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M. T. "Pepper" Jenkins Professor in Anesthesiology, Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center at Dallas, Dallas, TX
To the Editor:
I applaud Feiner et al. (1) for the excellent report of their department’s system of measuring the clinical productivity of the faculty. This is an important issue for our specialty in general and for academic anesthesiology in particular. If academic departments are to survive in the future, systems for accounting for faculty time will need to be in place. Any system must be capable of assigning value to the clinical, academic, research, teaching, and administrative limbs of our academic mission. As Feiner et al. (1) point out, clinical time is a valuable commodity; however, anesthesia time-based units may not work in all academic institutions as a measure of faculty clinical responsibility.
I have struggled with this issue in a county hospital and have looked carefully at many "parts of the equation." At a Level One Trauma Center we are asked to "have the capability to run X number of rooms at any particular time," 24 hours a day/365 days per year. I use the analogy of the fire station—I have no idea if there will be a fire, but I must be able to put it out. This is currently an institutional mandate. Availability for the potential delivery of anesthesia services is the essence of a Level One Trauma Center. Many hospitals are now providing set fees for anesthesia provision in 12- or 24-h increments, where payment is made by the institution to a group of providers for in-house availability, as productivity cannot be guaranteed.
I understand the methodology of Feiner et al. (1) in evaluating their billable hour system. I am concerned that part-time faculty were omitted from their analysis and that only faculty taking full call were included in their investigation. In the future, we as a specialty must be flexible enough to allow part-time staff the opportunity to function in an academic setting (individuals who desire a part-time appointment). If our methods for monitoring productivity are not applicable to part-time individuals, or those not taking call, we are risking the loss of an important part of our workforce, particularly in this time of manpower shortage in anesthesiology.
A difficult concept to grasp in the billable hour methodology, one that administratively generates significant challenges, is the concept of not giving credit for staffing more than one clinical site. I have a hard time determining in a given interval of time, that staffing an experienced senior resident in a complex case is "worth the same" as staffing two seasoned CRNAs in less complex cases, or is the same as doing a case with an inexperienced resident or a surgery rotator, or doing a case by yourself. From my perspective, these unique challenges must be better understood as we develop metrics to address faculty productivity.
I agree with Feiner et al. (1) that availability alone in a large department with multiple subspecialty groups is difficult to use, especially when confused by coverage at multiple hospitals. Ultimately, large departments with numerous subspecialty divisions may need to implement a modification of the system described by Abouleish et al. (2) for services that require immediate availability (OB/Level One trauma units), while divisions with out of hospital call coverage may require a modification of the productivity formula as outlined by Feiner et al. (1).
References
University of California at San Francisco, Department of Anesthesia, San Francisco, CA
In Response:
We appreciate the opportunity to interact with our colleagues, such as Dr. Whitten, regarding quantification of faculty clinical activities. We believe that the scholarly analysis of clinical activities has been enhanced by separation of actual clinical productivity versus clinical availability. This separation is important because their funding sources are usually different. Funding from traditional third-party sources (e.g., Medicare, contracts, insurance) is usually for only the actual delivery of clinical care not for the availability to deliver such care. Using these funds to pay for availability obviously dilutes the monies that can be used for the actual delivery of clinical care. Separating actual productivity, which is funded, from availability, which is not funded by third-party carriers, allows for much more precise discussions with the hospital. If they wish non-reimbursed availability to be present, perhaps they need to fund it. The separation of productivity from availability is less important for departments of anesthesia whose faculty are fully funded directly by the institution rather than indirectly from third-party carriers.
On a separate issue, a productivity analysis is helpful for explaining both intra- and intergroup (i.e., specialty) variability. Specifically, a productivity system will identify high versus low productivity anesthesiologists within a group. This allows separation of systems versus individual reasons for low and high clinical productivity from a given faculty.
Whitten’s emphasis on part-time faculty and the issue of concurrent care are important. To simplify our presentation, part-time faculty were not part of the analysis. However, we agree that part-time faculty can be very important and should be included in a more complex analysis than that which our paper provides. With regard to concurrent care, the focus of our paper was quantification of clinical time by actual delivery of anesthesia rather than availability. Whether single versus concurrent care is differentially treated is a variable to be considered in designing a productivity system. Our local experience is that this debate is substantial, and worthy of consideration. Lastly, we are not sure why the concurrent care issue was included in the Whitten letter because no previously described plan has treated covering two (versus one) operating rooms differently. If some program does not decide to treat them differently, this can be achieved in either an availability- or productivity-based system.
We disagree with the final conclusion of Whitten. The Abouleish et al. (1) system is a form of an "availability" system that we have used for many years. We believe an actual "clinical productivity" system based on the actual delivery of clinical care allows for better assessment and reimbursement of highly productive clinical faculty. Of prime importance is that an analytical and scholarly analysis of our funding sources and productivity allows departments of anesthesia to make better informed organizational and individual faculty decisions. In that regard, we believe that the study by Abouleish et al. (1) and, hopefully, our own study have facilitated understanding of academic anesthesia’s organizational options.
References
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