Anesth Analg 2006;102:1908-1909
© 2006 International Anesthesia Research Society
doi: 10.1213/01.ANE.0000215144.46906.C5
LETTER TO THE EDITOR
Unintended Consequences? Unanswered Questions?
Amr E. Abouleish, MD, MBA,
Donald S. Prough, MD, and
David A. Lubarsky, MD, MBA
Department of Anesthesiology; UTMB; Galveston, TX; aaboulei{at}utmb.edu
To the Editor:
We read with great interest Drs. Miller and Cohen's (1) report concerning the impact of their incentive system on faculty compensation. As noted in the survey of academic programs and the accompanying editorials (2–4), the issue of incentives and their impact on faculty and departments is important to faculty, department chairs, and medical school/hospital administrators. Unfortunately, there are few, if any, reports of the impact of incentives on anesthesiology departments. Therefore, Drs. Miller and Cohen's report addresses an important need.
Unfortunately, as noted in their report, the authors offer only a "qualitative description of the impact of this system." The lack of a quantitative analysis leaves open many questions. In particular, what was the impact of the incentive system on the total quantity of clinical work done in the operating rooms, i.e., did the system increase overall productivity or just redistribute income, and what was the short-term impact on academic productivity by junior faculty (<5 yr from residency)? The study did not cover enough time to assess the long-term impact on junior faculty, but we are very concerned that the result may be fewer career academicians. Finally, clinical work and time spent teaching often require balance. There was no concomitant survey of the perceived quality of teaching. For instance, did the incentive prompt faculty to cover two rooms instead of one during difficult cases, and did that impact resident education? Were the faculty more tired and hence less available for resident discussions? Every incentive system produces exactly the results for which it was designed, but we are all too often ignorant of what our incentives are truly designed to do! The law of unintended consequences must receive very careful attention, especially in our premier teaching and research institutions.
Because academic anesthesiology departments receive a large percentage of budget support from medical schools or hospitals (5), we must assume that any incentive system will be viewed by medical school or hospital administration as a means to increase productivity, especially numbers of surgical cases done. Therefore, an important outcome measure of an anesthesiology department incentive system is whether it increases numbers of surgical cases. As reported earlier (6), the billed hours per faculty changed after they instituted their incentive system. However, the impact on overall clinical work is not specified. For instance, billed hours per faculty could increase because fewer faculty members performed the same work, because more operating rooms were opened and more cases were done, or because more cases were performed in the same number of operating rooms. The overall financial impact on the hospital and the department is likely to be different for each of these alternatives. In the parlance of our previous work on measuring group clinical productivity (7), did institution of the incentive system increase the work done per operating room or anesthetizing site?
In regard to the potential impact of the incentive system on academic productivity, the authors note that providing increased incentives for clinical work did not decrease academic productivity, as evidenced by an increase in external funding. However, the change in funding provides only a partial answer. Incentives for clinical work are unlikely to prompt established researchers to reduce their efforts in research but are more likely to encourage junior faculty to choose (higher paid) clinical work rather than research and education. One way the authors could evaluate the impact is to evaluate the progress of junior faculty toward external funding; what specifically was the impact on K grants and other junior level grants? Similarly, was the incentive system associated with a change in the number of abstracts and peer-reviewed publications published by junior faculty?
Again we applaud the authors in reporting the impact of their incentive system. However, academic departments considering institution of a similar plan could benefit from analysis of some of the additional questions that are not explicitly addressed in this report.
References
- Miller RD, Cohen NH. The impact of productivity-based incentives on faculty salary-based compensation. Anesth Analg 2005;101:195–9.[Abstract/Free Full Text]
- Abouleish AE, Apfelbaum JL, Prough DS et al. The prevalence and characteristics of incentive plans for clinical productivity among academic anesthesiology programs. Anesth Analg 2005;100:493–501.[Abstract/Free Full Text]
- Miller RD. Academic anesthesia faculty salaries: Incentives, availability, and productivity. Anesth Analg 2005;100:487–9.[Free Full Text]
- Lubarsky DA. Incentivize everything, incentivize nothing. Anesth Analg 2005;100:489–92.
- Tremper KK, Barker SJ, Gelman S, et al. A demographic, service, and financial survey of anesthesia training programs in the United States. Anesth Analg 2003;96:1432–46.[Abstract/Free Full Text]
- Feiner JR, Miller RD, Hickey RF. Productivity versus availability as a measure of faculty clinical responsibility. Anesth Analg 2001;93:313–8.[Abstract/Free Full Text]
- Abouleish AE, Prough DS, Barker SJ, et al. Organizational factors affect comparisons of the clinical productivity of academic anesthesiology departments. Anesth Analg 2003;96:802–12.[Abstract/Free Full Text]
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