From the issue dated November 28, 2003
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Physician, Teach ThyselfMedical schools try to get faculty members, who are under pressure to bring in patient fees and research grants, back into the classroom
Diane R. Fingold has mastered the art of begging. To line up professors for one section of a Harvard Medical School course, she and a colleague put in about 30 hours on the phone, wheedling, flattering, and pleading with physicians to teach. "It's always down to the wire," says Dr. Fingold, an assistant professor of medicine who coordinates a required second-year course at Massachusetts General Hospital. "We're in panic mode a week before the class is supposed to start." The course, which teaches students how to examine patients and take medical histories, is taught at 11 hospitals and clinics throughout the Harvard system. Even though Harvard Medical School has more than 6,500 full-time faculty members, it is struggling to recruit professors to teach students, both into the classroom and in the hospital wards. And Harvard is not alone. At medical schools across the country, many faculty members are turning down teaching assignments, citing greater pressures to bring in patient-care revenue and research grants. Many professors also feel that teaching isn't rewarded by raises or promotions the way patient care and research are. A physician who brings in more money is rewarded not only with a fatter paycheck but, at some institutions, with a larger office or nicer laboratory. As faculty members shy away from teaching, medical students are getting less time with seasoned physicians and less feedback on their developing clinical skills. Unless the problem is solved, some critics fear, inadequately trained young doctors might end up botching procedures or prescribing the wrong medicines. Now medical educators at Harvard and other universities are striking back, looking for incentives to get professors back into the classroom. Administrators at New York University School of Medicine, for instance, are considering setting minimum teaching requirements for faculty members, and the University of California at San Francisco's medical school is working with Harvard's to develop teaching academies that award money specifically for education. "When I talked to course directors, virtually everyone reported that recruiting faculty to teach was the No. 1 problem they faced," says David L. Cardozo, a lecturer in neurobiology at Harvard who headed the medical school's Task Force on Faculty Teaching Responsibility. The panel submitted a report in March to the medical school's department chairmen and to its dean, Joseph B. Martin, who declined to release it. Says Mr. Cardozo, "The faculty say they have no time, that there's little financial compensation, and that the time spent teaching doesn't advance their careers." 'An Honor and a Privilege' It's easy to see why many medical faculty members avoid teaching, with little compensation available in either status or money. Stephen D. Sisson, for example, has been trying to get promoted to associate professor at the Johns Hopkins School of Medicine, based on his reputation as a highly regarded teacher and clinician. He created a Web-based curriculum that is used by 3,000 residents in internal medicine in 48 training programs around the country. He also directs the residents' clinics for Hopkins' department of medicine. The problem is, Dr. Sisson hasn't been able to get his paper about the Web-based curriculum published, and he can't get promoted without the publication, he says. "I love being a clinician and an educator, and it's tragic that the education portion isn't highly valued," he says. Hopkins officials say they cannot discuss Dr. Sisson's case, since promotion processes are confidential. They say teaching is important, but that professors have to document the impact of their teaching, and that the traditional way to do that is by publishing in peer-reviewed journals. Nonetheless, many faculty members continue to argue that teaching is not only undervalued in medical schools, it is also underpaid. Many professors make little or no money from teaching, and in fact are penalized if the time they spend in the classroom keeps them from bringing in the revenues expected from patient care or research grants. Typically, medical schools and teaching hospitals guarantee clinical professors a portion of their salaries, and they have to earn the rest by treating patients and securing research grants. They're not just supporting themselves. Many teaching hospitals set productivity quotas to ensure that faculty members are helping pay for themselves and for their departments' overhead. But covering those costs is getting harder to do. Shrinking reimbursements from managed-care companies, Medicare, and other forms of health insurance have contributed to financial crises at many teaching hospitals. Today insurers aren't always willing to cover the full cost of treating patients, especially in teaching hospitals, which have to cover the added costs of specialized training and equipment. To help recoup those losses, hospitals are counting on clinical professors to generate more revenue by taking on heavier patient loads, which leaves them less time to teach. "In the past, faculty used to view teaching as an honor and a privilege," says Dr. Fingold. "Now physicians are trying to stay alive. They're flooded with paperwork. They're imposed upon daily by pressures to see a patient every 15 minutes. They have to get prior approval for every medication they provide. There's no good will left among the physicians who are on the front lines to try to summon the energy to teach. They have nothing left to give." Harvard's junior faculty members are required to teach 50 hours per year if asked; senior professors, 100 hours. But Mr. Cardozo says most professors teach much less than that, in part because no one is enforcing the rules. Kathryn Agarwal, an instructor of medicine who has been teaching at Harvard since July, says she is fortunate to have a federal grant for the teaching of geriatrics, her specialty. Balancing clinical work and teaching is difficult, she says. "If you have a four-hour clinic session scheduled, you need to allow for at least an extra hour, likely more, for the time you spend teaching the student or resident who is with you," she says. "As faculty of a medical school, you are expected to teach so many hours a year without any pay for that time." When there aren't enough faculty members to teach, some of the slack is being picked up by medical residents and fellows -- medical-school graduates who treat patients under a doctor's supervision. While they are usually good role models and teachers, they're no substitute for experienced physicians, Mr. Cardozo says. If the trend continues, "students are going to become demoralized," he says. "They're coming to Harvard, which has extraordinary faculty, but they're being trained by other Harvard trainees. They're not being trained by the best we have to offer." Harvard's dean of medical education, Malcolm Cox, agrees that something has to change. "We must find a way to bring our experienced, senior clinical faculty back to teaching our medical students," he says. "Far too much responsibility has been given to residents for educating students over the past 20 years." Dr. Cox says the school doesn't have a shortage of teachers -- at least, not yet. "We're blessed with a large and dedicated faculty, but as these pressures continue to mount, we could face a shortage if we don't take appropriate action," he says. "Faculty are being pulled in two different directions, and no matter how elastic and committed they are, at some point they are going to break. That's what people are concerned about. Some individuals have already broken and begun to withdraw" from teaching, Dr. Cox says. Less Time With Patients Recruiting teachers is only part of the problem. The value of the hospital room as classroom has lessened because patients are there for such a short period of time. As cost-conscious insurers limit hospital stays, "patients come and go so fast that if you blink, you miss them," Dr. Cox says. That makes it harder for students to observe patients over time or chart the progression of an illness. "There was a time when a student could go into a patient's room and conduct a complete history and physical," says David Nichols, vice dean for medical education at Johns Hopkins. "Now, when patients are in the hospital, they are either under anesthesia for an operation or recovering from anesthesia," says Dr. Nichols. "As soon as they're awake enough, they're discharged. There's very little time for students to catch a patient when they're not in between tests or procedures." Students don't fare much better in community settings. "We send many students to private doctors' offices, but there are limits to what they can do," Dr. Nichols says of the school's network of community-based physicians, who are not paid to work with students. "They can't slow their practices down to take on students." Ideally, he says, a medical student should be able to work with a patient for 15 minutes and then call in the physician to discuss his or her findings. The entire visit might take 45 minutes. But with today's pressure to treat as many patients as possible during a day, the typical patient visit lasts only 10 or 15 minutes. The student is often relegated to the role of an observer, tagging along with a harried physician. "The ideal educational environment is not the ideal practice environment," Dr. Nichols says. "In a fiscally constrained time, the needs of the practice will have to take precedence." Even though they understand the money crunch, that trend frustrates many medical students, who argue that they deserve more time with professors, given tuition that they're shelling out. The average student graduates with more than $100,000 in medical-school debt. "We're working on getting caps or freezes on tuition hikes until the focus comes back to education," says Lauren Oshman, national president of the American Medical Student Association. "Faculty's time is dictated by who's paying them," and right now, the perception, at least, is that teaching doesn't pay, she says. "It's an indicator of where our health-care system is going," she says. "Physicians' activities are being driven by business instead of by patient care and education." At the Florida State University College of Medicine, they're doing things differently, according to Alma B. Littles, associate dean for academic affairs. That's because the nation's newest accredited medical school, created by the Florida Legislature in 2000, doesn't have a teaching hospital or a faculty-practice plan. It has 77 full-time faculty members with either Ph.D.'s or M.D.'s who spend their time teaching in the classroom, and 285 part-time faculty members, most of whom are community-based physicians who spend part of their time training students. "All of our faculty are hired with the understanding that teaching is their primary reason for being here," Dr. Littles says. "Our faculty don't feel that they have to hurry up and leave the class so that they get back to the lab or the clinic." The community-based physicians, who supervise students while they tend to their medical practices in clinics and offices, or at one of the school's 12 affiliated hospitals, are clearly not in it for the money. The medical school pays them $500 per week per student, and students spend four full days a week under the experienced doctors' supervision. The school sweetens the deal by offering the physicians faculty appointments, access to the medical school's library, and workshops on how to efficiently incorporate student training into their practices. A Different Approach Other medical schools are trying different tactics to attract teachers. When the Stanford University School of Medicine revamped its curriculum to include specialty tracks and more small classes this fall, it took steps to ensure that there would be enough medical professors to teach them. Instead of allocating money to departments and letting the chairmen decide how they wanted to spend it, this year they were told that 60 percent of their allocation had to be used for teaching salaries and other educational expenses. "This gave them a direct signal that education is a top priority," says Dean Philip A. Pizzo. (Stanford has approximately 730 full-time faculty -- about a tenth the number that Harvard has.) Reallocating existing money isn't enough, he says. In the past, teaching hospitals were able to charge more than other hospitals in order to subsidize teaching and care for indigent patients. But in today's health-care environment, they can barely charge enough to cover their expenses, and there's little money left over to support teaching. Stanford, like other medical schools, is seeking outside funds for that purpose. "We know that when faculty spend time teaching, they miss the potential to earn their salaries," says Dr. Pizzo. Even at Harvard, a nonprofit group-practice plan that employs about 500 Harvard-affiliated physicians is trying a different approach. If a student spends one afternoon a week with a practicing physician at that group, Harvard Vanguard Medical Associates, the doctor earns "productivity credits" for the work time he or she gives up in order to teach the student. For instance, if the physician usually spends four hours a day seeing patients, on the days he devotes to a student, he sees patients for only three hours. Instead of being penalized for lost "productivity," his teaching would earn him a comparable number of credits. The results have been dramatic. "In the past, you had to do endless arm-twisting to get someone to teach," says Richard Marshall, the plan's chief medical officer. "This year for the first time, we have more volunteers who want to teach than we can take on." Administrators are hoping that kind of enthusiasm for teaching will spread as Harvard embarks on a comprehensive review of its curriculum. Finding ways to encourage and reward teaching is a priority. "You don't debate whether it's a good thing to raise your children and feed them and clothe them," Mr. Cardozo says. "You do it because it's a necessity." By the same token, he says, "it doesn't make sense to ask if it's profitable to educate good doctors. It's our responsibility, and we can't afford to neglect it." http://chronicle.com Section: The Faculty Volume 50, Issue 14, Page A18 | |||||||||||||||
Copyright © 2003 by The Chronicle of Higher Education