Physician Incentive Compensation Plans in Academic Medical Centers: The Imperative to Prioritize Value.

The emphasis on clinical volume in physician compensation plans has diminished professional vitality in academic medical centers and increased the cost of health care. Physician incentive compensation plans that focus on clinical volume can distort clinical encounters and fail to incorporate the professionalism and intrinsic motivators of clinicians. We assert herein that physician incentive compensation plans should reward clinical value (quality/cost) rather than clinical volume. The recommended change is compelled by the tenets of medical professionalism, the need to cultivate meaning in clinical practice, and the urgent financial and moral imperatives to improve health outcomes and reduce cost. The design of physician incentive compensation plans should incorporate accurate and valid measures of quality and cost, behavioral economic considerations, transparency and equity, prospective assessment of the impact on key outcomes, and flexible elements that encourage innovation and preserve fidelity to unique practice circumstances. Physicians should be recognized in compensation plans for enhancing the value of care, inspiring and educating the future clinical workforce, and improving public health through discovery.

How to Launch and Continually Enhance an Effective Medical Campus Faculty Development Program: Steps for Implementation and Lessons Learned.

PURPOSE: Drawing on the decade of experience of Boston University Medical Campus' Faculty Development Office, this paper reports strategies used to launch and continually improve faculty development programming within an academic health sciences campus. PATIENTS AND METHODS: The authors explain the steps that Boston University Medical Campus took to institute their set of faculty development programs, including an overview of resources on how to periodically conduct needs assessments, engage key institutional stakeholders, design and evaluate an array of programming to meet the needs of a diverse faculty, and institute real-time program modifications. RESULTS: In a step-by-step guide, and by highlighting vital lessons learned, the authors describe a process by which biomedical educators can create and sustain a robust faculty development office within their own institutions. CONCLUSION: This paper identifies steps to launch and improve faculty development program. Faculty development programs should be expanded to support faculty in academic medical centers.

Developing Faculty in Emerging Areas of Interdisciplinary Research.

The availability of new techniques and technologies to answer important medical questions is accelerating at a breathtaking pace. In response to these exciting new opportunities, clinical departments, in general, and departments of medicine, in particular, have broadened their research portfolios. Organization of the traditional structures of clinical departments, research infrastructure, training programs, and rewards for faculty has only begun to catalyze emerging research areas such as artificial intelligence, bioinformatics, bioengineering, cell and tissue engineering, cost effectiveness, health services, implementation science, integrative epidemiology, medical informatics, nanomedicine, and quality improvement. Success in these emerging areas of research requires interdisciplinary collaboration on a much larger scale than in the past. The effectiveness of efforts to recruit, develop, mentor, and promote faculty in these exciting areas will be critical to the success of departmental and institutional research programs. We describe examples of initiatives from our 5 departments of medicine designed to develop and promote faculty conducting research in emerging interdisciplinary areas. We focus on core resources, training, organizational structures, and recognition and promotion. Faculty have a compelling opportunity and obligation to pursue emerging research areas that have the potential to further improve the prevention, diagnosis, and treatment of disease. As departments prepare to meet this exciting opportunity in the future, the lessons learned must inform investments in faculty development. Although many of the strategies outlined herein could and should expand beyond any individual department, departments of medicine have a distinct obligation and opportunity to lead this effort.

Integrating Social Determinants of Health Into Graduate Medical Education: A Call for Action.

Social determinants of health (SDH) are the major drivers of health and disparate health outcomes across communities and populations. Given this, the authors assert that competency in recognizing and mitigating SDH should become a vital component of graduate medical education in all specialties. Although the most effective approaches to educating trainees about SDH are uncertain, in this Invited Commentary, the authors offer several key principles for implementing curricula focusing on SDH. These include universalization of the material, integration into clinical education, identification of space for trainee introspection, clarification of specific competencies in identification and mitigation of SDH, and creation of robust faculty development programming. The authors highlight several examples of curricular approaches to SDH, touching on orientation, experiential learning, community-based and service-learning opportunities, interprofessional activities, and the hidden curriculum. The authors argue that all clinical trainees must learn to recognize and mitigate SDH and that doing so will allow them to achieve meaning and mastery in medicine and to better meet society's pressing health needs.

Thrombotic Microangiopathy: A Multidisciplinary Team Approach.

Thrombotic microangiopathy (TMA) is characterized by the presence of microangiopathic hemolytic anemia and thrombocytopenia along with organ dysfunction, and pathologically, by the presence of microthrombi in multiple microvascular beds. Delays in diagnosis and initiation of therapy are common due to the low incidence, variable presentation, and poor awareness of these diseases, underscoring the need for interdisciplinary approaches to clinical care for TMA. We describe a new approach to improve clinical management via a TMA team that originally stemmed from an Affinity Research Collaborative team focused on thrombosis and hemostasis. The TMA team consists of clinical faculty from different disciplines who together are charged with the responsibility to quickly analyze clinical presentations, guide laboratory testing, and streamline prompt institution of treatment. The TMA team also includes faculty members from a broad range of disciplines collaborating to elucidate the pathogenesis of TMA. To this end, a clinical database and biorepository have been constructed. TMA leaders educate front-line providers from other departments through presentations in various forums across multiple specialties. Facilitated by an Affinity Research Collaborative mechanism, we describe an interdisciplinary team dedicated to improving both clinical care and translational research in TMA.

Strategies for Developing and Recognizing Faculty Working in Quality Improvement and Patient Safety.

Academic clinical departments have the opportunity and responsibility to improve the quality and value of care and patient safety by supporting effective quality improvement activities. The pressure to provide high-value care while further developing academic programs has increased the complexity of decision making and change management in academic health systems. Overcoming these challenges will require faculty engagement and leadership; however, most academic departments do not have a sufficient number of individuals with expertise and experience in quality improvement and patient safety (QI/PS). Accordingly, the authors of this article advocate for a targeted and proactive approach to developing faculty working in QI/PS. They propose a strategy predicated on the identification of QI/PS as a strategic priority for academic departments, the creation of enabling resources in QI/PS, and the expansion of rigorous training programs in change management and in improvement and implementation sciences. Professional organizations, health systems, medical schools, and academic departments should recognize successful QI/PS work with awards and promotions. Individual faculty members should expand their collaborative networks, consider the generalizability and scholarly impact of their efforts when designing QI/PS initiatives, and benchmark the outcomes of their performance. Appointments and promotions committees should work proactively with department and QI/PS leaders to ensure that outstanding achievement in QI/PS is defined and recognized. As with the development of physician-investigators and clinician-educators, departments and health systems need a comprehensive approach to support and recognize the contributions of faculty working in QI/PS to meet the considerable needs and opportunities in health care.

The Department of Medicine in 2030: A Look Ahead.

The authors described the features of a hypothetical academic Department of Medicine in 2030 that would be most effective in improving the public health. Future departments of medicine will be compelled to respond to a projected shortage of physicians through augmented training strategies. The clinical programs will be more decentralized and responsive to patient preferences while demonstrating greater value. Departments will create adaptable, accountable structures in which clinicians working in interdisciplinary teams continuously improve processes and outcomes of care, and clinician and patient satisfaction. The restructuring of health care will afford exciting opportunities to align clinical and scholarly activities. The growing ability to link biological and clinical phenotypic information will lead to more effective and efficient clinical care. In view of the funding constraints and the remarkable opportunities for high-impact research, departmental research programs will become increasingly disciplined. Successful research programs will require durable investments in faculty career development, enabling infrastructure, interdisciplinary research teams, and diverse funding sources. The educational programs will demonstrate proficiency of trainees in the 6 current core competencies, as well as in additional areas critical to health care transformation. To improve organizational effectiveness, departments will create more nimble organizational structures led by individuals with diverse backgrounds. Chairs of departments of medicine will be expected to continuously expand their capacity to meet the evolving needs of their departments and institutions. Members of departments of medicine will be continuously fortified by the privilege and obligations of our profession while embracing the risks necessary to meet the extraordinary opportunities in 2030.

Promoting interdisciplinary research in departments of medicine: results from two models at Boston University School of Medicine.

We have sought to broaden our department's research capacity using two different interdisciplinary approaches. First, we created the Evans Center for Interdisciplinary Biomedical Research (ECIBR) - a virtual center that promotes and funds Affinity Research Collaboratives (ARCs) initiated by faculty from within and outside Boston University (BU). Of the 11 funded ARCs, the 4 ARCs in existence for a minimum of 3 years have a total of 37 participants, 93 co-authored publications, and 33 new grants. Second, the Department of Medicine (DOM) created a Section of Computational Biomedicine in 2009 to enhance analytical and computational expertise in the DOM. After 3 years, the section is comprised of 10 faculty members and 21 trainees. The faculty members have collaborated with 20 faculty members in other sections or departments and secured 12 extramural grants (totaling ∼$20 million in direct costs). The ECIBR and the Section of Computational Biomedicine represent new organizational approaches to stimulating innovation in research in a DOM.

Perspective: key indicators in academic medicine: a suggested framework for analysis.

Key Indicators in Academic Medicine (KIAMs), a new feature in Academic Medicine, are intended to substantially inform teaching hospitals and medical schools on those metrics that may best gauge their health, including the performance of units and programs within these organizations. Ultimately, KIAMs may promote effective growth and development in a dynamic clinical, training, and research environment. At the outset of this laudable feature, the authors of this perspective offer a suggested framework for analyzing key indicators with the goal of enhancing the usefulness of the published KIAMs. They outline their view of pitfalls and opportunities in the development of key indicators and suggest strategies. The authors close by suggesting how this feature could form the framework for a comprehensive national project.

Establishing policies for the relationship between industry and clinicians: lessons learned from two academic health centers.

The relationship between faculty in academic health centers (AHCs) and commercial entities is critically important to improving the public health, yet it may be prone to conflicts of interest that adversely affect medical education, research, and clinical care. The Association of American Medical Colleges has recently recommended that medical schools and AHCs develop policies that better manage and occasionally prohibit interactions between academic medicine and industry. Because the development of more stringent policies is complex and potentially contentious, the author reports the lessons learned from developing new policies for the interactions between faculty and industry related to medical education and clinical care at Yale School of Medicine and Boston University School of Medicine/Boston Medical Center. The content of the policies was strongly influenced by the tenets of medical professionalism. Faculty support for new policies was strong, an iterative and inclusive process of formulation was critical, compromises in content were necessary, and the views of faculty concerning industry relationships were complex. After implementation of the new policies, the departmental food-related expenses increased, the loss of gifts was not appreciably missed, the faculty assumed more responsibility for educating trainees on the evaluation of new products, a central repository for receiving and evaluating grants from industry was useful, enforcement of the policies has been a lingering challenge, and the new policies generated positive publicity. Several recommendations are proposed. Creating these policies affirmed the importance of an inclusive process, open communication, support of institutional leadership, and focus on professional values.

The impact of the lack of health insurance: how should academic medical centers and medical schools respond?

The lack of health insurance has significant deleterious effects on the health of individual patients and creates substantial financial pressure on health care institutions. Despite the historical role of academic medical centers (AMCs) and medical schools in caring for the uninsured, financial shortfalls have increased pressure on these institutions to restrict care of this population. Limiting care of the uninsured, however, conflicts with the ethical foundations of academic medicine and risks further harm to the health of this population. Instead of restricting care, the effects of uninsurance should be mitigated through the joint efforts of medical schools and AMCs by measuring clinical work using work Relative Value Units rather than collections; recognizing faculty who provide care for the uninsured in the promotions process; adjusting billing rates for clinical services according to patients' ability to pay; delivering one standard of care irrespective of insurance status; continuing to evaluate the impact of uninsurance and intervention strategies; providing leadership in measuring and improving the quality of care; ensuring that trainees and the public are familiar with the effects of a lack of health insurance; and assisting safety net providers by providing educational materials pertinent to their respective patient populations and more fully integrating these providers into the academic community. Although all physicians in the private and public sectors should share in the care of the uninsured, academic medicine must remain faithful to its historical role of providing care to the uninsured and should improve the health of the uninsured through a proactive strategy involving advocacy, clinical care, education, and research.

Improving clinical productivity in the academic setting: a novel incentive plan based on utility theory.

PURPOSE: Academic internal medicine practices face growing challenges to financial viability due to high overhead, competing institutional missions, and suboptimal physician productivity. The authors describe the development of a clinical incentive plan for a group of academic subspecialty physicians at the Dana Clinic, an outpatient setting at Yale School of Medicine, and report on results of the first year's experience under the plan. METHOD: Utility theory was used to assess the risk profile of clinic faculty and identify incentive payments that would optimize faculty benefit or "utility" while minimizing departmental costs. Under the plan, physicians who reached a productivity target based on work Relative Value Units (wRVUs) between October 2003 and November 2004 had overhead costs covered and received a fixed payment to support salary; additional incentive payments were available for those exceeding the target. Physicians failing to reach the target were responsible for their own overhead costs and received no fixed payment. Physician productivity as measured by wRVU per full-time equivalent (FTE) was compared for the year prior to, and the year following, incentive plan introduction. RESULTS: Forty-seven members of eight academic sections were included in the analysis. Median productivity improved by 34%, with 42 of 47 physicians showing improvement. Significant improvements were also noted in collections (62%) and visit volume (23%), and shifts were observed in coding patterns. CONCLUSIONS: The unique threshold-based structure of the incentive plan, as determined through utility theory modeling, as well as permitting physicians to choose how to achieve the wRVU target were key features of its success, resulting in improved productivity without increasing practice resources or faculty salaries.

Guidelines for interactions between clinical faculty and the pharmaceutical industry: one medical school's approach.

A productive and ethical relationship between the pharmaceutical industry and physicians is critical to improving drug discovery and public health. In response to concerns about inappropriate financial relationships between the pharmaceutical industry and physicians, national organizations representing physicians or industry have made recommendations designed to reduce conflicts of interest, legal exposure, and dissemination of biased information. Despite these initiatives, the prescribing practices of physicians may be unduly influenced by the marketing efforts of industry and physicians may inadvertently distribute information that is biased in favor of a commercial entity. Moreover, physicians may be vulnerable to prosecution through federal anti-kickback and false claims statutes because of potentially inappropriate financial relationships with pharmaceutical companies. Since academic medical centers have a critical role in establishing professional standards, the faculty of Yale University School of Medicine developed guidelines for the relationships of faculty with the pharmaceutical industry, which were approved in May 2005. Input from clinical faculty and from representatives of the pharmaceutical industry was utilized in formulating the guidelines. In contrast to existing recommendations, the Yale guidelines, which are presented as an Appendix here, ban faculty from receiving any form of gift, meal, or free drug sample (for personal use) from industry, and set more stringent standards for the disclosure and resolution of financial conflict of interest in Yale's educational programs. The growing opportunities for drug discovery, the need to use medications in a more evidence-based manner, and preservation of the public trust require the highest professional standards of rigor and integrity. These guidelines are offered as part of the strategy to meet this compelling challenge.

Measuring physicians' productivity in a Veterans' Affairs Medical Center.

The mission of the Department of Veterans Affairs includes patient care, education, research, and backup to the Department of Defense. Because the measurement of physicians' productivity must reflect both institutional goals and market forces, the authors designed a productivity model that uses measures of clinical workload and academic activities commensurate with the VA's investments in these activities. The productivity model evaluates four domains of physicians' activity: clinical work, education, research, and administration. Examples of the application of the productivity model in the evaluation of VA-paid physician-staff and in the composition of contracts for clinical services are provided. The proposed model is a relatively simple strategy for measuring a broad range of the work of academic physicians in VA medical centers. The model provides incentives for documentation of resident supervision and participation in administrative activities required for effective and efficient clinical care. In addition, the model can aid in determining resource distribution among clinical services and permits comparison with non-VA health care systems. A strategy for modifying the model to incorporate measures of quality of clinical care, research, education, and administration is proposed. The model has been a useful part of the process to ensure the optimum use of resources and to meet clinical and academic institutional goals. The activities and accomplishments used to define physician productivity will have a substantial influence on the character of the medical profession, the vitality of medical education and research, and the cost and quality of health care.