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
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). 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.
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.
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).