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What Does it Mean to be a Full Time Faculty Member at an Academic Medical Centre?

The Interesting Case of Dr. Bigbottom

Accountable (Oxford English Dictionary)

adjective

  • 1required or expected to justify actions or decisions
  • 2able to be explained or understood

Accountability is in the air in Ontario, and the academic medical centres are not exempt. We are being asked to do more with less, work smarter, and most importantly, be accountable. If we consult the dictionary for a definition we see that accountability relates to justifying what we do in a manner that can be understood by others. Accountability sounds great in principle; however applied accountability, i.e. operationalizing principles to achieve accountability in the real world, is complex, can have unintended consequences and is a political exercise that requires the support of those individuals being held accountable. Moreover, accountability is a two way street and the leadership must itself be accountable to the members. The starting point in achieving an accountability framework involves consultation and due process. In this spirit, I would like to share a story, a sort of case-report, and gather your thoughts on accountability. To do this, a little background is offered (for context) and then the case study is presented (for your amusement). Please take the embedded survey so we can learn what resonates and what is dissonant.

Case Report

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Dr. Bigbottom is a preeminent Auto-Umbilicologist and Professor of Medicine at Peripatetic University (PU). He is highly regarded nationally as an expert in noninvasive approaches to examining the navel. PU’s Department of Medicine has a Practice Plan which links Dr. Bigbottom’s income to fulfilling a job description which acknowledges his contributions in three domains: research, education and patient care. His earnings last year were $400,000 which is approximately the 50th percentile for academic umbilicologists in his home province, and similar to the income of specialists in related disciplines, such as robotic Obfuscationists ($375,000) and noninvasive interventional Chiropodists ($420,000).

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However, Dr. B is entrepreneurial and to “advance the reputation of PU and further the science of of Omphaloskepsis” he engages in a variety of remunerative activities. These activities account for about 30 days per year and he does not report this revenue to his Division Chair or Department Head. The work falls in to three categories: consulting for device companies who are perfecting an umbilical occluder to prevent unwanted navel gazing, advising Pharma, who have a new drug that purports to enlarge the umbilicus, although it can have the adverse effect of converting an ‘innie’ to an ‘outie’, and performing clinical service at various CAN Gaze Centres (Centres for Advanced Navel Gazing), aimed at improving clients’ chakra. Dr. B’s net income from these extracurricular activities is around $75,000 per annum. These activities are not performed during vacation time and most occur during the work week. However, Dr. B is meeting one of the Practice Plan’s major metrics: shadow billing 70% of his income. Recently the Department has undergone reform to increase accountability for public funding, which supports their AFP. In addition, some of Dr. B’s colleagues have complained to the Head that they make less than Dr. B and feel, that because their job descriptions require that they remain present on campus, they are more frequently tapped for teaching and committee work and don’t have the opportunity for out-of-scope earnings. The Head notes that Dr. B is disinterested in serving on committees and does not attend Medical Grand Rounds or the monthly Departmental meeting. When approached, Dr. B states that he is meeting the Practice Plan’s metrics and is not a ‘committee person’. He further states that he works harder and more efficiently than his colleagues and it is this personal effort/ability which creates the time that he uses to perform his outside activities, which he views as benefitting PU.

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Before soliciting your thoughts on Dr. B, let me provide a little background on what is afoot at Queen’s University. Physicians in the Department of Medicine are paid through an Alternative Funding Plan (AFP) funded by the Ontario Ministry of Health.  Like our colleagues in private practice, members of the Department work long hours and provide superb patient care. However, they also have the mandate and responsibility to run a medical school and perform research. The AFP, which is physician-led, mandates that 70%+ of the Department’s revenue must be justified by clinical activity. Clinical service is measured by shadow billing, which is the same as real billing, in that it uses the provincial fee code and generates a verifiable record, however no bill is actually submitted to OHIP. In acknowledgement of the latter two components of our tripartite academic mission, the remaining 30% of the aggregate physician time is to be spent on scholarly activity: research and education. Productivity in these domains are also judged by increasingly rigorous and transparent metrics.

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Members of the Queen’s Department of Medicine Accountability Committee
Note to Dr. Bigbottom: This committee is advisory and the ultimate responsibility for ensuring the financial integrity of the Department and for establishing role descriptions lies with the Department Head

We have established an Accountability Committee to tackle the complex issue of how to retain professional autonomy, ensure that our Department remains an enjoyable place for creative people to work and yet ‘delivers the goods’. This committee, reflective of the Department in its composition (gender, seniority and job description), is chaired by Dr. Bill Paterson, Chair of the Division of Gastroenterology. It wrestles with many issues that Dr. B’s case raises. The committee will help to clarify job descriptions, establish performance metrics and inform the revision of our Practice Plan to ensure accountability. For example, the metrics that underlie designation as a Clinician Scientist will likely include the expectation that the faculty member holds one or more national grants and has a recognized program of investigation, evidenced by publications, awards, speaking engagements, trainees etc. Clinical metrics include productivity, based on shadow billing and success in creating/leading innovative clinical programs. On the education front, metrics will likely include serving a major medical education leadership role, such as Program Director or creating/directing of major educational programs. There are certain core activities that all faculty members are expected to participate in, notably teaching at the undergraduate and postgraduate levels. Meeting the accountability metrics gains the faculty member protected time for research or educational activities and satisfies the spirit of accountability: justifying their income in a manner others can understand.

In addition, the evolving accountability framework values citizenship, recognizing that all members are expected to participate in certain activities that make the Department an enjoyable collegial place to work. These citizenship activities also support our tripartite missions of research, education and clinical care. Citizenship metrics will include attendance at Medical Grand Rounds, Morbidity and Mortality Rounds, monthly Departmental meeting, Departmental retreats and one’s own Divisional meeting. All faculty are allotted time (~10%) for conduct of scholarly pursuits including developing initiatives to enhance quality of care and perform personal research (i.e. case series, pilot research studies).

However, delivering accountability while retaining flexibility and rewarding excellence requires the full – and arguably the full-time – engagement of all faculty members.

So, back to our case. Here are some questions raised regarding the interesting case of Dr. Bigbottom. Your advice is appreciated! Complete the anonymous survey and you will be rewarded with footage of a Department of Medicine Head at work (click the image at end of this blog).

 

Create your free online surveys with SurveyMonkey , the world’s leading questionnaire tool.

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12 Responses to What Does it Mean to be a Full Time Faculty Member at an Academic Medical Centre?

  1. Bill Paterson says:

    Stephen,
    Your blog nicely identifies a critical issue that has been festering within the School of Medicine for years. While SEAMO has brought many positives to Queen’s, I think most would agree that SEAMO’s inability to develop and implement a fair and transparent accountability process that equitably recognizes and rewards all aspects of an academic clinician’s work has been its’ greatest failing. This has not only hindered our ability to take full advantage of the opportunity afforded us by the AFP, but also has negatively impacted on collegiality within and across departments. The issue of professional earnings outside of SEAMO is probably the most contentious and divisive issue that needs to be addressed in our new accountability framework. Many argue that as long as SEAMO deliverables are met, what an individual earns on his or her “own time” should be none of SEAMO’s business. But is that fair to the many faculty members who spend vast amounts of their “own time” doing non-remunerated academic or administrative work that greatly benefits the School of Medicine? Looking forward to the results of your survey!
    Bill Paterson

    • Angeles Garcia says:

      This is a universal problem that might be reduced (perhaps even solved) by “demanding” signing full and exclusive contracts, and outside work to be allowed only by specific approval of the Department Chair, if the time to be used in “out of the University” payed work exceeds X number of hours/month.
      This should not affect unpaid work, but regardless, the Department Chair should be aware of all work we do.

      • Thanks Angela. My hope is that by getting input from the faculty members and beginning a respectful dialog within the Department will cause the vast majority of the faculty to recognize that disclosure is the right thing to do. I believe we can do this in a way that does not impune people’s motivations or significantly threaten their income. In this happy event, I won’t be “demanding” anything. Once we have consensus around the need for disclosure of professional income the next step…what do we do with disclosed information…may be more complex. I (like you) believe that we can only serve one master. Allowing members to be entrepreneurial up to a certain time and $$$ limit may be a reasonable compromise. The art of the deal may be deciding on how much time and how much money we allow faculty to generate.

  2. Stephen Archer says:

    Thanks Bill. I appreciate that it is a challenging issue but as you indicate one that must be addressed. I hope our members will take the survey and provide you committee (and me) with input. Interestingly, in consulting the Heads of Medicine across the country through an informal email process, it appears that most Departments have some combination of mandatory reporting of income and a cap on earnings.

  3. Tony Sanfilippo says:

    Hello Steve,

    A nice articulation of a difficult problem.

    If our shared activities were uni-dimensional and easily quantified, then one might reasonably argue that someone willing and able to provide service above and beyond their agreed-to expectation should retain whatever hard earned extra compensation comes their way. Our reality, of course, is quite different. We have reduced our “core” activities by an average of 30% in order to provide every member opportunity to participate in equally important, but less easily quantified “academic” pursuits, which require a degree of commitment above and beyond the nominal time allocation provided. Taking on “out of scope” work threatens our collective ability to provide those academic roles but compromising both incentive and opportunity. In addition, the fact that these income generating opportunities are not available to all members is intrinsically inequitable. A process that shares extra earnings between the individual and the collective would seem to be a reasonable compromise.

    Tony

    • Tony I agree. With disclosure and sharing of revenue an outside activity might quickly change from being perceived as an activity which only benefits one person to one which is part of “practice building”. For example if a physician were to provide an officially sanctioned service in another city to build referral to our programs of distinction that might be viewed as win-win. The individual could be allowed to generate some revenue, our program would benefit and we would have control over how much work is done off site, how often and by whom. Currently, the outreach is “unofficial” and neither the Division, Dept or SEAMO get credit for the work done nor does the Dept of Division capture funds to compensate for the time spent by individuals who is occupied with out of scope work.

  4. Chris Smith says:

    Stephen

    Thank you for highlighting these issues. I think for all of us being accountable for our time and income we earn is something that Dept should know. We had all asked for transparency around issue of finances and this is linked to this. I think it is not recognized by all in faculty that there are multiple potential sources of income for some in Dept. I think it very reasonable that we should have a discussion about this and what should and should not “count” as our Faculty income.

    Related to this is what sustainable mechanisms do we have to fund activities of the dept as a whole and for divions. I think it highly unusual here that nearly all monies flow straight to physicians without some kind of collective tithe that would enable us to pay for things that would enhance skills and training of faculty and to make dept a more interesting place to work (e.g. getting top notch speakers for Grand Rounds etc). For example GIM division has no source of revenue at all as far as I can tell & I think all divisions should be able to have the opportunity to use some resources to decide how they’d like to benefit their own members as well as Departmental benefits.

    My personal feeling is that all of us should contribute something to this (not just high earners) but that we should have discussion about caps – should there be a hard or soft cap? Should a tithe be linked with all earnings and / or graded up if earning over specialty approved caps?

    Look forward to hearing responses.

    • Chris: Thats an interesting proposal…ie we all contribute something to support the mission but those who generate a lot of outside revenue might contribute more.I have a feeling that the vast majority of the Department would not be in a position to pay much/any tax for outside activity. If I understand your suggestion a tithe on income (of modest amount) would be what most faculty would experience with those doign more out of scope work contributing some additional funds (if they exceed the exemption threshold).

      Re what we do with the funds: It is true that very little money is held centrally by my office and even less by Divisions. Using a tithe system-which “sees” all income (as occurs at many/most DOM’s in Ontario) could help fund both a Departmental $ pool and a Divisional $ pool to fund the many services we are trying to put in place.

      I am supportive of the idea of Divisional Chairs having an account that allows them to support fellow travel and professional development etc within their Divisions…a tithe/tax could be a funding source.

      The initial accountability proposal may suggest that once one exceeds a cap there is a “tax free” window (?$20K) after which a progressive tax is applied. The revenue generated in this manner would be equally shared by the Division and the Dept.

  5. Hoshiar Abdollah says:

    I would suggest that the Department should address the issue of conflict of commitment. The Department should account for every half day or any other metric the Department to choose to asses the accountability. None of us should take on tasks (with renumeration or not) which are in conflict with our job description. Any task outside these commitments must be approved by the Division Head and Department Head. As for reporting outside income I would suggest that we need to look at what SEAMO will do and how the Department will enforce uniform method of reporting which is accurate and stands legal mustard.

    • Stephen Archer says:

      Hoshi

      Thanks. I agree on both points. SIgnificant commitment of time should be approved by the Chair/Head. While it will be easier to instate the related concepts of professional income declaration and a graded tax on outside income beyond a threshold once SEAMO makes this a policy, we need to be prepared as a Dept for this likely eventuality. To be able to deal with such a policy we need to agree to declare professional income and consider the possibility that outside activities that generate more than $20K/year may be a COI. The evolving proposal is that outside income <$20K/yr be tax empt but declared and those above $20K be incrementally taxed (with the funds shared between the Dept and Division).

  6. Elaine Petrof says:

    Dear Stephen,

    I think if you earn extra cash on your own free time, then that is your own business and should not be subjected to scrutiny by the Department. However, if you are earning said extra cash when you are supposed to be at work doing your regular job, then I think that income should be fair game. if someone wants to do a bit of extra moonlighting on their holidays or their weekends off on their own time, eg. for some extra cash to pay for their vacation to Costa Rica, I think that is very different from someone who is regularly earning a double-income and getting paid to be doing their University job while they’re off getting paid to do another job somewhere else.

    By the way – on the subject of tithes
    I think Queens is the only University I know of that does not require a tithe to be paid by its Dept. Medicine faculty members. Not that I don’t mind this fact, but it has always struck me as bizarre and frankly as an unsustainable formula for running a Dept or a Division… even memberships to societies like OMA, IDSA, CAG, etc charge a fee! Frankly don’t know how you can do it.

    Elaine

    • Stephen Archer says:

      Elaine..Costa Rica..sounds great (bring me back coffee). The idea of a tax or tithe on SEAMO income is reasonable and I agree is the rule (we are the exception).

      However, the issue of outside income is a separate issue.

      If faculty member A makes $0 outside of her practice while faculty member B generates $50K of outside income, I expect the former would feel a “flat tax” on internal income was inequitable.

      The proposed tax on outside income is not an attempt to harvest money..it is meant to change behaviour and have faculty focus on the broader academic mission and limit outside work to a reaosnable amount (ie <$20K).

      This is conceptually different than your proposal, which is intended to raise operating dollars (and is not designed to change behaviour). It may be that both interventions are necessary.

      A modest flat tax to generate operating funds for the Divisions and Dept is worth considering.

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Dr. Archer, Dept. Head
Dr. Archer, Dept. Head