Correspondence

More on Compensation for Teaching

N Engl J Med 1996; 335:1537-1538November 14, 1996

Article

To the Editor:

In response to intense market competition and severe cost pressures, many academic medical centers are attempting to unbundle their complex patterns of conjoint activities and cross-subsidization in order to examine the processes and costs of education, research, and patient care separately. Isolating the costs of medical education, particularly undergraduate medical education, is perhaps the most difficult of these analytic tasks.

In quantifying the teaching efforts of the faculty of the Department of Medicine at Columbia–Presbyterian Medical Center (Jan. 18 issue), Shea et al.1 elected to count activities that combined clinical service and teaching entirely as teaching time. The assumption is troubling, as was noted in the accompanying editorial2 and the subsequent letter from Noble,3 both because of its substantial effect on the estimate of the faculty teaching effort and because most of the teaching done under these circumstances was directed at house staff (Table 1 of the article) and would ordinarily be expected to be paid for through a combination of Medicare reimbursement for direct medical education and revenues from clinical service. Although Table 6 (“Departmental Teaching Revenues and Offsets”) acknowledges the receipt of $1.158 million from the Presbyterian Hospital for what is said to be a combination of teaching, teaching supervision, and medical administration, it does not explicitly identify any funds as derived from reimbursement for direct medical education. The authors acknowledge the receipt of $19,817,195 as revenues for clinical service (Table 5) but choose to recognize as support for teaching only the tiny fraction (2.6 percent) that was collected on the teaching units themselves, a figure that is then further reduced by subtracting the costs of collection and departmental administration. This presentation obscures the basis of the contribution from the hospital and obfuscates any understanding of a balance sheet relating costs for the teaching of house staff to reimbursements.

There are other problems with the methods used. For example, if the full costs of education are to be assessed, it makes no sense to exclude from the calculus both the costs and the revenues associated with educational administration. Table 5 (“Sources of Salary Support”) shows a pattern not atypical of private, research-intensive medical schools. However, in their selective presentation of revenues used to support teaching activities, Shea et al. offset the sizable contribution from the medical school ($1.3 million) by the amount of the dean's tax and, in addition, by the costs of departmental administration. By this computational legerdemain, they conclude that the medical school made no net contribution at all to the teaching efforts of the department.

Quantifying the costs of medical education accurately is important, but it requires the use of credible methods that permit confidence in the data and support comparisons among institutions. Such methods must distinguish the provision of clinical services from education and must distinguish undergraduate from graduate medical education, since these activities differ in their relevance to the central academic mission, as well as in the sources of revenue that can appropriately be identified as supporting them. Shea et al. may be correct in concluding that their departmental faculty members perform a large amount of markedly undercompensated teaching, but that conclusion cannot be drawn with confidence from the data presented.

David Korn, M.D.
Robert F. Jones, Ph.D.
Association of American Medical Colleges, Washington, DC 20037

3 References

1. 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

2. 2

   Kassirer JP. Tribulations and rewards of academic medicine -- where does teaching fit? N Engl J Med 1996;334:184-185
   Full Text | Web of Science | Medline

3. 3

   Noble JT. Compensation for teaching medical students and house staff. N Engl J Med 1996;335:58-58
   Full Text | Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: In response to Drs. Korn and Jones, we wish to comment first on the question of how time spent on attending rounds in the supervision of house staff and medical students could count both as teaching time and as direct patient care. We cannot agree that it is “troubling” to combine clinical service and teaching time. Philosophically, since the time of Osler, the clinical training of students and house staff has rested on the concepts of case-based learning, graded responsibility for patient care, and learning by doing, with appropriate supervision. In our hospital, patients on a ward service are the responsibility of the attending physician on the ward; the attending physician and the house staff function as a team; and the functions of teaching and supervision are combined with the service function. This system is common in teaching hospitals, and it is consistent with existing laws and regulations governing the care of Medicare and Medicaid patients both at the national level and in New York State.

The next set of issues has to do with reimbursement. Drs. Korn and Jones, like Dr. Noble in his earlier letter,1 question the small amount of billable revenue recovered by the department. We presented the actual amount collected, which is low because of the very low payment by Medicaid for physicians' services in New York State ($7 per inpatient follow-up visit) and the predominance of Medicaid patients on our ward service. We included only those revenues “collected on the teaching units themselves” because the department does not receive revenues from physicians' activities on the private service; those are billed by private physicians, who receive the revenues. All business accounting methods charge the costs of bill collection and program administration against the revenue realized.

Our department did not receive any of the Medicare funds for direct or indirect medical education received by the hospital, other than what is shown in Table 6 as part of the $1.158 million. It is the hospital, not the Department of Medicine, that receives these funds.

Drs. Korn and Jones also question the use of the dean's tax as an offset against the contribution of $1.3 million to the department by the medical school. The underlying confusion is similar to that over the issue of hospital funds. The balance sheet we present is that of the Department of Medicine, because it is the Department of Medicine that is responsible for the salaries of its faculty members. The hospital and the university each have their own balance sheets. We analyzed the department's balance sheet — revenues net of costs — in order to show the actual funds available to support the time spent by departmental faculty in teaching and to highlight the degree to which medical school faculty members have traditionally contributed their time to train the next generation of physicians. We believe that the balance-sheet approach is the only credible method and that in further examinations of the costs of medical education in other departments, at other institutions, and at the level of hospitals and medical schools, the balance-sheet approach will also be followed, on an entity-by-entity basis. Whether those conducting such studies will find it desirable or practical to separate clinical service from education more fully is, we believe, questionable, just as it is questionable whether academic health centers should separate these functions on a day-to-day basis.

Steven Shea, M.D.
Katherine G. Nickerson, M.D.
Myron L. Weisfeldt, M.D.
Columbia–Presbyterian Medical Center, New York, NY 10032

1 References

1. 1

   Noble JT. Compensation for teaching medical students and house staff. N Engl J Med 1996;335:58-58
   Full Text | Web of Science | Medline

Citing Articles (1)

Citing Articles

1. 1

   Gregory W. Rouan, Robert G. Wones, Joel Tsevat, John H. Galla, John W. Dorfmeister, Robert G. Luke. (1999) Rewarding Teaching Faculty with a Reimbursement Plan. Journal of General Internal Medicine 14:6, 327-332
   CrossRef