Transcript Beyond the Ivory Tower: Solutions for Faculty Development

Jedd Roe, MD, MBA, Chair, Department of Emergency Medicine,
William Beaumont Hospital, Royal Oak, MI
Brigitte M. Baumann, MD, MSCE, Head, Division of Clinical Research,
Department of Emergency Medicine, Cooper University Hospital, Camden, NJ
Christopher A. Lewandowski, MD, Residency Program Director,
Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI
Arvind Venkat, MD, Director of Research, Department of Emergency Medicine
and Ethics Consultant, Allegheny General Hospital, Pittsburgh, PA
Disclosures
 Jedd Roe – None to disclose
 Brigitte M. Baumann – Member of SAEM BOD
 Christopher Lewandowski – None to disclose
 Arvind Venkat – Editor, “Challenging and Emerging
Conditions in Emergency Medicine”, Wiley-Blackwell
Publishing, August 2011
Introduction
 Community-based tertiary care centers are an
important locale for clinical care, research and
education in emergency medicine.
 However, establishing the academic mission in this
setting can be challenging.
 At the same time, there are potential advantages to
the academic endeavor in this setting that are unique
and contribute significantly to the field.
Definition and Epidemiology
 Community-based tertiary care centers with an academic
mission in emergency medicine have the following
characteristics:
 Clinical revenue stream that is independent of and not
shared with a larger university.

May not be independent of parent corporation
 Research enterprise that is not reliant upon larger
university infrastructure and support.
 Primary training site for an emergency medicine
residency program.
 A rough estimate reveals that 50 of 155 accredited
allopathic emergency medicine residency programs fall
within these centers.
Theoretical Challenges to the
Academic Mission
 How does the department attract resources for and
incentivize academic productivity in faculty where
revenue is primarily from the clinical stream?
 How is research conducted effectively in a resourcelimited environment when compared to the larger
infrastructure of the university setting?
 How does the department attract high quality medical
students and residents to train in this environment?
 How is academic productivity incentivized among medical
students and residents?
Theoretical Advantages to the
Academic Mission
 Independence to model the academic mission of the
department in novel ways compared to the more
traditional model of the university setting.
 Broader range of research questions which are feasible
to pursue in comparison to the university setting where
funding feasibility is paramount.
 Wider range of academic output that carries currency in
this type of institution in comparison to the university
setting.
 Training environment that is more easily translated to a
broader range of practice settings upon graduation from
residency.
Goals
 Provide examples of addressing challenges in
faculty development, research and education in the
community-based tertiary-care setting.
 Show how these solutions can take advantage of
opportunities unique to the academic mission in the
community-based tertiary care environment.
 Discuss how these solutions can be tailored to
different practice settings that are part of communitybased tertiary care centers.
Supporting the Academic
Mission at a Communitybased Tertiary Care Center
Jedd Roe, MD, MBA
Chair, Emergency Medicine
William Beaumont Hospital, Royal Oak, MI
Professor and Chair, Department of Emergency Medicine
Oakland University William Beaumont School of Medicine
Objectives
 Background
 Organizational Structure
 Department Finances
 Challenges
 Strategies for Community-based Centers
My Training
 Williams College, BA
 Royal College of Surgeons in
Ireland
 Kern Medical Center
 EM residency 1986-90
 University of Denver
 MBA / MS (Finance) 1999-2001
Currently
 Chair, Department of
Emergency Medicine, William
Beaumont Hospital
 Professor and Chair,
Department of Emergency
Medicine, Oakland University
William Beaumont School of
Medicine
Organizational Structure
Dean =
Organizational Structure
How to sort this out?
How is the Department funded?
 Employed model
 Contracted, fee-for-service
 How is the academic mission supported?
 You need $$$ and time
 Who pays?
Faculty Compensation
 Base compensation +
 Incentive Plan (meaningful amount, transparent &
measurable metrics, MD can influence)
 Model: (Earn points / Total points) * Incentive $$$ =
incentive payout
 Annual distribution
 Entry criteria

The “basics”
 e.g. medical record completion, annual testing, etc
Incentive Plan Categories
 Productivity
 Quality
 Patient Satisfaction
 Align with hospital / department goals
 Academic
 Academic value units?
 Annual goals
Mission Conflict
Academic
Clinical Service
 Institutional
 Department
Culture
What’s at Risk?
 All non-clinical MD funds flow
 Residency

Positions over cap?
 Research Support
 Department fund

How is this generated?
 CME, Faculty Development $$
Beware of………
Potential Strategies
 Build institutional credibility
 $$$ not the only useful currency
 Sell value of emergency medicine




Do you know % of admits that come through ED?
Downstream revenues?
Who knows flow better than we do?
Manage transitions of care
 Gain control over your funds flow
 Mission-based budgeting?
 Cross-subsidize from clinical $$?
 Philanthropy
Potential Strategies
 Network
 AACEM
 ABEM
 ACEP
 Recruitment / Retention
 Technology
 Resources
 Clinical Population
Research at a
Community-based Tertiary
Care Center
Brigitte M. Baumann, MD, MSCE
Head, Division of Clinical Research
Associate Professor of Emergency Medicine
Cooper University Hospital, Camden, NJ
Objectives
 Background
 Opportunities at Community-based Centers
 Challenges: Mine, and probably yours
 Solutions: Mine, and hopefully yours
My Background
 Harvard College, BA
 Cornell University Medical College
 University of Pennsylvania
 IM residency 1995-97
 EM residency 1997-2000
My Current Affiliation
 Cooper University Hospital
 Tertiary care center
 Level 1 trauma center
 Adult ED with a nested pediatric ED
 Southern NJ


Across the Delaware River
2 miles from Philadelphia
Current Affiliation
University of Medicine
and Dentistry of NJ
Robert Wood Johnson
Medical School
New Brunswick
Piscataway
Camden
Brigitte M. Baumann, MD, MSCE
UMDNJ-RWJMS at Camden
My New Affiliation
Brigitte M. Baumann, MD, MSCE
Cooper Medical School of Rowan University
First class anticipated: 2012
Challenges: T0
 Fairly small department (faculty=10)
 RD had just departed = No “on site” mentorship
 No ongoing research
 No federal funding
 No industry funding
 No support staff
 No statistician
 No practical training/experience with IRB/protocols
Lay of the Land
T0: Resources at my CBTC Center
 Faculty and resident #’s increasing
 Didn’t know that I was supposed to fail
 Anything is better than nothing (research)
 Masters in Clinical Epidemiology
 IRB was conservative but turnover was pretty quick
Challenges: TNOW
 Select faculty interested in research (faculty=25+)
 Few true mentors for federal grants
 Maintain 100% financial support of research staff
 Balancing “home grown” studies with fiscal realities?
 Lack of grants office infrastructure/resources
 Limited collaboration within the system
Solutions: Lack of Training
 Pros
 Completed majority of Masters coursework in 1 yr
 Statistical methods, epidemiology, stats programs
 Excellent feedback on my thesis
 Cons
 First “outside” and first EM masters applicant
 Multiple mentors
 Dissuaded from the “grant pathway”
 Unaware of NIH educational loan repayment awards
 Conflicting responsibilities led to 3 yr hiatus from
completion of masters degree
Solutions: Support Staff
 Started an Academic Associate Program
 Pilot data used for federal grant applications
 Eventually built up enough momentum for a FT
Research Coordinator
 Now able to handle industry projects
Academic Associate Program
 Service to the Institution
 Data collection for departmental projects
 Assist with other departmental studies
 Allows students to “shadow”
 Now, may serve as a conduit for prospective medical
students for new medical school
 HUGE time investment, but now paying off…
Solutions: Practical Knowledge
 Member of IRB
 Basics on how to write a protocol
 Consent forms / HIPAA
 In contact with other researchers
 In contact with statistician (hired 5 yrs later)
Solutions: Mentorship
 Maintained prior mentors from U Penn
 Established new ones
 Our dept hired a PhD (Federal funding)
 Made contacts at SAEM and ACEP




Research directors interest group
Public Health interest group
Program Committee (SAEM)
Other organizations - American Society of HTN
Resources at other CBTCCs
 Physician extenders may be interested in research
 Data collection
 Subject enrollment
 Co-investigators
 Part of their advanced degree requirements
 IRB may be a central one or, if local, may also have
fast turnover
 If MS or residents are present, they may also want
to participate in research efforts
 IT personnel, MBAs – different skill sets
Types of investigations: CBTCCs
 Case reports  novel findings, consider a pilot study
 EMLA cream for pediatric abscesses
 Investigations that focus on ED throughput and
patient satisfaction (Press Ganey Scores)
 Scribes
 Fast tracks
 Physician-based triage
 Elimination of waiting room
 Clinical decision units
Types of investigations: CBTCCs
 Focus may be more “systems-based”
 If residents are primarily interested in clinical jobs,
then give them projects that will help them advance
 Scholarly tracks: “Simulation Track”
 Reduction in medical errors
 Improving pain
 Improving documentation
 RVUs
Types of investigations: CBTCCs
 Fit the study to your resources
 Medical Record reviews
 Use established databases
 Electronic medical records
 Improve your resources
 Enlist undergrads or medical students
 Develop a medical student elective (co-author)
Challenges: Protected time/staffing
 Funding
 Ongoing industry projects -- recovery of indirect $$
 Small institutional grants
 Federal funding
 http://www.grants.gov
 Cons
 Working on projects that do not interest you
 Too many simultaneous projects
 Project brings in revenue but no publications
 What happens when the project is over?
Challenges
Academic
Associate
Program
Federal
Funding
Home-grown study
Research
Coordinator
Resident or MS study
Manage
AAP & Ind.
Research
Industry
Research
Staff turnover
Challenges
 “Few people are doing research in my department”
 “No one is interested in my research area”
 Solutions:
 Look outside your department
 Collaborate with others from other institutions
 Join EM and other national organizations
 Expect some failures before success
Challenges
 “There’s no tenure at my institution, so few people
are interested or motivated to publish. Why bother?”
 Always approach your career as if you are working up
the academic ladder
 Surprise! We now are going to have a medical school
 major changes and expectations from
administration
Challenges
 “My chair wants more service to the institution but I
want to focus on CV building”
 See if you can pick responsibilities that mesh with your
interests (IRB, lab committee)
 Medical student mentor (recruit students)
 “I’d love to do more academic work (research, book
chapters, teaching) but where to find the time?”
 Pick an area of interest and focus on that
 Salami projects
Conclusion
 Set goals for yourself
 1, 3, 5 and 10 year goals
 If you meet them, wonderful
 If not, time to reassess
Christopher A. Lewandowski, MD,
Residency Program Director
Department of Emergency Medicine
Henry Ford Hospital, Detroit, MI
Henry Ford Hospital
 Established in 1914
 Provides primary health care
to the community
 Referral Center
 Academic Medical Center
 Research Center
Goals
 Discuss how to structure educational programs for
residents and students
 Review options for incentivizing clinical educator
productivity
 Review the strengths of education in the community
based tertiary care center (CBTCC)
Educational Programs in the
CBTCC
 Understand your environment
 Why is medical education important to your institution?


Mission
Vision
 What is the organizational structure?
 How does the money flow?
Educational Programs in the
CBTCC
 What components of medical education are a
priority?
 Allied health care professional
 Medical students
 Residents
 Fellows
 Who does the institution value the most?
Educational Programs in the
CBTCC
 Where do you fit in?
 What are your interests?
 How well do your interests align with the
institution’s?
 What are the opportunities for advancement?
 Role models
 How does your department fit in?
Educational Programs in the
CBTCC
 Why does my department want students or
residents?
 What is the commitment for their support?
 What is the role of the chair?
Building an Educational Program
in a CBTCC
 What benefits the department the most?
 Residency program often come first
 Use institutional resources
 Create institutional resources
 Know the rules of the road for residencies
 The RRC is your friend
 CORD is a major ally
Building an Educational Program
in a CBTCC
 Medical students
 Layered on top the residency
 Require a very organized approach
 Make the rotation fun, not stressful
 Provide direct faculty direction and contact
 Allied Health Care Professionals
 EMT programs
 US tech programs
Building an Educational Program
in a CBTCC
 The Role of the Chair
 Needs to view education as a core mission
 Sets the tone, creates the environment in the
institution
 Financial support





PD, APDs, Coordinators
Residents
Faculty development
Facilities
Incentives
Building an Educational Program
in a CBTCC
 Core faculty vs Key faculty
 Core faculty meet RRC requirements for scholarly
activity
 Key faculty – you can’t run the day to day operations
without them
 Create a program that plays to your strengths
 Critical care
 Peds
 Trauma
Building an Educational Program
in a CBTCC
 Recruitment for residency
 Take the long view
 Recruit medical students as future faculty
 Invest in their development
 Help them create a vision of their own future
 Recruit faculty with specific educational roles in mind
Building an Educational Program
in a CBTCC
 Define Productivity
 Clinical Supervision and Evaluation of Residents
 Formal Teaching


Classroom
Simulation
 Scholarly Activity


Development of new knowledge
Dissemination of existing knowledge
 Administrative Work
Building an Educational Program
in a CBTCC
 Faculty
 Must have adequate clinical staffing
 Recruit with clear expectations and live up to them
 Develop goals for each faculty
 Career Tracks
 Needs chair buy-in
 Clearly defined roles
 It takes a village




Clinicians
Educators
Researchers
Operations / Administration
Incentivizing Clinician Educator
Productivity in a CBTCC
 Money Talks
 Clear Incentive plan
 Fair
 Metrics


Measurable
Reinforce desired behaviors
 Base pay structure
 Pooled incentive fund


Baseline Requirements
Competitive structure
Incentivizing Clinician Educator
Productivity in a CBTCC
 EVUs
 Educational Value Units (points)
 Similar to RVUs,

Directed for non-RVU generating educational activities
 Funding from Incentive pool and GME

Reward both Resident and Medical Student Activities
 Need an internal committee to define what activities are
valued and how many points are assigned
Incentivizing Clinician Educator
Productivity in a CBTCC
 EVUs
 Eligibility

Faculty without protected time for education
 Activities:
 Didactic Lectures
 Interactive Educational Activities
 Residency Responsibilities
 Remediation
 Professional Development
 Medical Student Responsibilities
Incentivizing Clinician Educator
Productivity in a CBTCC
 EVUs
 Auditing and Tracking



Criteria are chosen a priori
Choose verifiable activities
Create method of monitoring outcomes, reporting
 Quality measures
 Evaluations
 CME
 Scholarly output
 Roll out to all faculty
Educational Programs in a CBTCC
Strengths
 Faculty can choose their career track
 Flexibility to modify track based on personal goals
 Less pressure toward tenure
 Self selection for each track
 Can provide time to develop interests
Educational Programs in a CBTCC
Strengths
 Faculty growth through various stages of life
 Work life balance
 University affiliations
 Provide academic titles
 Provide other avenues of development and
involvement
Educational Programs in a CBTCC
Weaknesses
 Requires great internal motivation
 Difficult to keep the playing field even
 Tension between faculty on different career paths
 Requires parity in compensation
Conclusion
 Community-based tertiary care centers are an
important locale for clinical care, research and
education in emergency medicine.
 However, establishing the academic mission in this
setting can be challenging.
 Achieving solutions to promote faculty development,
research and education in community-based tertiary
care centers require institutional commitment and
departmental flexibility and creativity.