Tuesday, September 3, 2019

Robbing Peter to pay Paul in Academic Medicine

"To robbe Petyr & geve it Poule, it were non almesse but gret synne.
("To rob Peter and give it Paul, it were not alms but great sin.")
Jacob's well: an English treatise on the cleansing of man's conscience, circa 1450

Measuring Clinical Effort

An increasing trend in American medicine is that clinicians (specifically Physicians) are expected to take EMR work home and take care of patient issues after hours on a daily basis.  This is rarely the case for the majority of other professions.  As the recent New York Times editorial points out, the system is taking advantage of our professionalism and altruism. (https://www.nytimes.com/2019/06/08/opinion/sunday/hospitals-doctors-nurses-burnout.html). Not surprisingly, in an academic enterprise, calculation of clinical effort is more complex than in a non-academic enterprise.  Clinical effort, in my opinion, is defined as including all patient care activities, including EMR charting and responding to homework issues (EPIC inbasket).

We should develop systems to allow all clinical documentation to be done by the end of business, daily.  Clinicians taking work home and spending time away from family and other life obligations to document in the EMR are at high risk for burnout and decreased productivity. Pajama time and weekend charting are a major source of burnout and clinician dissatisfaction. 

From various sources, enlightened non-academic enterprises include EMR documentation time into their work days and allow time for clinicians to address EMR and homework issues.  They also employ clinician extenders to triage homework so only the relevant issues are presented for their review.  In enlightened practices, a clinician that is 100% clinical (5 full days of direct patient care per week) actually has half day to a full day built into their templates to address homework issues.  I will explore this topic further in another post, but before I get there, let’s discuss the crux of the issue for academic physicians.

Robbing Peter to pay Paul

In the academic arena, all too frequently, homework spills into the other half of our mission, the “academic time” which is comprised of all activities that are not direct patient care related (non patient care education / research / administrative service).  What complicates the equation is the education component, which can fall into both buckets. Clinicians that spend four days a week in clinic spend the bulk of their academic day responding to homework issues, thus negating their ability to be productive on their academic time.

Academic centers also “rob Peter to pay Paul” when it comes to allocating conference and academic travel.  Clinicians that are out for conferences are forced to make up clinics on administrative days to prevent a fall in RVUs.  As such, the academic mission suffers further. Conversely, in the private practice world, clinicians work 5 days a week (without a significant administrative component) simply accept time lost to conference and CME as the cost of doing business, and as such, lower revenue and RVU targets.  Loss of revenue is mitigated by income and business tax deductions for the conference.
Additionally, those in private practice that have administrative duties in the practice or local hospital are compensated as such.  For many in academic medicine, administrative service is simply part of the expectation of service.  Many of us enter academic medicine precisely to serve in a variety of roles.  The conflicts start to arise when one component spills into the other.

In the majority of academic institutions, conference and CME time, is taken away from academic time.  The clinician is not on campus to take care of their education / research / administrative duties, and is actually “working” full time at the conference.

For the typical work week in the academic setting, a month has 20 business days.
A clinician at 80% clinical is defined as working 80% of their time in a clinical role, so 16 days a month of direct patient care.

If a clinician is 80% clinical and goes for a four day conference, then they are expected to make up those 4 days, so the following month of 20 business days, they are swapping their four academic days to make up for their missed clinics, so they end up being 100% clinical for that month.  The average for the two months then becomes: 16 days direct patient care + 20 days direct patient care = 36 direct patient care days / 40 business days = 90% clinical effort.

As you can see, we have robbed Peter (Academic) to pay Paul (Clinical Care) and the clinician is now no longer at 80% clinical, but 90% (the great sin!)

Therefore, it is imperative that we consider CME/Conference time as a subtraction from the denominator of available business days.

My attempt at a solution:

I have had the following schema in place since 2015 as Section Chief of the Consultative Medicine service:

We have three major buckets, on any given business day, you are either in a
  1. Clinical Role: Direct patient Care +/- Patient Care education duties
  2. Non Clinical Role: Academic / Administrative / Non Patient care education duties
  3. Away: Not at work in the hospital or your office, vacation, Family Medical Leave (special case), conference, jury duty, etc.

For the typical work week in the academic setting, a month has 20 business days.  We actually break out each day into 2 sessions and have half day administrative and half day clinical care roles and do the math based on 40 business sessions a month.  For the purposes of this thought piece, I am simplifying.

A clinician at 80% clinical is defined as working 80% of their time in a clinical role, so 16 days a month of direct patient care:

Clinical Care Days / Business Days = Numerator / Denominator = 16 days / 20 days = 80%

A clinician at 60% clinical is defines as working 60% of their time in a clinical role, so 12 days a month of direct patient care:

Clinical Care Days / Business Days = Numerator / Denominator = 12 days / 20 days = 60%

My calculations:

Numerator = Number of business days per month in clinical role.
Denominator = Number of AVAILABLE Business days in a month.  (Business days – Away days)

It’s crucial to remember that clinical effort is the same if a clinician is away from the institution for vacation time.

If the clinician has 5 days of vacation, the number of available business days drops to 15 days in that month.  The 80% clinician is responsible for 80% of AVAILABLE business days: 15 x 0.80 = 12 business days of direct patient care.

The same applies for conferences and CME:

In the above example: 3 days of conference + 2 days of vacation = 5 days AWAY
Numerator = # of business days in a clinical role.

Denominator = Number of business days in a month MINUS number days away
So 12 / (20-5) = 80%

In my current practice model, no one is 60%/80%/90% each month on the dot, there are variances month to month, but the goal is to make it as close to goal as possible on a rolling quarterly basis.  In other words, at the end of each quarter, you should be close to goal, and I make manual adjustments to the next quarter to make it work out.  Any clinician that is within 5% of goal at the end of the fiscal year is considered to be on target.

Systemic and transparent use of the calculation allows us to maintain the integrity of academic enterprise.  All too often, clinicians in an academic environment are asked to sacrifice teaching / research / administrative work in pursuit of the RVU benchmark.  As a result, academic RVU benchmarks, in my opinion are over estimated.  The clinician who is forced to add on extra clinics to make up for academic conference time or vacation is actually “squeezing” more RVUs into the 80% bucket and as such inflated numbers are being reported to bench-marking organizations such as AAMC and MGMA.

At this point, health care administrators and physician leaders reading this are about to storm the barricades and make various arguments about the need for increased clinical throughput, not less.  My point is that we should be increasing clinical throughput (efficiency) for providers while they are in their clinical roles, not relying on them to make up for missed clinics by sacrificing the academic component.

Thoughts appreciated!

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