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Johns Hopkins Hospital Baltimore, MD 21287
I read with interest the article by Eschelman et al.
[1], which explored the
relationship between clinical productivity, measured by relative value units
(RVUs), and academic productivity, measured by the number of articles and
presentations produced at an academic radiology department. The authors found
an inverse correlation between the two that was unaffected by variables of
age, academic rank, administrative responsibilities, and sex. The authors
concluded that the increased pressures placed on academic faculty to generate
income negatively impact academic
output.
,,,
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Although I agree with the premise and conclusions of the article, there are some assumptions I disagree with. I, a neuroradiologist, can interpret many MR scans of the head (50-70 per day at 2.24 pro-fee RVUs) and generate many times more RVUs than a gastrointestinal radiologist performing barium enemas all day (1.51 pro-fee RVUs). Despite this, my time commitment to do this work often is less than that of my colleague. Thus, to suggest that an individual who generates more RVUs has less time to perform academic work is questionable. There are individuals in a radiology department working long and hard hours who simply, by virtue of the studies that they perform (mammograms, pediatric films, gastrointestinal studies), do not generate high RVUs.
I believe that there are other important factors that were neglected in the analysis of the data. Were senior faculty members placed on the schedule less than the junior faculty or allotted extra vacation and meeting days? Someone who is away giving more presentations will have fewer clinical days than one who does not go to such meetings. Faculty members who dislike traveling often give up their allotted "meeting days" and instead get assigned more clinical days.
I have also noted that one of the most influential factors on academic productivity is the presence of new or young children in the family. I know that the years after my children were born saw a dramatic drop in the time I spent at academic work after hours and a corresponding drop in academic output.
It seems intuitive, given a finite period of time that academic radiologists have to devote to their career, that academic productivity would decline when clinical work increases. This is unfortunate because most academic centers now rely more heavily on extramural funding to remain viable. Submitting grants requires a large commitment of time in a setting where more clinical dollars are needed. When funding is obtained, this reduces the clinical load expected of that faculty member. We do not know the levels of extramural salary support for the faculty members of this institution. Other, very time-consuming, academic endeavors that are not considered in this article include serving on a study section of the National Institutes of Health, as an officer for a national or regional professional organization, or as an examiner for board certification. The residency training director and medical student training director must spend many hours a week in their teaching functions.
In summary, it is my belief that RVUs need not correlate with time spent performing clinical work, but often reflect higher technology procedures requiring additional training. Therefore, I do not believe that the RVU scale can be used to determine conversely the amount of time an individual has left in the workweek to devote to medical research. In any event, we must all think like a team. We must set independent standards for both aspects of the academic practice and apply them and incentivize them. In that way one will have a successful enterprise that achieves all the goals of the university-based practice: clinical work, teaching, and research.
References
Jefferson Medical College Thomas Jefferson University Hospital Philadelphia, PA 19107
Dr. Yousem raises several interesting points regarding our article comparing clinical and academic productivity in our university hospital radiology department [1]. Some of his concerns affirm the difficulty we and other authors have encountered when attempting to objectively quantify physician work.
How can one measure the amount of work performed? The number of dollars billed or collected or the number of studies interpreted or performed are not accurate means of determining work. Charges today are merely suggestions, reimbursements vary among different payers, and counting the number of studies does not account for their complexity.
In radiology... payment reform [by use of the relative value scale] has achieved an important rationalization of relative payments for services. Equitable payment within radiology—with equity determined by the organized radiology community—has replaced underpayment of some services and overpayment of others [2].
Like others [3, 4], we used the RVU (relative value unit) system to evaluate physician clinical productivity. Although there may be inconsistencies in the RVU system, this is the most comprehensive, reliable scale available. Dr. Yousem believes that his work interpreting MR scans of the head is overvalued compared with other radiology services. Even if this is true, one specific example of an inconsistency does not undermine the entire RVU system, which rates each examination or procedure relative to others. Recognize also that the RVU system rewards not only the time spent but also the intensity of the effort required, which may justify the value awarded to CT and MR scans. At the time of our study (July 1994—June 1996), neuroradiologists and vascular-interventional radiologists were generating almost twice as many RVUs a year as the other full-time radiologists in our department. Is their work truly overvalued by a factor of two, or are these individuals also working longer hours, performing more procedures during nights and weekends on call, and spending more of their workdays involved with clinical efforts and, hence, dedicating less time to academic pursuits?
To address some of Dr. Yousem's other concerns, presentations as defined in our article were considered a component of academic productivity, and we found a similar inverse relationship between the number of presentations and clinical productivity. Not only is time required to prepare and deliver these presentations, but one must also perform the research. All of these activities take time away from clinical responsibilities, in support of our hypothesis.
It is difficult to quantify the effect of family commitments on academic pursuits. This was not a variable we analyzed, especially because one cannot equate the mere presence of children with an interest in and time commitment to their upbringing. An academic physician could potentially perceive completion of several research projects leading to career advancement as the best means to provide for his or her family's future well-being. If they have less demanding clinical responsibilities, parents may still have ample time during the workday to pursue research interests. Several of the faculty in our department with high academic productivity had young children at the time of this study.
We chose not to include the amount of grant funding as a separate determinant of academic productivity, but this may be worth evaluating in future studies. We did include one faculty member in our analysis who took a 6-month sabbatical and two others with faculty development fellowships because, as hypothesized, their diminished clinical responsibilities allowed more research time, during which they wrote several articles. Service to regional or national medical organizations, time spent peer-reviewing manuscripts, and other laudable professional commitments were not analyzed for their effect on clinical or academic productivity. These functions are difficult to quantify and are dispersed among many of the faculty in our department. Nonetheless, the chairman regularly emphasizes the importance of research and encourages faculty to make research a priority over these other activities. Note that both the residency program director and the residency selection committee director were included in the administrative group, but administrative responsibilities did not affect the level of academic productivity.
Our report showed an inverse relationship between clinical and academic productivity. However, causation cannot be proven by this correlational analysis. Nonetheless, the findings certainly support the intuitive concept that if clinical responsibilities consume more of an academic radiologist's time, there will be less effort devoted to academic pursuits. Our intent was not to foster division within academic radiology departments, but rather an understanding of the pressures that academic health centers and their faculties face in fulfilling all components of their academic mission.
References
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