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Background Changes in the organization and financing of health care threaten to alter the prevailing system of financing the teaching of medical students and residents. Little information is available from private medical schools and teaching hospitals about the extent of teaching by faculty members or the mechanisms and levels of reimbursement for teaching.
Methods We surveyed faculty members in the Department of Medicine at Columbia–Presbyterian Medical Center to ascertain the extent of their teaching activities. A standard number of hours was assigned to each activity, and the total number of teaching hours was calculated for each faculty member. Teaching of fellows and in continuing medical education programs was excluded. We also determined how much money the Department of Medicine received in payment for faculty members' teaching activities, and the sources of this compensation.
Results In the 1992–1993 academic year, the 188 full-time faculty members spent a total of 46,086 hours teaching (mean [±SD], 245±178 hours per faculty member); 10,780 hours (23.4 percent) were spent teaching medical students, and 35,306 hours (76.6 percent) teaching house staff. Eighty percent of faculty members taught for 137 or more hours each. In a multivariate analysis including faculty rank, subspecialty division, years since graduation from medical school, sex, and tenure or clinical track, we found that senior faculty members (P = 0.02), members of certain subspecialty divisions (P<0.001), and women (P = 0.05) contributed more than the average number of teaching hours. An additional 56 non–full-time faculty members contributed a total of 5684 hours. The net reimbursement to the department for teaching totaled $965,808, or about $16 per hour of teaching by full-time faculty members, after the cost of fringe benefits was excluded.
Conclusions Faculty members of the department of medicine at a major medical center contribute a large number of hours teaching medical students and house staff. This effort is poorly compensated. Cost-containment efforts have the potential to jeopardize fragile social contracts at academic health centers whereby the faculty participates in teaching by contributing unreimbursed or underreimbursed time.
One of the most important effects of financial pressure is to highlight these shifts in costs and revenues, and the individual physicians who make up the medical school faculty and hospital staff at academic health centers find themselves affected by institutional efforts to identify and justify each budgetary allocation, particularly those perceived as cross-subsidies. Less attention has been given to services provided by these physicians that are generally unreimbursed, such as the teaching of medical students and members of the house staff. At our institution, all faculty members are currently expected to contribute to the teaching of medical students and house staff. Faculty members are also expected to generate all or most of their salary through research or clinical activities. However, at a time when payment for most physicians' services is stable or declining5,6 and research grants have become more difficult to obtain,7-9 faculty members may be less willing than in the past to contribute time to teaching without direct reimbursement.
We analyzed the number of hours spent in teaching by the faculty of the department of medicine at one academic health center in order to quantify this contribution. We were concerned with three specific issues. First, was this contribution made by a limited number of people who did a large amount of teaching, or was teaching spread widely and more or less evenly? Second, to what extent were variations in the amount of time spent in teaching related to factors such as sex, subspecialty division, rank, years since graduation from medical school, and type of appointment (clinical or research)? Third, to what extent were physicians compensated for their teaching activities?
Methods
A list of all teaching activities for the academic year running from July 1, 1992, through June 30, 1993, was generated from the records of the Department of Medicine at Columbia–Presbyterian Medical Center. Activities that combined clinical service and teaching, such as serving as attending physician on a ward, were counted in full as teaching time. We excluded teaching activities directed exclusively to fellows (e.g., supervision of endoscopic procedures or the electrophysiology laboratory) or graduate students and activities with no teaching component, such as patient care in the medical subspecialty clinics; teaching activities for which faculty members are paid in addition to their salaries, such as the department's annual board-review course, were also excluded. Activities related to the administration of courses, such as time spent by course directors in activities other than teaching, or to the administration of teaching activities, such as the time of division chiefs or the director of the Medical Service, were also excluded.
Each faculty member was sent a list of his or her major teaching activities and asked to verify its accuracy and completeness. These data were reviewed and verified again by three of the study investigators, with reference to departmental teaching schedules. Each faculty member then verified his or her list a second time. Each teaching activity was assigned a standard duration (e.g., one month for attending on a ward) and an estimated time in hours (Table 1) by one of the study investigators, in consultation with the department chairman and selected colleagues. For example, attending on a ward, which accounted for a total of 91 hours (Table 1), involved conducting rounds with house-staff members and students for 2 hours per day, 6 days per week, for 4.5 weeks (54 hours); writing and countersigning notes on charts (27 hours); reviewing and signing discharge summaries (2 hours); participating in meetings of attending physicians at the beginning and end of the month (2 hours) and in two grading sessions for the students (2 hours); completing written evaluation of house staff (1 hour); and writing letters of reference for house-staff members applying for fellowship programs (3 hours).
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In tabulating departmental teaching revenues, the same exclusions were applied as for teaching hours. Funds used to support administrative activities related to teaching were excluded. In addition, the amounts available to support the department's teaching activities were determined from the actual allocation of unrestricted funds.
The two-sample t-test was used to compare the means of two categories. The F test (from one-way analysis of variance) was used when more than two categories were compared, and groups from Tukey's studentized range test (
= 0.05) were computed, in order to adjust for multiple comparisons. Adjusted means were calculated with a least-squares linear-regression model, with simultaneous adjustment for the number of years since graduation from medical school, sex, faculty rank, subspecialty division, and type of appointment. Comparisons of these adjusted means were tested for statistical significance by F tests.
Results
The 188 full-time faculty members spent a total of 46,086 hours teaching (mean, 245±178 hours) in the 1992–1993 academic year. Of this time, 10,780 hours (23.4 percent) was spent teaching medical students and 35,306 hours (76.6 percent) teaching house-staff members (Table 1). The activities that accounted for the largest number of hours were serving as attending physician on a ward (13,468 hours, or 29.2 percent of the total) and acting as attending physician on a subspecialty service (8152 hours, or 17.7 percent). No other activity accounted for more than 10 percent of the total, indicating the breadth of teaching activities in which the faculty was engaged. The activities related to the teaching of medical students that consumed the most hours were serving as preceptor in the second-year Abnormal Human Biology course (3300 hours, or 7.2 percent) and the third-year clinical rotation in internal medicine (2600 hours, or 5.6 percent). Physicians who attended on wards had contact with medical students as well as house staff, but this activity was classified as teaching house-staff members because it was not designed exclusively for students.
The 39 part-time faculty members contributed a total of 3572 hours of teaching; 8 faculty members with primary appointments outside the Department of Medicine contributed 780 hours; 6 who were based at other affiliated hospitals contributed 826 hours at Presbyterian Hospital; and 3 emeritus faculty members contributed 506 hours. Thus, a total of 5684 hours (mean, 102 hours per faculty member), or 11 percent of the total departmental teaching effort, was contributed by non–full-time faculty.
Table 1 also shows the broad participation of the faculty in the department's teaching activities. For example, 134 of the 188 full-time faculty members (71 percent) attended on wards, 128 (68 percent) attended on subspecialty services, and 66 (35 percent) participated in the Abnormal Human Biology course as preceptors (some served as section directors and lecturers as well). The frequency distribution of teaching hours for the 188 full-time faculty members (Figure 1) also illustrates the breadth of the faculty's participation in teaching. The 20th percentile for time spent teaching was 137 hours; therefore, 80 percent of the faculty contributed at least this number of hours. The teaching effort involved substantial amounts of time on the part of a large proportion of the faculty, rather than very large contributions by a few; this was so despite the fact that eight faculty members each spent more than 500 hours in teaching. These were mainly the directors of the intensive care unit and the unit for patients with the acquired immunodeficiency syndrome (AIDS) and faculty members in the Infectious Disease Division who served as attending physicians for several months in the intensive care units, the AIDS unit, or the infectious-disease consultation service.
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The total amount available to the Department of Medicine in support of its teaching was therefore $965,808, or $20.96 per hour, exclusive of fringe benefits and excluding the 3572 hours spent by part-time faculty members in teaching. The fringe-benefit rate is 33.5 percent; after the cost of fringe benefits was subtracted, the compensation to the department for teaching by faculty members was approximately $15.70 per hour. These departmental teaching revenues were passed through to the divisions but not linked line by line to support for individual faculty members, nor were these funds specifically earmarked for the support of teaching, as distinct from research, administration, clinical programs, or fellowship programs.
Of the 188 full-time faculty members, 43 received some direct salary support from the department, other than revenues from clinical services or grants; 13 of these 43 were division chiefs or the chair or associate chair of the department. The departmental salary support for these 13 faculty members with major administrative responsibilities was excluded from the total amount available for teaching compensation; it is shown in Table 6 as the amount expended for departmental administration under "professional fees collected." Only 1 of the 39 part-time faculty members who spent time teaching received any salary support from the department. Thus, the majority of faculty members who taught medical students and residents within the department received no salary support from it and therefore were not compensated for the time they spent teaching. Faculty members who did receive salary support through divisional budgets may be viewed as receiving compensation for their teaching, but in most cases this was not made explicit. The general departmental philosophy was and is that teaching is a service required of faculty members as part of the privileges and obligations of faculty appointment.
Discussion
In the academic year 1992 –1993, 188 full-time faculty members of the Department of Medicine spent 46,086 hours teaching residents and medical students (for a mean of 245 hours per person per year). There was remarkably little variation in this level among subspecialty divisions, with the exception of the Infectious Disease Division, whose faculty members did significantly more teaching than those in the other subspecialties. Senior faculty members taught somewhat more than junior faculty members, and women somewhat more than men. However, our chief conclusion from these analyses is that almost all the faculty spent substantial time teaching medical students and residents and that the overall effort reflected this broad distribution of teaching time, rather than many hours spent in teaching by a subgroup. The amount of financial support was small in relation to the extent of the teaching by department faculty members.
Our estimates of total teaching time are almost certainly conservative, for several reasons. We excluded 56 non–full-time faculty members from the main analysis; taken together, these men and women taught for a total of 5684 hours, or 11 percent of the total departmental teaching effort. We also excluded teaching activities outside the Department of Medicine by faculty members who had primary appointments in that department but who taught both in medicine and in other departments of the Medical School, such as the Department of Physiology, or in the School of Public Health. Many hours of informal teaching were also excluded.
The observation that the senior faculty spent more time in teaching than the junior faculty may reflect the fact that tenure-track junior faculty members are protected from some teaching responsibilities as well as the fact that senior faculty are committed to the department's teaching programs, particularly the Abnormal Human Biology course, and to service as attending physicians on wards and subspecialty services. It is also possible that the greater amount of teaching by these faculty members was a consideration in their promotion to senior rank. It is of interest that women contributed more hours of teaching than men.
We could not completely separate the teaching of medical students from the teaching of the house staff and fellows. Although some of the teaching activities shown in Table 1 clearly involve only medical students, such as the Clinical Practice and Abnormal Human Biology courses and the activities of preceptors for the third-year medical clerkship, other activities, such as attending on a ward, involve a mixture of students and house-staff members, and some, such as the subspecialty consultation service, include students, house staff, and fellows. We excluded teaching directed exclusively to fellows — for example, supervising endoscopy, bronchoscopy, or the electrophysiology laboratory.
The amounts of time spent in teaching undoubtedly vary widely among departments as well as among institutions. Our institution may not be typical of academic health centers across the country, and the amount of teaching time may be greater at Columbia than elsewhere, for several reasons. The time-intensive commitment to the teaching of medical students has already been described. Two attending physicians are assigned to our teaching services, whereas many other institutions use a single attending physician. We also have a very large medical service, with nearly 500 beds, and a commensurately large house staff of approximately 150 residents (as of the time this study was done).
At our institution faculty members in the department of medicine are largely responsible for generating their own incomes, through either clinical activities or research grants, and there is relatively little central financial support for teaching activities from either the hospital or the university. At academic health centers with direct state financing, support for teaching may be more widespread. Clinical arrangements in our department are diverse and include private practice, departmental clinical-practice plans, and full-time salaried status. Other academic health centers with mainly full-time staffs or hybrid arrangements may build teaching into these arrangements in ways that are not possible in the private-practice model.
A substantial amount of federal money is currently paid to academic health centers and teaching hospitals that is specifically designated as compensation for the costs of training house staff.1,4 These funds are awarded as the direct and indirect medical-education components of the Medicare payment for hospital services and are meant to support the salaries, fringe benefits, and administrative costs of house staff, the costs of teaching, and the greater cost of care in a teaching setting. One conclusion of our study is that the amount of money passed through to the Department of Medicine from these funds is not commensurate with the time spent by physicians on the faculty in training members of the house staff.
The necessity for unreimbursed teaching has traditionally been accepted as a quid pro quo for appointment to the university faculty, which was until recently a requirement for hospital privileges, but hospital admitting privileges have recently been opened to nonteaching physicians. Another traditional benefit of the teaching program to the clinical faculty members has been that their private inpatients are covered by house staff, but private patients are increasingly being treated as outpatients, short-stay inpatients, or "off-service" patients who are not cared for by the house staff. Thus, the residents are serving the needs of the private attending physicians less clearly than before, and the perceived benefit of teaching is correspondingly less. As hospitals expand their part-time faculty to increase admissions, while exempting many of these part-time staff members from teaching, and as hospitals reduce special benefits, such as subsidized office space, to full-time staff members, the full-time faculty is called on to do more teaching without compensation. As a result, physicians may view teaching as a burden or an unreimbursed service rather than as a privilege, a mark of recognition for excellence, and a pleasure.
This study shows that faculty members in our department contributed substantially through unreimbursed teaching time to the training programs of both the medical school and the hospital that make up our academic health center. In a cost-competitive health care environment with a truly level playing field, there would be direct payment to faculty members for time spent in teaching. However, the financial pressure on hospitals, medical schools, and clinical departments, coupled with the proposed reduction in Medicare payments for the training of physicians,4 make this unlikely. The sense of privilege and the personal rewards of teaching will remain important, but uncompensated teaching time is likely to become an issue in an era in which financial compensation for physicians' activities is more closely watched.
Source Information
From the Departments of Medicine (S.S., K.G.N., J.T., T.Q.M., K.O., E.P., M.L.W.) and Statistics (D.R.), Columbia University, New York.
Address reprint requests to Dr. Shea at the Division of General Medicine, PH 9 East, 622 W. 168th St., New York, NY 10032.
References
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Related Letters:
Compensation for Teaching Medical Students and House Staff
Noble J. T., Ziegelstein R. C., Henrikson C., Shea S., Nickerson K. G., Weisfeldt M. L.
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N Engl J Med 1996;
335:58-59, Jul 4, 1996.
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More on Compensation for Teaching
Korn D., Jones R. F., Shea S., Nickerson K. G., Weisfeldt M. L.
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N Engl J Med 1996;
335:1537-1538, Nov 14, 1996.
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