ACAD EMERG MED • June 2002, Vol. 9, No. 6 • www.aemj.org
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Simple but Not Perfect Many factors impact on the financial success of an academic emergency department. Medical school financial solvency, hospital affiliation support, grant and contract success, and clinical revenue generation are all important components. Many academic departments of emergency medicine are facing decreased financial support from their medical schools and affiliated hospitals. This coupled with potentially decreasing clinical revenue is forcing many departments to closely scrutinize their ‘‘costs’’ and revenue streams. Certainly, the largest cost in any academic department of emergency medicine is faculty salary support, while the largest revenue stream comes from the clinical activity of the faculty. Many departments are investigating novel models for determining faculty clinical commitment and compensation. In this issue of Academic Emergency Medicine, Dr. Guss describes the faculty compensation plan at the University of California San Diego Department of Emergency Medicine.1 The components of this plan include a base salary along with additional compensation for academic rank, years of service, grants/contracts, and administrative duties. All faculty have a core clinical load of 96 hours/month with bonus pay given for working additional clinical hours. Faculty can decrease their clinical load by taking a matching percentage decrease in base salary. This compensation plan has several interesting components that deserve further exploration. The core incentive in this plan is to work more clinical hours. Where do these ‘‘extra’’ clinical hours come from? One would assume that the core clinical responsibility of 96 hours/month/faculty would completely cover the staffing requirements of the emergency department. Hence, extra clinical hours would come from faculty members decreasing their clinical commitment to pursue other activities such as education, research, or administration. What would happen if a faculty member decided to decrease his or her clinical commitment, had a revenue stream to support it, but no other faculty members wanted to work any extra clinical hours? It appears from this compensation plan that working extra clinical hours is voluntary. What happens when these clinical hours are not ‘‘covered’’? Are they assigned by the chair or division chief? To which faculty members? Using what criteria? Does the department staffing pattern change (decreased coverage) if these hours are not picked up? Is double or triple faculty coverage jeopardized? Is a novel clinical program (urgent care or observation unit) closed due to lack of coverage? Is there a min-
imum clinical commitment below which faculty members cannot fall? These questions are important and are not answered by this compensation plan. What is the fate of the other academic missions in this plan? Although each faculty has educational and scholarly expectations (not detailed in this article), there is no incentive to pursue these activities above and beyond the ‘‘expected’’ level. The incentive is to work more clinical hours. This has the potential to undermine the department’s educational and research missions. In the current plan, a novel educational activity that required increased faculty time commitment (such as bedside evaluation or supervising simulated patient encounters) most likely would not be met with resounding enthusiasm by the faculty. Of significant concern is the impact this plan may have on young faculty beginning a research career. A successful research career is ultimately based on the availability of time and money. In the current plan, the department can develop an intramural grant to support a faculty members research activity. While this seed money is helpful for research program development, the faculty member also requires protected time to further define and carry out the research program. In the current plan, this time must come from the personal commitment of the faculty. Even with the research seed money, it is extremely difficult for a young faculty member to develop and carry out a research program while carrying a full clinical load. This, coupled with the continued pressure to work more clinical hours to supplement individual income, makes pursuing a successful research career almost impossible. A faculty member serious about a research career should be assured seed money and protected time for two to three years until he or she can develop a selfsufficient research program. This does not seem possible (or supported) in the described plan. Nowhere in the described plan is there any measurement or reward for quality. All faculty members have baseline educational requirements, but are all faculty effective educators? If one of the baseline educational requirements is to give a faculty-developed didactic lecture, what incentive is there to pick a new topic, update an older lecture, or assure that material is delivered using a novel educational platform? Certainly the time spent developing a new lecture or delivery method for educational material could be spent working more clinical hours and supplementing income. The same could be said for developing any novel edu-
620 cational program or pursuing non-funded scholarly activity. In the described plan these activities are simply not rewarded by the department. The only reward for these activities comes from academic advancement in rank and the accompanying increase in salary. While this may be incentive enough for some, it has the potential to devalue these activities. In fact, even quality in clinical activity does not seem to be rewarded in this plan. Bonus pay is purely tied to the proportion of actual clinical hours worked. There is no reward for productivity. No reward for complete and accurate charting. No reward for clinical efficiency. No reward for patient satisfaction. In theory, the slowest faculty member with an abrasive bedside manner and sloppy charting could work the largest number of clinical hours and receive the largest proportion of bonus pay. Certainly there should be some incentive for quality. While this plan may be a ‘‘simple plan,’’ it is far from a ‘‘perfect plan.’’ Dr. Guss does not claim that it is a perfect plan. It is purely submitted as one possible plan for the readership to consider. Dr. Guss should be commended for submitting this plan for peer review and editorial/readership scrutiny. It brings to the forefront many important issues facing academic emergency medicine. The day
DeBehnke • PLAN FOR FACULTY COMPENSATION
of unfunded ‘‘protected time’’ is gone. We are too financially lean to support this. There is a quantifiable cost to protected time. To have decreased clinical commitment will require either a decrease in overall salary or a revenue stream (grant/contract, administrative stipend, etc.) to support it. However, we must not lose track of our other academic missions. They are equally important. Educational and research/scholarly activities must be quantified. Metrics should be developed to measure faculty activity and the quality of that activity. These activities must then be rewarded just as clinical productivity and quality are rewarded. While this may require cross-subsidization from clinically derived revenue, it is essential to our academic mission. The perfect plan most likely does not exist. The readers of this journal are encouraged to submit their plans, metrics, and ideas to the same scrutiny as Dr. Guss. By doing so we may be able to assemble the ‘‘perfect plan.’’— Daniel DeBehnke, MD (
[email protected]), Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI
Reference 1.
Guss DA. A simple plan—faculty compensation in an academic department of emergency medicine. Acad Emerg Med. 2002; 9:654–7.
