Correspondence

Compensation for Teaching Medical Students and House Staff

N Engl J Med 1996; 335:58-59July 4, 1996

Article

To the Editor:

In their article “Compensation to a Department of Medicine and Its Faculty Members for the Teaching of Medical Students and House Staff,” Shea et al. (Jan. 18 issue)1 attribute all the hours spent by attending physicians on wards to teaching. Are we to assume that attending physicians in the department of medicine at the Columbia–Presbyterian Medical Center do not bill for clinical services provided to patients? The care of hospitalized patients is a full-time job that is still rather generously compensated by patients and payers.

One hopes that the authors of this article will acknowledge that attending staff members are in fact compensated for their ward activities and that most of the time that attending physicians spend on the wards is spent in direct patient care, not teaching. The alternative interpretation, that the attending physicians in the department of medicine either are not billing for their patient care activities or are fraudulently billing patients for time spent in teaching, does not bear examination.

James T. Noble, M.D.
New England Medical Center, Boston, MA 02111

1 References

1
Shea S, Nickerson KG, Tenenbaum J, et al. Compensation to a department of medicine and its faculty members for the teaching of medical students and house staff. N Engl J Med 1996;334:162-167
Full Text | Web of Science | Medline

To the Editor:

Although the relatively poor compensation of faculty members for the teaching of medical students and house staff is clearly important, individual recognition and reward may have a stronger influence on faculty members' involvement in teaching. In a recent study, junior faculty members most often identified an institutional failure to recognize teaching and educational contributions in the academic promotion system as the main problem with faculty evaluation.1 Even if departmental reimbursement increased, without a clearly defined system of evaluation and rewards for teaching, priority might still be given to other activities with more obvious value to one's academic career, such as research and patient care.

Sir William Osler stated, “I desire no other epitaph . . . than the statement that I taught medical students in the wards, as I regard this as by far the most useful and important work I have been called upon to do.”2 The work of Shea et al. suggests that if substantial changes are not made, we can begin writing the epitaph of teaching on the wards.

Roy C. Ziegelstein, M.D.
Johns Hopkins University School of Medicine, Baltimore, MD 21224

2 References

1
Jones RF, Froom JD. Faculty and administration views of problems in faculty evaluation. Acad Med 1994;69:476-483
CrossRef | Web of Science | Medline

2
Osler W. In: Strauss MB, ed. Familiar medical quotations. Boston: Little, Brown, 1968:600.

To the Editor:

By combining data in the article by Shea et al. with the data provided in the 1992 student handbook of the Columbia University College of Physicians and Surgeons, I calculated the average proportion of each medical student's academic year directed by department of medicine faculty members to be around 27.4 percent. Should not these faculty members therefore receive 27.4 percent of tuition revenues? If one assumes that all 600 students enrolled in the College of Physicians and Surgeons were paying the full tuition of $20,290 (for the 1992–1993 academic year), then the total tuition collected for that year was $12,174,000, of which 27.4 percent is $3,335,676.

Shea et al. calculate that the faculty spent a total of 10,780 hours teaching medical students that year. Thus, medical students paid $309.43 per hour of instruction. Clearly, there is a discrepancy between the amount of money paid by medical students for teaching and the amount available to pay the teachers. Although tuition presumably supports many medical school, hospital, and university functions, it appears that only 6.8 percent is used to pay faculty members for teaching. As the financial pressures on the medical school faculty increase, perhaps tuition could be investigated as a potential source of funds for direct payments to faculty members for teaching.

Charles Henrikson, B.S.
Columbia University, New York, NY 10032

Author/Editor Response

The authors reply:

To the Editor: In response to Dr. Noble: the great majority of teaching-service patients at our hospital are insured by Medicaid or are indigent and uninsured. In New York State, Medicaid pays $7 per follow-up visit. Attending physicians in our clinics do not write chart notes every day. Thus, collections for these services totaled $237,032 in 1992–1993, as shown in Table 6 of our paper. These funds were collected by the department, not the individual attending physicians. Attending physicians split their time between patient care and teaching, with patient care involving supervision of house staff as well as direct contact with patients.

Mr. Henrikson notes the disproportionately small share of tuition revenues received by the department of medicine for teaching. It is true that basic-science departments, which do not have clinical income, receive a share of central funds out of proportion to their effort in teaching medical students. These funds are derived largely from tuition and taxes on clinical practice. This is one of the long-standing cross-subsidies to which we alluded in our paper and which have now come under increasing scrutiny as revenues diminish.

We share Sir William Osler's view of teaching, quoted by Dr. Ziegelstein. We also believe that the task of teaching the next generation of physicians, which long predates reimbursement of hospitals based on diagnosis-related groups, will survive managed care and capitation. How academic health centers, with their unique confluence of basic and clinical research, advanced technology, infrastructure to support teaching, and a culture that nurtures an intellectual approach to patient care, will continue to participate in this process is a challenge that now lies before us.

Steven Shea, M.D.
Katherine G. Nickerson, M.D.
Myron L. Weisfeldt, M.D.
Columbia University, New York, NY 10032

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