Planning for undergraduate teaching

Planning for undergraduate teaching

Attempts to develop objective models

for medical school faculty compensa-

tion re¯ecting actual effort and contri-

bution to students' education are

proliferating. As is noted in the article

by Clack, much of this work has eman-

ated from the, US.1 Nonetheless, the

calls for new models of ®nancial support

for medical education that approximate

the reality of the effort are widespread.2

While the desire for objective models of

faculty compensation appears straight-

forward, what should be considered

before adopting such models? As noted

in the article, the apparent objectivity of

models such as this for teaching man-

power and compensation decisions is

appealing. However, is this objectivity

misleading? As the authors acknow-

ledge, it is impossible to quantify all of

the `non-scheduled' teaching. One-on-

one discussions, career advice, men-

toring and similar interactions are not

captured by the proposed models.

Oftentimes these activities are the most

powerful `teaching'. The proposed

model provides greater reward for

faculty to give large group lectures as

compared to small group exercises. Is

this the direction the school's academic

leaders desire medical education to

move? An incentive model, which is

what this is, will in¯uence faculty

behaviour. The school's leadership

must consider carefully whether the

proposed model will in¯uence faculty

to participate in desired educational

activities. Unfortunately it is often

dif®cult to envision the unintended

implications of an incentive plan.

The importance of including some

measure of educational outcomes in the

model, i.e. the quality of the education,

cannot be overstated. The current

emphasis on time and numbers of stu-

dents would potentially introduce

relatively perverse incentives that may

not be compatible with optimal educa-

tion. Since many of the faculty will be

in ambulatory practice situations, the

opportunity for peer review of their

teaching might actually be less than

in a hospital or large medical centre.

Ensuring that an appropriate level of

instruction and attendant student

learning is achieved prior to the distri-

bution of funds is a reasonable position.

Just as these models are being promul-

gated to redistribute funds that are

viewed as entitlements by faculty who

currently receive them, so too these

new plans will soon be viewed as enti-

tlements by the faculty who receive

them. Hence the importance of intro-

ducing a balanced model that is coup-

led to desired outcomes.

But these caveats are obvious to all

educators. What are the fundamental

issues that underlie these efforts to

explicitly support medical education?

Potentially, consideration of the `root

causes' will provide medical educators

insight into solutions. Let us look at the

USA, where the intensity of this effort is

greatest, and see if there are lessons that

potentially apply broadly. In the US the

coalescence of several factors is creating

strains on medical school ®nances.

Fundamental changes in the delivery of

health care have inexorably altered

medical education. For decades, medi-

cal school faculty and student clinical

education were predominantly hospital

based. However, markedly shortened

hospitalizations and the continued

migration of patient care to ambulatory

settings have necessitated that clinical

education also move to ambulatory

settings. As the site of clinical education

changes, so too the faculty involved in

education is changing. In the US,

the numbers of full-time pre-clinical

faculty increased from 14 105 in 1985

to 17 526 in 1999; a 24% increase.

During this same time period, the

numbers of full-time clinical faculty

grew from 47 193 to 81 391; a 72%

increase.3 Meanwhile, the total number

of medical students stayed constant or

decreased slightly.4 Medical schools

have responded to the fundamental

changes in clinical care delivery and

clinical education by rapid expansion of

their cadre of clinical educators, essen-

tially creating a new faculty to teach

medicine in the context of ambulatory

practice where most of their students

will eventually practice. This is not

unique to the USA.5

The growth in faculty numbers,

however, was not driven solely by the

need for faculty to teach in ambulatory

sites ± it also was fuelled by the growing

reliance of medical schools on clinical

care dollars. The percentage of US

medical school budgets derived pri-

marily from clinical income rose from

23% in 1975 to 43% in 1985 and to

57% in 1995.6 Subspecialty and pro-

cedural faculty contributed the most

to this growth in clinical revenue.

Indeed, the actual involvement of many

full-time clinical faculty in medical

student education has become negli-

gible. Medical schools have sized their

faculty to capitalize on clinical market

opportunities, not to their educational

or research missions. While clinical

reimbursement was stable, the growth

in faculty numbers generated positive

margins that bene®ted the educational

and research missions. However, recent

changes in healthcare ®nancing have

limited or reversed the growth of clinical

revenues. As the economic paradigm

that helped shape the composition of

the full time clinical faculty changed,

new sources of funding to replace the

clinical income losses have not been

forthcoming. The response of many

schools has been implementation of

explicit links between salaries and clin-

ical activity. As these clinical incentive

programmes are put in place, the per-

sonal ®nancial cost for faculty to parti-

cipate in `non-compensated' activities,

including teaching, is a real disincen-

tive. Stress on medical schools due to

Commentaries

Correspondence: James O Woolliscroft, Uni-

versity of Michigan Health System, 3107

Med Sci I, Ann Arbor, Michigan 48109±

0610, USA

94 Ó Blackwell Science Ltd MEDICAL EDUCATION 2001;35:94±96

changes in their economic base is not

limited to the USA.7

A third factor contributing to the

strains on many medical schools was

the growth of managed care. The most

obvious effect was the impact on clin-

ical revenue. However, as tightly man-

aged, capitated care models began to

develop, academic health centres in the

US attempted to build integrated

health systems to preserve access to

and support their existing subspecialty

dominated clinical faculty.8 Academic

Health Centre leaders reacted by

committing human and ®nancial

resources to the development of integ-

rated health systems. The rapid growth

of networks of primary care practi-

tioners were part of this strategy. Whilst

voluntary community-based primary

care practitioners have long been

integral members of the faculty, the

expansion of full time employed medi-

cal school faculties to include large

numbers of primary care clinical faculty

is a recent development in the US.

However, the anticipated domination

of this model of managed care has yet

to materialize and many medical

schools are facing the conundrum of

how to manage the large numbers of

new clinical faculty they hired. In this

case, academic leaders anticipated a

fundamental change in clinical care

delivery and made signi®cant commit-

ments to prepare for a change that did

not occur as predicted.

What can we learn from this attempt,

albeit super®cial, to consider some of

the `root causes' underlying the call for

new faculty compensation models in

the USA? One lesson is the need to

focus on the core missions of our

medical schools. As medical school

faculties were sized based on economic

opportunities rather than the demands

of the educational mission, changes in

the economic model now leave schools

in a precarious position. Academic

leaders need to differentiate between

faculty whose role is central to the core

business of education and those whose

role is supportive. The pursuit of

®nancial opportunities is not inappro-

priate. However, our schools should

not be primarily driven by these

opportunities.

Another lesson is the need to re-

establish the expectation that a primary

responsibility for faculty members is

teaching. We are in an era of rapid

transition in medicine. As the under-

lying science of medicine and delivery

of health care changes, the need for

faculty to teach in new ®elds or in

new practice contexts will grow. The

response cannot be that new faculty will

be hired in addition to the existing

faculty to meet these needs. Rather, the

expectation must be that faculty mem-

bers will grow and change and continue

to contribute to the teaching mission.

However, in many of our schools,

membership on the medical faculty has

been disconnected from teaching and

teaching from compensation. Indeed,

the observation in this paper that

faculty members have an expectation of

only an additional half-day spent in

medical education as compared to non-

faculty highlights this problem. The

implementation of educational RVU

models seeks to re-establish the link

between teaching and compensation.

However, in my view, the fundamental

lesson is that academic leaders must

work to re-establish the expectation

that a major responsibility for every

medical school faculty member is

teaching.

A third lesson is the unintended

consequences of apparently reasonable

administrative decisions. Just as schools

are increasingly requiring faculty

members to `earn their own keep'

through clinical activities, faculty are

now beginning to ask for compensation

for a myriad of activities that once were

considered part of the duties of a

faculty member. This expectation on

the part of the faculty towards the

institution is an unexpected outgrowth

of the increasing pressures of many

institutions on their faculty for

accountability in the generation of their

salaries. Just as efforts to develop

integrated delivery systems had unin-

tended consequences, management

efforts aimed at maintaining clinical

revenues through explicit activity-based

incentive plans may have unintended

consequences on the sense of academic

community and contributions to the

institution as a whole. Unfortunately,

the ability of Departmental and Insti-

tutional leaders to manage the efforts of

groups of individuals to achieve the

multiple missions of the medical school

may be eroded by formulaic manage-

ment tools.

While based on experience in the

USA, these are basic lessons that

educational leaders everywhere must

consider. Regardless of location, the

fundamental question is how best

to manage the educational mission.

Attempts to rationalize and objectify

funds ¯ow to match faculty teaching

efforts may be true advances for our

medical schools or an acknowledge-

ment of failure on the part of the

educational leadership to manage the

human resources necessary to support

undergraduate teaching. Tools such as

described may provide those charged

with leading the educational mission a

mechanism to make appropriate deci-

sions that previously were dif®cult to

implement. However, it does not

address the serious problems that many

of our medical schools face. Imple-

mentation of such systems should not

be confused with a solution to the

problems of faculty being disengaged

from the educational mission, loss of

focus on our core missions and the

compromise of education by the clinical

service demands imposed upon our

faculty.

James O Woolliscroft

Michigan, USA

References

1 Clack G. The development of a more

equitable approach to resource allo-

cation and manpower planning for

undergraduate teaching in a UK medi-

cal school. Med Educ 2001;35:102±

1091 .

2 Seabrook M, Booton P, Evans T, eds.

Widening the Horizons of Medical

Education. London: King's Fund, 1994.

3 Robinson L, ed. AAMC Data Book.

Statistical information related to medical

Planning for undergraduate teaching · J O Woolliscroft 95

Ó Blackwell Science Ltd MEDICAL EDUCATION 2001;35:94±96

schools and teaching hospitals. January

2000: p 33.




2000: p 8.

5 General Medical Council. Tomorrow's

Doctors. London: GMC, 1993.




2000: p 39.

7 Thorne S. Medical schools seeking new

ways to cope with funding cutbacks.

CMAJ 1997;156:1611±3.

8 Billi JE, Wise CG, Bills EA, Mitchell

RL. Potential effects of managed care

on specialty practice at a university

medical center. NEJM 1995;333

(15):979±83.

Planning for undergraduate teaching · J O Woolliscroft96

Ó Blackwell Science Ltd MEDICAL EDUCATION 2001;35:94±96

Documents

Planning for undergraduate teaching