The Cost of Medical Education in an Ambulatory Neurology Clinic Anna Abramovitch, BS; William Newman, BS; Bimal Padaliya, BS; Chandler Gill, BS; and P. David Charles, MD Nashville, Tennessee
Financial support: Provided by the Department of Neurology, Vanderbilt University Medical Center. Decreased revenue from clinical services has required academic hospitals and physicians to improve productivity. Medical student education may be a significant hindrance to increased productivity and income. This study quantifies the amount of time spent by faculty members teaching medical students in an ambulatory neurology clinic as well as the amount of time students occupied rooms when seeing patients on their own. Over a three-week period in an ambulatory neurology clinic, an observer noted these quantities of time, and the opportunity costs of both amounts of time were determined. Attending physicians spent an average of 19.6 minutes per medical student per half-day teaching, which translates to an average cost of $20.78 per half-day clinic. Students spent an average of 49.9 minutes per half-day seeing patients in the absence of an attending physician, an opportunity cost to the clinic of $142.50 per student per half-day. Key words: cost of medical student education a cost of medical education * ambulatory clinic
© 2005. From School of Medicine (Abramovitch, Newman, Padaliya) and Division of Movement Disorders, Department of Neurology (Gill, Charles), Vanderbilt University Medical Center, Nashville, TN. Send correspondence and reprint requests for J NatI Med Assoc. 2005;97:1288-1290 to: P. David Charles, MD, The Movement Disorders Clinic, Vanderbilt University Medical Center, 2100 Pierce Ave., Suite 301 MCS, Nashville, TN 37212-3375; phone: 1615) 936-2025; fax: (615) 936-1229; e-mail:
[email protected]
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INTRODUCTION In the current environment of increasing managed care and marketplace competition, academic hospitals are often forced to accept less reimbursement for the services they provide.' Hospital clinics are under pressure to increase their productivity to compensate for this decrease in revenue.2 Medical student education utilizes significant amounts of physician time and clinic resources and may prevent maximal clinical productivity. For example, in the period of time during which physicians teach, they could potentially be seeing more patients, thus increasing their clinical productivity. These new pressures may force a decrease in the resources devoted to education. In order to meet new standards of productivity, physician educators are increasing their patient loads and subsequently finding themselves with limited time for teaching students. Similarly, when students occupy rooms to practice their skills with patients, the rooms are unavailable for evaluation of other patients, thereby decreasing physician productivity. This study seeks to quantify the actual and opportunity costs of educating medical students in an ambulatory neurology clinic at a private university medical center. In 1982-1983, Kirz3 surveyed physicians at an academic medical center and found that teaching students in various clerkships took a mean of 46.8 minutes of faculty time per half-day clinic. In 1995, Ricer" determined that private family physicians spent an average of 36.9 minutes per half-day in teaching activities while serving as preceptors for third-year students. In this time-motion analysis, an hour of a preceptor's time was estimated to cost $60, and it was thus determined that a typical 17-day rotation would cost $1,254.60 per student. In a 1994 study, Vinson5 found that academic physicians spent 31.5 minutes per half-day on student-centered activities when a fourth-year student was present.
METHODS We prospectively collected data for 10 physicians working half-day (four-hour) clinics over a three-week VOL. 97, NO. 9, SEPTEMBER 2005
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period in 2001 in the ambulatory neurology clinic at Vanderbilt University Medical Center (VUMC) in Nashville, TN. Three of the physicians held the appointment of full professor, three were associate professors, and four were assistant professors. During each of the 34 half-day clinics evaluated in this study, an observer recorded which physician was working and whether or not a medical student was involved in the care of any of the patients. For each patient seen by a medical student, the observer noted how long the attending physician discussed the patient individually with the student outside of the patient's room as well as the amount of time that the medical student spent with the patient alone in the room. We analyzed the results using data on clinical revenue and faculty salaries and workload. Average salaries of private medical school faculty for 20012002 were obtained from the AAMC's Report on Medical School Faculty Salaries.6 The annual salaries of full, associate and assistant professors were $189,300, $149,000 and $119,000, respectively. The mean salary of the Vanderbilt University Department of Neurology faculty was calculated with these values and weighed to reflect the faculty composition and was estimated to be $140,060. We increased this value by 20.3% to account for fringe benefits for an approximate sum of $168,500. We analyzed Vanderbilt University Department of Neurology physician quarterly time reports and determined the average faculty workload to be 55 hours per week. We used these calculations to determine the amount of money saved by changes that occurred in the structure of the third-year neurology clerkship at Vanderbilt.
RESULTS Cost of Faculty Time The number of half-day clinics worked by each physician ranged 1-6 (Table 1). Two of the physi-
cians never worked with a student, and one taught students in every clinic. For those clinics in which students were present, the number of patients seen by a student ranged 1-12. When students were present, attending physicians spent an average of 19.6 minutes per medical student per half-day discussing cases with the student outside of the patients' rooms. Assuming that a faculty member works 48 weeks per year yielded a total of 2,640 hours worked in a year. Dividing this value into $168,500 (determined from the faculty composition and the salaries published by the AAMC), the mean salary was an estimated earning of $63.83 per hour, or $1.06 per minute for faculty members. The average amount of time faculty spent per student per clinic teaching students individually was multiplied by the per-minute earning rate to get an average cost of $20.78 per halfday of faculty time spent teaching medical students.
Cost to Clinic Medical students were present on 20 of 34 half-day clinics. On days with students present, students spent an average of 49.9 minutes each per half-day seeing patients in the absence of an attending physician. Based on a typical clinic schedule of three new patients and five return visits during a half-day, the 49.9 minutes per half-day during which exam rooms are occupied by a student seeing patients alone could conceivably be used by a physician for two return-patient consults (level three, CPT code 99214), each 25 minutes long. VUMC charges $147 for this level of return visit; thus, the physician could potentially charge $294 for services rendered in this amount of time. With a 2002 collection rate of 48.47% for the department of neurology, the opportunity cost of medical students seeing patients alone in the clinic (lost clinical revenue due to students and patients occupying clinical space) is $142.50 per student per half-day.
Table 1. Characteristics of faculty clinics, neurology clinic, Vanderbilt University Medical Center, 2001
PhysicianClassification Number of Clinics Number of Clinics Average Number Worked over Worked with of Patients Seen Three-Week Period Student Present per Clinic when Student Present 1 Professor 5 4 3.50 2 Professor 3 3 8 3 Professor 3 0 4 Associate 5 4 5.75 5 Associate 5 2 3 6 Associate 3 2 6.50 7 Assistant 6 3 2 8 Assistant 1 2 3 9 1 1 Assistant 3 10 1 Assistant 0
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Average Time Spent Alone when Student Present 3.13 4.93
10.40 12.50 10.40 8.75 3.25 3
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Changes in Clerkship Structure At VUMC, a change in the structure of the neurology clerkship for third-year medical students resulted in a decrease in clinical teaching time. Before this change occurred in November of 2001, five-eighths of the class (65 students) rotated to the ambulatory neurology clinic as part of the clerkship. The rotation in the clinic was -composed of nine halfday clinics per week for two weeks. This equals 1,170 half-day clinical experiences per year, a cost of $24,307.92 in physician time and $166,725 in missed clinical resources. Beginning in November of 2001, the number of students rotating through the clinic decreased to one-half of the class (52 students), and the schedule for students was cut down to three half-day clinics per week for two weeks. This equaled 312 half-day clinical experiences for students per year, a decrease of 74%. The new scheme costs $6,483.36 in physician time and $44,460 in lost clinical revenue per year.
DISCUSSION Decreased revenue from clinical services has required academic hospitals and physicians to improve productivity. Due to its time-consuming nature, medical student education may be a significant hindrance to increased productivity and income. Educating medical students in an ambulatory neurology clinic at a private university medical center costs $20.78 for physician time and $142.50 of missed clinical revenue per student per half-day. Physicians spend an average of 19.6 minutes per student per half-day teaching medical students directly when they are present in the clinic. This is much less than the values found by others.35 Several factors may account for the difference. One factor is the number of patients seen by medical students per clinic, a value that varies widely even within one hospital. Further, teaching neurological illness may require more or less time than diseases in other fields. However, the results of the studies suggest an additional factor when they are viewed chronologically. The time difference may result from a trend of decreasing quantities of time devoted to clinical teaching activities. In the field of neurology, it is clear that the education of medical students is already insufficient.7 Financial forces are not only shaping physicianpatient interactions but are also significantly influencing medical student education. At VUMC, moving the setting of education from the ambulatory clinic to the hospital has significantly reduced the cost of educating medical students during the neurology clerkship. This change potentially affected the abilities of stu-
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dents to diagnose and treat neurological illnesses. Ideally, we could measure whether a decrease in students' competencies occurred following the change in the clerkship but, unfortunately, due to a lack of standardized clinical competency examinations and also because as at this point only four classes have completed the new clerkship, such evidence does not currently exist. Perhaps, in the future when there is a sufficient sample size of those having gone through the new clerkship, such data can be gathered using a number of bad outcomes or malpractice suits. Financial pressure continues to influence the amount of time that faculty devote to teaching and the clinical settings where educational opportunities occur. More work is needed to measure not only the cost but also the quality of education in order to ensure that medical students are being exposed to sufficient learning opportunities. A survey by Grayson et al.8 found that physicians reaped many intangible rewards from teaching, such as increased enjoyment in their practices and a greater desire to keep up with recent developments in medicine. Perhaps a strategy to keep medical students in the clinic can focus on these nonfinancial aspects of teaching.
REFERENCES 1. Blumenthal D, Meyer GS. The future of the academic medical center under health care reform. N EngI J Med. 1993;329:1812-1814. 2. Campbell EG, Weissman JS, Blumenthal D. Relationship between market competition and the activities and attitudes of medical school faculty. JAMA. 1997;278:222-226. 3. Kirz HL, Larsen C. Costs and benefits of medical student training to a health maintenance organization. JAMA. 1986;256:734-739. 4. Ricer RE, Van Horne A, Filak A. Costs of preceptors' time spent teaching during a third-year family medicine outpatient rotation. Acad Med. 1 997;72:547-551. 5. Vinson DC, Paden C, Devera-Sales A. Impact of medical student teaching on family physicians' use of time. J Fam Pract. 1996;42:243-249. 6. Alexander H, Herold C. Report on medical school faculty salaries, 2001-2002. Washington, DC: Association of American Medical Colleges, 2003:60. 7. Charles PD, Scherokman B, Jozefowicz RF. How much neurology should a medical student learn? A position statement of the AAN Undergraduate Education Subcommittee. Acad Med. 1999;74:23-26. 8. Grayson MA, Klein M, Lugo J, et al. Benefits and costs to communitybased physicians teaching primary care to medical students. J Gen Intem Med. 1998;13:485-488. A
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