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The Relationship of Clinical and Academic Productivity in a University Hospital Radiology Department

¹ Department of Radiology, Jefferson Medical College/Thomas Jefferson University Hospital, Ste. 4200, Gibbon Bldg., 111 S. 11th St., Philadelphia, PA 19107.

Received May 7, 1999; accepted after revision June 7, 1999.

 
Address correspondence to D. J. Eschelman.

Abstract

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OBJECTIVE. The purpose of this study was to evaluate the relationship between clinical and academic productivity over a 2-year period in a university hospital radiology department.

MATERIALS AND METHODS. Clinical productivity, as determined by the number of total professional relative value units generated, was compared with academic productivity, which was determined by the number of published peer-reviewed articles, published non-peer-reviewed articles, published abstracts, and presentations delivered by each full-time clinical faculty member. The relationships of age, academic rank, administrative position, and division within the department were also assessed for their effect on relative value units and academic productivity.

RESULTS. We found a significant inverse relationship between relative value units and the number of published peer-reviewed articles, published abstracts, and presentations. Age, academic rank, and administrative responsibilities had no effect on the number of relative value units. Faculty in the neuroradiology and cardiovascular-interventional radiology divisions generated more relative value units than did other faculty members.

CONCLUSION. Faculty members with higher levels of clinical productivity showed significantly lower levels of academic productivity. This finding is consistent with the idea that increases in the clinical workload may diminish research output.

Introduction

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As the clinical responsibilities of academic physicians increase and reimbursements for these services decrease, the ability to conduct clinical research may be jeopardized. This may occur because of less time to spend on research activities and reduced financial support for research generated by clinical activities [1, 2, 3, 4, 5, 6, 7]. We suspected that among the full-time faculty in our academic radiology department disparity existed between clinical productivity, as determined by the number of total professional relative value units billed, and academic productivity, based on the number of articles and abstracts published and presentations delivered. The purpose of this study was to determine if a relationship exists between clinical and academic productivity among faculty in our department.

Materials and Methods

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This retrospective study evaluated data from July 1, 1994 to June 30, 1995 (year 1) and July 1, 1995 to June 30, 1996 (year 2). We studied 33 full-time clinical faculty in year 1 and 32 in year 2. These numbers do not include part-time clinical faculty (n = 6, year 1; n = 7, year 2), nonclinical physician faculty (n = 1), or nonphysician research faculty not participating in clinical work (n = 9). Members of the Division of Nuclear Medicine (n = 3, year 1; n = 2, year 2) were also excluded because relative value unit data were not available from their billing system, which is separate from the rest of the radiology department. Full-time clinical faculty who were on a 6-month sabbatical (n = 1) or who received a faculty development or research fellowship (n = 2) were included in the analysis. No full-time clinical faculty members took a maternity leave during either academic year. Two full-time clinical faculty members left the department after year 1, and two new full-time clinical faculty members were hired for year 2. One clinical faculty member who worked full time in year 1 worked part time during year 2. This same faculty member worked part time in the academic year before July 1, 1994. All other full-time clinical faculty members were on staff in that capacity for at least 22 months before July 1, 1994. One faculty member working 90% of the time was included as a full-time clinical faculty member because she was always assigned to clinical responsibilities.

During year 1 our study group included 12 professors, eight associate professors, 12 assistant professors, and one instructor. In year 2 the study group included 11 professors, nine associate professors, 11 assistant professors, and one instructor. Most (year 1, 85%; year 2, 88%) of the full-time faculty were on an academic track rather than a clinical track for professional advancement. Of the faculty working full time (100%), there were no differences in the clinical assignments based on professional track during the study. Only two faculty members had tenure, and this track was not available to any other faculty member. Faculty were categorized by their primary area of clinical assignment, though several worked in more than one division of the radiology department. For purposes of this analysis, faculty members were classified into the following sections during year 1: body imaging (CT, sonography, and MR imaging), 13; general diagnostic radiology (chest radiography; radiography of the gastrointestinal, genitourinary, and musculoskeletal systems; mammography; and pediatric radiology), 10; neuroradiology, six; and cardiovascular-interventional radiology, four. In year 2, general diagnostic radiology was staffed by nine full-time faculty members; the number of full-time faculty in the other divisions did not change.

The chairman of the department of radiology at our university hospital annually determines faculty remuneration, which consists of a base salary and a separate bonus representing approximately one quarter to one third of total income. The base salary is largely determined by academic rank. Academic and clinical productivity are the dominant factors used to establish the bonus. The chairman regularly and enthusiastically encourages research, and these research efforts are rewarded through the bonus system.

The annual reports to the dean of the medical school prepared by the department chairman for these 2 years were reviewed. These comprehensive reports include detailed lists of all of the articles and abstracts published by radiology faculty and the presentations that they delivered. The following categories in the annual report were tallied for each full-time faculty radiologist as a determinant of academic productivity: published peer-reviewed articles, published non-peer-reviewed articles (including review articles, editorials, book chapters, and other non-peer-reviewed manuscripts), published abstracts, and presentations (including scientific presentations or exhibits at regional, national, and international meetings; grand rounds at other institutions; plenary sessions or workshops at regional, national, or international meetings; and lectures at continuing medical education courses) (Table 1). Articles, abstracts, and scientific exhibits were credited to a faculty member if he or she was the first author or if he or she was the second author when the first author was a trainee (medical student, resident, fellow, or visiting fellow). All presentations other than scientific exhibits were made only by a faculty member. Letters to the editor were excluded.

Clinical productivity was determined by the total professional relative value units billed annually per faculty member during these two academic years using an internally developed radiology information system operating on a 9000K Class computer (Hewlett Packard, Palo Alto, CA). The relative value units were recorded on the basis of the faculty name with which each radiology report was dictated, regardless of whether the report was dictated by that faculty member or a trainee with whom the case was reviewed or performed. All relative value units billed by all full-time clinical faculty members are included for year 1. A small portion (1%) of the clinical revenue during year 2 is not included in this study because it comes from work at an affiliated institution performed exclusively by our neuroradiologists.

Age (range, 32-65 years; mean, 43 years; median, 40 years), academic rank, division within the department, and administrative position (division directors, vice chairman, associate chairmen, and director of the residency selection committee; n = 11) were also analyzed as independent variables.

Because the 2 years of data cannot be treated as independent cases for statistical purposes, the means of the variables of interest were calculated for subjects with 2 years of data. Single-year values were taken for the five faculty members who were on the full-time staff for only 1 year of the study. The number of relative value units, age, academic rank, administrative position, and division were compared by correlation analysis to the number of peer-reviewed articles, non-peer-reviewed articles, presentations, and abstracts. Separate correlation analyses were also performed among the four categories of academic productivity and between the number of relative value units and age, rank, administrative position, and division.

We began using correlational analyses to explore the relationships among these continuous variables. However, as Figure 1 shows, the relationship between relative value units and academic output lacks homoscedasticity; in other words, low levels of relative value units show greater variance than do high levels of relative value units. Therefore, we switched to a nonparametric analysis that we thought would be more sensitive to these relationships. The continuous variables of relative value units (4985 versus <4985) and age (>40 versus 40 years) were dichotomized. Academic rank was divided into senior faculty (professors and associate professors) and junior faculty (assistant professors and instructors). The presence or absence of significant administrative responsibilities was also studied as a variable. Mann-Whitney tests contrasting high and low values of these dichotomous variables of interest were then conducted in comparison with the various determinants of academic productivity. The Kruskal-Wallis test was used for the four-group analyses based on division. The Mann-Whitney test was also used to compare the number of relative value units with age, rank, and administrative position. These calculations were repeated excluding one faculty member who showed the highest levels of academic productivity. Statistical analysis was performed using SAS version 6.12 for Windows (SAS Institute, Cary, NC).

View larger version (11K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1. —Bivariate distribution of relative value units (horizontal scale, running from 2000 to 11,000) and academic productivity (vertical scale, 0 to * as defined) are shown on this chart. Each data element is plotted. Four distributions (peer-reviewed articles [, 0-9 on vertical scale], non—peer-reviewed articles [[UNK], 0-5 on vertical scale], presentations [[UNK], 0-50 on vertical scale], and abstracts [, 0-10 on vertical scale]) are superimposed, each with its own scale, because they are so similar. Higher levels of relative value units are associated with lower academic productivity. Higher variability is seen in academic output among faculty members with low levels of relative value unit generation than in those with high levels.

Results

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A significant inverse relationship existed between the number of relative value units and number of peer-reviewed articles (p = 0.011), presentations (p = 0.015), and abstracts (p = 0.002) (Table 2). No such relationship existed for non-peer-reviewed articles, but the overall number of these publications was small. Variables that might confound the relationship between relative value units and academic output were examined. Correlational analysis showed that generation of relative value units was not affected by age, academic rank, or administrative responsibilities. We found a positive correlation between the number of relative value units and division. Higher levels of relative value units were associated with faculty in the neuroradiology and cardiovascular-interventional radiology divisions when compared with faculty in the general diagnostic and body imaging divisions (p = 0.0001).

Senior faculty had significantly more non-peer-reviewed articles (p = 0.049), presentations (p = 0.016), and abstracts (p = 0.012) than did junior faculty. Age and administrative responsibilities were not associated with level of academic productivity. Members of the general diagnostic radiology and body imaging sections had more presentations than did faculty in the neuroradiology and cardiovascular-interventional radiology divisions (p = 0.027). None of these results changed when the faculty member with the greatest academic productivity was excluded.

Discussion

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To control the growth of payments to physicians, Congress directed the Health Care Financing Administration in 1987 to develop a resource-based relative value scale for payments under the Medicare system [8]. This scale is designed to correct inequities in reimbursements for the same service among different physicians and to provide a rational system for quantifying work efforts both within and between specialties that would be used to determine appropriate payments. The scale is a system of nonmonetary units representing work for each service or procedure based on the length of time required and the intensity of the effort in consideration of such variables as "mental effort and judgment, technical skill and physical effort, and psychological stress" [9]. Other factors are the time spent before and after the service or procedure, practice costs including malpractice insurance premiums, and the opportunity cost of reduced income during specialty training [10]. Through the use of monetary conversion factors, this system has been accepted for determining physician payments under the Medicare system, and it has been widely adopted by many thirdparty payers. Through surveys and consensus panels organized by the American College of Radiology, a resource-based relative value scale was developed by radiologists that produced a rational system of relative payments within our field [8].

Relative value units have been used to evaluate physician clinical productivity [11]. This method is considered a more reliable measure of clinical effort than hours worked, patients seen, or revenue generated because reimbursements can vary considerably. Baystate Health Systems developed a system to measure physician productivity [12]. Generation of relative value units played a significant role in their analysis, and this relative value unit information was used to optimize clinical productivity. Other similar efforts have been made to quantify academic productivity [13, 14] and educational efforts [15]. In 1996, the Department of Medicine at the Louisiana State University School of Medicine developed a relative value scale to quantify faculty activity in teaching, research, administration, and patient care [13]. To their knowledge, that system was the first comprehensive way of calculating and comparing faculty productivity in these four areas. The authors admit some bias in the creation of their relative value system, and the values assigned to some of these efforts are certainly debatable. We chose to measure academic productivity by the number of peer-reviewed articles, non—peer-reviewed articles, and abstracts published, in addition to the number of presentations delivered or exhibits prepared. Although peer-reviewed articles and published abstracts represent research output, we also included non—peer-reviewed articles and presentations (which included educational lectures) for separate analysis as components of academic productivity because these nonclinical activities contribute to the important educational mission of academic health centers and generally require substantial time and effort to prepare. Administrative responsibilities were analyzed as a separate independent variable affecting both generation of relative value units and academic productivity.

Medical research depends not only on investigators having time to devote to research but also on clinical revenues for support of such activities. The increase in managed care resulting in decreased payments for services may jeopardize this relationship. Medical schools in areas of high managed care penetration have experienced slower growth in the number and dollar amounts of grants from the National Institutes of Health than have schools in markets with a low or medium market share by managed care plans [4]. Clinical revenues provide money for pilot programs before application for such research grants and support faculty between grants [4, 6]. Furthermore, a large proportion of medical research is not funded by external sources, emphasizing the critical importance of revenues from clinical practices to support these programs [16, 17]. Ten percent of the revenue from clinical faculty practice plans of United States medical schools was used to support research activities in the 1992-1993 academic year [1]. Sponsoring research that clearly benefits society through improved health care is one of the prime missions of academic health centers. One recent study revealed that risk-adjusted mortality rates and length of stay are lower at major teaching hospitals than at nonteaching and minor teaching hospitals [18].

As reimbursements from payers decrease, efforts are often made to increase the clinical workload to maintain income, which may adversely influence academic productivity [1, 5, 6]. This study establishes a significant inverse relationship between clinical and academic productivity among the full-time faculty of our radiology department. Although causation cannot be confirmed, others have observed similar trends, which tends to support a cause-and-effect relationship. For example, clinical researchers in highly competitive health care markets have fewer peer-reviewed publications than do those in less competitive markets [5]. Other groups of researchers have proposed the logical assumption that as the clinical workload increases, less time can be devoted for research [6, 12, 19]. To our knowledge, this direct relationship has not been previously investigated.

As shown in Figure 1, levels of academic productivity vary among faculty with low levels of relative value unit generation. We can only speculate as to the cause, but it certainly may relate to a diminished interest in research despite working in a department that is, overall, productive academically and that values and rewards research efforts. However, faculty members with high levels of relative value unit generation have significantly lower levels of academic productivity because more of their time and effort is dedicated to clinical work.

We acknowledge several limitations to this study. The study represents the experience of one academic radiology department over only a 2-year period. Relative value unit data are not available for work performed by our faculty at imaging centers outside of our main campus in subsequent years. Since this study, the clinical workload in our department has increased for all staff, with some faculty members generating approximately 15,000 relative value units annually. Unfortunately, the effect of this increased clinical workload on academic productivity cannot be assessed by the individual basis used in this study. This is a correlational analysis, and causal inferences must be made with caution from a study of this type. The sample size was too small to perform multivariate analysis between the level of relative value units and the other variables. We did not attempt to adjust the value of peer-reviewed articles on the basis of either significance of the work or the journal in which they were published, but the number of case reports and technical notes was small. We could not account for the normal lead time that exists between manuscript submission, revision, and eventual publication. However, the academic productivity of the department was similar in the year preceding and following this study period. Also, ours is a stable faculty; 94% of the full-time radiologists were on the staff for at least 22 months before this study period. Finally, we did not analyze the relationship between clinical work and teaching responsibilities. Lectures to radiology residents are distributed throughout the faculty, and teaching of residents or fellows occurs with most studies as they are interpreted or procedures as they are performed.

In conclusion, a significant inverse relationship exists between clinical work as measured by relative value units and academic productivity based on the number of peer-reviewed articles, abstracts, and presentations. One potential implication of this finding is that continuing demands for increased clinical workload to maintain revenue may decrease research activities.

References

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