The idiocy of productivity measures
Medical Rants April 21st. 2008, 2:29pmA question appeared on a list serve this weekend about productivity measures and incentive pay. Aaaarrrrgggghhhhh! This concept has broadly infected academic “primary care” practices. Here is the concept. The MGMA publishes averages for the daily, weekly or monthly billing of internists and family physicians. Administrators use these averages (or even the 75th percentile) as targets for academic physicians. So academic physicians have a target of seeing a certain number of patients (with minor adjustment for complexity and new patient visits.)
I assume that administrators use these targets to stimulate the physicians to work hard. The targets are like any other measurement. As we focus on the 50th or 75th percentile, we note that the target increases each year. Thus, we cannot all remain like the children of Lake Wobegon.
Why do we set arbitrary statistical targets? These targets negatively influence physicians, encouraging them to spend less time with each patient. Many physicians use their “academic” time to support their clinical time (allowing for incentive pay.) When the measurement becomes the issue, then other important components of ones job suffers. Given a zero-sum time game, more time devoted to seeing patients (here I refer to the time spent when one is not scheduled for clinic) means less time for teaching, scholarly activity, administrative duties and even reading.
Academic medicine in 2008 often focuses too much on money. The heroes are those who bring in grants, or many patients, rather than those who publish important articles (unless those result from the grants) or those who are great teachers. The pursuit of money is corrupting the academic mission.
But then, does this really surprise anyone?
April 21st, 2008 at 5:26 pm
Stimulate them to work harder? Yep. To generate more income.
WHEN will bean counters learn that you can count the number of lug nuts an assembly line worker tightens in a given time period. but you CAn NOT apply this to cognitive professions? My answer: Never.
Medicine has been taken over by MBAs, Wall Street, etc. Even in academics.
April 21st, 2008 at 5:57 pm
I left academic medicine because of this. All that mattered to my chief and my chair was how many RVUs I could generate. Teaching evaluations were irrelevant. When asked to give a lecture, my collegues would answer “how many RVUs will I get for that?”
Had I stayed, I would have been on the non-teaching service for 48 weeks a year, academic ward attending for 2 weeks a year, and 2 weeks vacation.
Why would anyone take a pay cut to clinical work without any time teaching? At a community hospital 8 miles away, I get more pay, more vacation, and more support and generate more RVUs. I don’t ever see residents but is this so different than my old job?
Dr. Centor, you are right on target with your quesitons. How will academic medicine continue to recuit and retain young faculty unless it worries about something more than RVUs?
April 22nd, 2008 at 8:10 am
dr. centor-i was the one who asked the questions you kindly answered regarding relationships between attendings and trainees. it is my opinion that the relationships are strained to the point of breaking. i do not hear recently graduated residents sing the praises of their attendings-note i say attendings and not mentors. i hear the recently graduated physicians complain that they weren’t taught properly, that their attendings were not engaged in preparing to teach them things, that focus was on rvu’s, or research etc. additionally, as attendings are increasingly hired to do the ‘clinical’ work and given titles such as acting instructor or some such insulting position of decreased recognition and pay, the age and experience differential decreases dramatically. lastly, these acting instructors seem to be quite miserable. they feel that the senior attendings don’t support them. they feel underpaid. the system is too competitive. the residents don’t appreciate them. the medical students grade them, so if you give an honest assessment that someone is deficient, that can come back to haunt you during your own evaluation. that misery is transmitted quite clearly to the trainees. that, imo, is why people don’t go into primary care.
as for academic primary care, why would they? the specialists do most of the clinical research in the 3 institutions i trained at. the academic primary care groups started requiring general internal medicine fellowships and mph’s to join. what sense does it make? they turned away their own chief residents who subsequently went on to do specialty fellowships instead. instead of nurturing those with interest, they just cut them the off at the knees with unrealistic demands that the attendings themselves had never achieved.
i am pleased you manage to continue to treat your students and residents in such a caring fashion. i would respectfully submit that yours is an unusual situation, rather than the norm. possibly your longstanding experience and success has allowed you to carve out a niche that today’s young attendings may not be able to. especially since in contrast to Erik above, you have just a few clinical months a year. how good would you be if you were following his schedule? it is clear from the description, that Erik’s mentor’s did not have his long term career interests in mind when they created his schedule. imho, that is the typical experience.
respectfully submitted.
April 24th, 2008 at 8:08 pm
The bills (your salaries, for example) need to be paid somehow. In case you haven’t noticed, the Medicare program has decimated IME and Direct payments as well. Seeing patients pays bills. If you have a better idea that will keep the doors open let someone know, rather than hoping for the great ‘ol days to return. They won’t.