-123
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Develop rational method for distributing funds to departments
Track resources spent on teaching/educational activities
“Address department chairs’ mistrust of dean’s office about hidden money”
Counteract the myth that faculty cannot afford to teach or are not compensated to do so
Provide an incentive to faculty to participate in current or expanded educational activities
Make the educational mission more visible

How do medical schools use measurement systems to track faculty activity and productivity in teaching?
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Mallon and Jones
(Acad Med 2002;77:115-123)
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41 schools surveyed for teaching metrics
Two main methods identified: contact hours and
RVUs
Contact hours:
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Some models allocated an additional amount of time to account for preparation and evaluation
Some models counted actual contact hours only
RVU method
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Assigned each teaching activity a relative weight

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Resource-based relative value scale (RBRVS)
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Used by Medicare to determine how much medical
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 providers should be paid
Assigns a relative value to procedures, adjusted by geographic region
Multiplied by a fixed conversion factor (changes annually)
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 to determine payment
Prices are determined based on physician work (52%), practice expense (44%) and malpractice expense (4%)
RBRVS does not include adjustments for outcomes, quality of service, severity or demand.
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Procedures categorized by CPT code
Each code assigned a Relative Value, expressed as RVUs
Relative Value Units can be used to track clinical productivity

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Teaching efforts can be assigned a “relative value”
Track and align with departmental funds
Account for faculty productivity
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“Like clinical complexity, teaching complexity possesses four components: time; educational value; labor intensity, and degree of patient risk and responsibility assumed.”
Yeh and Cahill. J Gen Intern Med 1999;14:617-621

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Challenges:
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Lack of culture of using data in management
Skepticism of faculty and chairs
Misguided search for one perfect metric
Expectation that metric will eliminate ambiguity about teaching contributions
Lack of measures of quality
Tendency to become overly complex
Mallon and Jones. Acad Med 2002;77:115-123

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Yeh and Cahill 1999: Designed 3 step process for calculating teaching productivity based on RVUs:
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Teaching Value Multiplier (TVM) addressed the differences in complexity of various teaching tasks. TVM is a ratio describing the worth on a given unit of time spent teaching relative to the equivalent amount of time spent on clinical activities.
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RVU generated through teaching = TVM x time required by activity x regional median clinical RVU productivity rate
(#RVUs per hour).
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Related all RVU calculations to the regional RVU production rate to ensure that teaching physicians would be compensated at no better or worse than the median rate for other area physicians.

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A few institutions reallocated resources based on the metrics
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More often, the outcome was increased attention to the educational mission without resource reallocation
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“It puts medical education on the table.”
Mallon and Jones. Acad Med 2002;77:115-123

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1999- Watson and Romrell (U. Fla.) reported development of a process that came to be known as “mission-based budgeting”.
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3-step process
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 identifying revenue streams to fund each of the institution’s missions evaluate each faculty member’s productivity with regard to each mission align funding source with faculty effort.
Stites S et al. Acad Med 2005;80:1100-1106

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AAMC established a Mission-Based Management (MBM)
Program to aid in the task of realigning funds to match missions.
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The MBM task force for medical education suggested a template for approaching MBM in education, beginning with
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 listing all faculty educational activities, assigning each activity a weight in RVU’s include time to perform function, preparation, level of expertise, and relative importance of the activity.
Attempt to link compensation to quality of teaching rather than quantity only.
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MBM met with mixed reactions. Resistance to change; logistical difficulty collecting data.

Stites S, Vansaghi L, Pingleton S et al. Aligning compensation with education. Acad Med 2005;80:1100-1106
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In 2003, U. Kansas Dept of Internal Medicine created a task force to develop a teaching metric.
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Reviewed faculty Medicare time sheets, historical distribution of financial support, and educational responsibilities; reviewed literature.
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Task force was concerned about the subjectivity in assigning weight to various teaching activities.
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Goal was development of a new metric that would be:
 easily understood
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 have a prospective, goal-setting approach an efficient use of faculty time and resources
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Decided against RVU metric; chose to create a time-based metric.

Stites et al. Acad Med 2005
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Educational value unit (EVU) was defined as a unit of time spent in education of students and residents.
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Avoided subjective assignment of relative values.
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Chose to value different activities with the same metric regardless of subspecialty or level of experience.
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0.1 EVU represented ~4 hrs work per week. Dollar value calculated for each 0.1 EVU.
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In theory, the EVU for a particular activity represents the fraction of the time devoted to purely education related functions while completing the activity.

Stites et al. Acad Med 2005
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Core and Clinical subdivisions of EVU
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Core EVU was defined as teaching time spent educating students and residents that is not associated with billable clinical activity (Grand
Rounds, morning report, CPC, small-group with medical students, all development time for didactic lecture preparation and presentation; administration of programs).
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Each faculty member was presumed to
 contribute a baseline of 0.2 core EVU while conducting non-billable clinical activities.
To be validated during year with recorded logs submitted by faculty.

Stites et al. Acad Med 2005
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Clinical EVUs were defined as those associated with billable clinical activities. Could be accrued automatically based on inpatient and outpatient attending schedules. Not meant to fully replace clinical income but to compensate for the expected decrease in faculty efficiency and productivity during patient care in the presence of learners.
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An EVU template was developed for each faculty member, allowing them to determine their proportion of work and compensation for the educational mission.

Stites et al. Acad Med 2005
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Hospitalist with 4.5 months inpatient rounding and 2.5 months general medicine consults; also serves as student clerkship director:
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Clinical EVU
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Inpt attending: 0.020/month x 4.5 mo = 0.09
EVU = 11,305.80
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Consults with resident: 0.015/mo x 2.5 mo =
0.0375 EVU = 4,710.75
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Total = 0.1275 Clinical EVU = 16,016.55
Core EVU
Baseline expectation = 0.20 EVU = 25,124.00
Administration = 0.10 EVU = 12,562,00
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Total = 0.30 Core EVU = 37,686
Total: 0.4274 EVU = 53,702.55

Stites et al. Acad Med 2005
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57 faculty members had a change in their salary structure as a result
34 had a decrease in salary support from the university.
23 had an increase.
Overall realignment of 1.66 million.
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“A number of faculty who were heavily involved in teaching were able to decrease their clinical responsibilities, allowing time for teaching activities while maintaining their salaries.
Those who were less involved had a decrease in university educational support, and were more dependent on clinical activities to maintain their salaries.”
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Despite shift, application of the metric did not appreciably change total faculty compensation, but rather created a realignment of salary sources with the department’s educational and clinical missions.

Stites et al. Acad Med 2005
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Faculty survey 4 months later: 39% felt educational productivity would be better, 46% unchanged. Varying opinion on fairness of dollar amounts.
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Dramatic improvement in faculty attendance at Grand
Rounds, CPC and M&M conference. (No evidence of faculty over-reporting).
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This system differs from previously reported metrics:
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Time-based
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Prospective
Compensates bedside teaching in addition to formal lectures and program administration.
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“Simple system that allowed faculty to self-report their time spent in educational effort… Established a market value for an internist’s teaching time, which is not specialty-specific.”

Stites et al. Acad Med 2005
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EVU system might discourage subspecialists with higher rates of reimbursement for clinical work from teaching
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Prospective approach allowed leadership to set clear expectation of teaching productivity by faculty members. A clinical productivity incentive program simultaneously implemented.
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The value of the EVU depends on university funding which can vary from year to year.
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Limitation: no incentive program to measure quality of teaching effort and adjust compensation accordingly.

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Barchi RL, Lowery BJ. Scholarship in the medical faculty from the university perspective: retaining academic values. Acad Med 2000;75:899-905
Irby DM, Cooke M, Lowenstein D, Richards B. The Academy Movement: A structural approach to reinvigorating the educational mission. Acad Med 2004;79:729-736.
Mallon WT, Jones RF. How do medical schools use measurement systems to track faculty activity and productivity in teaching? Acad Med 2002;77:115-123
Martin GJ et al. EVUs: Development and implementation at two different institutions. www.im.org/.../Documents/AIM%20Presentations/wkshp%20104educational%20value%20units.pdf
Schindler et al. Recognizing clinical faculty’s contributions in education. Acad Med 2002;
77:940-1
Simpson D, Fincher RM, Hafler JP et al. Advancing educators and education by defining the components and evidence associated with educational scholarship. Med Educ
2007;41:1002-9
Stites S, Vansaghi L, Pingleton S et al. Aligning compensation with education. Acad Med
2005;80:1100-1106
Thomas PA, Diener-West M, Canto MI et al. Results of an academic promotion and career path survey of faculty at the Johns Hopkins University School of Medicine. Acad
Med 2004;79:258-264
Yeh MM, Cahill DF. Quantifying physician teaching productivity using clinical relative value units. J Gen Intern Med 1999;14:617-621