The Modern Teaching Physician—Responsibilities and Challenges: An APDIM White Paper

Article Outline

• Clinical Care
• Teaching Activities
• Scholarship/Research
• Financing
• Satisfaction
• Conclusion
• Acknowledgments
• References
• Copyright

The practice of medicine is a complex endeavor involving the application of a broad array of knowledge, skills, and attitudes to the promotion of health and well-being and the diagnosis and treatment of patients with acute and chronic illness. Undergraduate medical education (medical school) is only the first step in training physicians capable of providing independent patient care. Graduate medical education (GME) is essential for the development of critical skills, knowledge, and professionalism required for competent, safe, and independent patient care.

Essential to the delivery of GME at sites of patient care, teaching physicians find themselves in a veritable vise grip of competing forces. Both the process of GME and the environment in which it is delivered have been the target of mounting financial pressures and more intense regulation. The shrinking profit margin for health care systems has increased efforts to maximize efficiencies even though the process of care in a learning environment has inherent inefficiencies. In most environments, teaching receives little, if any, direct financial reward and may be among the least career-sustaining activities in which these physicians engage.

The primary intent of this article is to review the functions of teaching physicians and underscore the complex requirements for serving in this capacity. Although our perspective is from internal medicine training, the principal roles and requirements are applicable in most other specialties.

Traditionally, the term “teaching physician” refers to a medical doctor who teaches basic science or clinical medicine within a medical school or residency. While there is significant variability in the responsibilities of teaching physicians, certain activities are common to many clinician-educators. Table 1 is a sample schedule that illustrates the breadth and diversity of the work of teaching physicians. Many activities occur outside the boundaries of the traditional work week and are not captured in this table.

Table 1. Example of a Teaching Physician's Weekly Schedule

The teaching physician may be a full- or part-time faculty member of a medical school or hospital who is salaried by the institution or serves as an unsalaried affiliate. The teaching physician may educate in a variety of venues, including classrooms, laboratories, hospital wards, or outpatient clinics. In addition to their educational responsibilities, most teaching physicians have other obligations; the amount of time spent teaching is highly variable.

The typical teaching physician has 3 main duties: delivering high-quality, safe, and efficient patient care; providing comprehensive physicians-in-training education; and contributing to scholarship. Each of these duties has regulatory aspects with which the teaching physician must comply. Additionally, some teaching physicians have specific administrative responsibilities within their institutions.

The first priority for teaching in the clinical environment is always the provision of high-quality patient care. Beyond knowing the current standards of care, the teaching physician must invest time to stay at the “cutting edge” of medical science. A great deal of time is spent defining new standards of care and communicating these standards. Medical school graduates are far from finished products. Unqualified to provide patient care independently and with no significant training in a specialty, the resident achieves competence through the efforts of teaching physicians, who are mentors, advisors, role models, instructors, evaluators, and safety officers.

Teaching physicians mold the attitudes and culture of the next generation of physicians. The functional adoption of increased regulatory scrutiny and pay-for-performance and patient safety initiatives is facilitated by the efforts of teaching physicians to make these initiatives understandable and acceptable to physicians-in-training.

Although teaching institutions employ layers of safety checks and oversight, it is the teaching physician who is ultimately responsible for every patient. These individuals oversee procedures, participate in all significant decision-making processes, and ensure that safe and effective health care is provided. Teaching physicians play a central role in advancing patient safety initiatives and promoting a culture of safety among new physicians.

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Clinical Care 

Teaching physicians can provide direct patient care without interacting with physicians-in-training, functioning much like a private physician. They may see patients accompanied by a student or resident who observes their activities. Simple shadowing can add more than 30 minutes to a half-day clinic session.¹ Teaching physicians also might supervise up to 4 residents in an outpatient setting. In a primary care continuity clinic, this supervision involves reviewing each patient's medical care with the resident and making an entry in the medical record.

Despite a wide variety of inpatient clinical care settings, most situations involve a teaching physician making daily rounds with residents, which must include at least 4.5 hours of teaching per week (in addition to time spent discussing management) to comply with Accreditation Council for Graduate Medical Education (ACGME) requirements. To bill for services, the supervising physician must see each patient and make a suitable entry in the medical record. The multiple permutations of this inpatient care model, many of which blend teaching and patient care activities, make accounting for relative effort in these areas difficult.

Over the past decade, the use of hospitalists as inpatient teaching faculty has been an increasing trend. Such physicians spend a significant amount, if not all, of their clinical time caring for hospitalized patients. Few data exist on the impact of this trend on the quality of the residents' educational experience; some studies indicate a favorable effect for residents.², ³

Realizing the heterogeneous nature of the modern teaching physician's clinical work, we can at least examine trends in the amount of clinical care they provide by looking at standard measures of productivity, such as resource-based relative value units (RVUs) and revenue. Hospitals in general, and teaching hospitals in particular, have faced increasing financial challenges, resulting in pressure on faculty to be more clinically productive. Data gathered by the Medical Group Management Association indicate that for the 3 calendar years spanning 2002-2004, productivity as measured by RVUs increased by 19% for academic internists, while private-practice internists experienced only a 4.4% boost. In 2004, the average academic internist full-time equivalent produced 92% of RVUs of internists in private practice.⁴, ⁵ As clinical demands increase, teaching physicians face greater challenges in meeting the educational needs of physicians-in-training.

An examination of the clinical work of academic faculty also should consider the types of patients they serve. In addition to caring for patients who generally have more serious illnesses and are more complex than in non-teaching hospitals, teaching physicians provide a disproportionate amount of care to underinsured and uninsured patients. According to the Association of American Medical Colleges, medical schools and teaching hospitals account for only 6% of our nation's hospitals, yet they provide nearly one-half of all hospital charity care.⁶

Health care providers have been beleaguered by increasing amounts of paperwork, and teaching physicians are no exception. Documentation requirements for clinical care provided while supervising a physician-in-training have become more extensive at the same time that teaching physicians are seeing more patients. Failure to comply with such requirements may limit reimbursement or subject the physician or institution to fines or charges of fraud.

While administrative faculty, such as department chairs, program directors, and associate program directors, must have substantial knowledge of pertinent regulations, notify the faculty of relevant requirements and available resources, and appropriately monitor the educational environment, it is the clinician-educator on the wards and in the clinics who must ensure day-to-day compliance. Of the regulatory bodies listed in Table 2, the typical teaching physician should be most familiar with the regulations promulgated by ACGME, the Joint Commission, and the Centers for Medicare and Medicaid Services.

Table 2. Regulation of Graduate Medical Education

While institutions have dealt with the clinical ramifications of the ACGME duty hour restrictions in different ways, faculty workload typically increased to some degree. Although few objective data exist, some authors have noted adverse effects on faculty workload and quality of life without additional patient care revenue to counterbalance the change.⁷, ⁸ A surgical residency study found that faculty work hours and clinical productivity showed little change after duty hour restrictions were instituted; however, it was likely that faculty were replacing activities such as teaching with nonremunerative clinical work. Indeed, 83% of the surveyed faculty felt that their academic productivity decreased during the study period.⁹ In a multi-institutional survey of faculty in internal medicine residencies, more than one-half of the respondents reported decreased satisfaction with teaching, and more than two thirds noted decreased opportunities for both bedside and didactic teaching. One third experienced a decrease in overall career satisfaction.¹⁰

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Teaching Activities 

Several activities of the teaching physician are directly related to the training of medical residents. In broad terms, they include direct teaching through lectures, small group discussion, and supervision of residents' clinical activity; curriculum development; evaluation of physicians-in-trainings; and career mentorship for residents (including writing letters of recommendation).

The teaching physician must educate residents in their primary specialty. This body of knowledge is wide, complex, and constantly changing. For example, the American Board of Internal Medicine defines 16 separate subject areas to be mastered, as well as 12 separate “cross-content” areas.¹¹ Mastery is directed and driven by the teaching physician. Beyond advancing the physician-in-training's knowledge and clinical skills, the teaching physician must encourage interpersonal and communication skills and professionalism, foster continuous quality improvement, and develop residents' abilities to utilize best evidence for practice.

From a societal standpoint, a critical component of the teaching physician's job is the evaluation of residents and assessment of readiness to practice independently. With input from teaching physicians, residency programs approve suitable physicians-in-training as candidates for board certification, qualifying the resident for a certification examination. Over the past few years, a new education and evaluation paradigm has been developed based on the ACGME focus on competency-based curricula and outcome measures.¹² In residency training, this shift in thinking has contributed to an increase in responsibilities for teaching physicians, particularly with respect to the evaluation of residents and curriculum development. New evaluation tools have been introduced to residency programs, such as objective structured clinical examinations, 360-degree evaluations, and witnessed patient encounters (clinical evaluation exercises). Such assessments require significantly more faculty time.

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Scholarship/Research 

Teaching physicians also might help fulfill the mission of medical schools and teaching hospitals by participating in biomedical research and promoting an atmosphere of scholarship. Participation in this endeavor varies among individuals, departments, and institutions. Scholarship includes any activity that contributes to an environment of scientific inquiry and is not limited to formal research. It includes activities such as case reports and reviews.

Academic success and promotion have historically been predicated on scholarly activity, and some medical school faculty have fulfilled this mandate by designing, implementing, and participating in research studies.¹³ In addition to the obvious societal gain from the advancement of scientific knowledge, residents also benefit from their involvement in research. Teaching physicians help physicians-in-training learn basic laboratory techniques and develop scientific reasoning skills as well as serve as role models for individuals who will pursue independent research. However, research-oriented teaching physicians have become less accessible to residents as they spend less time on the wards due to added regulatory burdens and market forces that favor physicians who concentrate on hospital care.

During the past few years, the academic medicine community has become increasingly concerned about the ability to obtain funding for research endeavors. In this era of restricted spending, academic and clinical departments will likely find it difficult to financially support the scientific endeavors of faculty who do not receive salary support from research dollars. Many institutions have instituted mission-based management plans in an attempt to align their missions with practical funding streams.¹⁴ RVUs or educational value units have been used to credit various faculty activities such as clinical care, research, or teaching.¹⁵, ¹⁶ Although the National Institutes of Health provides salary support through its research grants, many granting agencies do not provide such support for the grant recipient. Based on the 2005 Administrators of Internal Medicine/Association of Professors of Medicine Statistical and Salary Survey, which includes responses from 65 departments of internal medicine, approximately 20% of total departmental faculty salaries were supported by grants (nonpublished survey data).

The work of academic researchers plays a significant role in training and mentoring the next generation of investigators. Production of physician-scientists has slowed in recent years and care must be taken to maintain the supply of these physicians who are in a unique position to advance the understanding and treatment of diseases.

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Financing 

The financing of GME in the United States is complex and beyond the scope of this article. Although it impacts the lives of virtually every teaching physician, few understand the mechanics of this revenue source. While Medicare is the largest single source of GME funding, other federal funds (including Medicaid), state-level Medicaid, and other state-appropriated funding contribute to the total support. Considerable variation exists from institution to institution on the amount of support received for each resident. Significant differences also exist in the method and amount of GME support that each state provides.

The time and effort of teaching physicians is theoretically covered by direct graduate medical education funding. This terminology is used by Medicare and some states for costs related to the residents' stipend and fringe benefits, faculty involvement, program administration, and insurance costs. The specific costs attributable to graduate medical education are difficult to determine because teaching is frequently blended with patient care and research activities. Uncoupling and examining specific costs attributable only to GME is a complicated task. In an article published in 2001, Nasca et al¹⁷ endeavored to establish specific line-item costs attributable to a graduate training program in internal medicine. This article established a framework for the analysis of direct costs attributable to GME.¹⁷ The total annual cost per resident for conducting a program that meets the ACGME requirements ranged from $70,692 to $95,143, for inpatient-intensive residency programs with resident complements of >100 or <25, respectively, inclusive of resident salaries and fringe benefits. These figures do not include the indirect costs of educating residents attributable to technology, case mix at teaching hospitals, or increased length of stay.

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Satisfaction 

Satisfaction among teaching physicians is important in 2 critical ways. First, satisfaction is directly related to faculty retention and turnover rates.¹⁸ Second, satisfaction of the teaching physician can have a substantial effect on the learner and on patients.¹⁹ At the same time, careers in academic medicine provide unequaled opportunities for personal reward through shaping the next generation of physicians, passing on the foundations of medicine, and contributing to the discovery of new knowledge in the medical sciences.

Surveys of faculty conducted over the past 2 decades have generally indicated high levels of satisfaction, although the relative satisfaction was related to rank (increased satisfaction with increasing rank) and, especially in competitive markets, the balance of major clinical responsibilities (decreased satisfaction with increasing clinical responsibilities).¹⁶ Still, leaders in academic medicine have drawn attention to the potential for declining satisfaction and burnout as the stress of working in teaching hospitals has increased.²⁰, ²¹ Despite the stressors facing teaching hospitals, faculty are most satisfied when they are educating.²² The preservation of teaching time is the major challenge for teaching hospitals.

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Conclusion 

The role of a teaching physician has become increasingly complex and challenging. A good teacher not only possesses knowledge, but effectively conveys it to residents while also modeling and encouraging the practice of compassionate medicine. Teaching physicians guarantee the future of high-quality health care by ensuring that physicians-in-training acquire the knowledge and skills necessary for independent practice. Numerous forces threaten to compromise the function of this vital group of teaching physicians. As our health care and educational systems evolve, we must protect this resource that is essential to maintaining the supply of competent and skilled physicians.

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Acknowledgments 

The authors wish to acknowledge Charles P. Clayton and Allison Haupt for their assistance in the preparation of this article. Their contributions included administrative and organizational services for our committee as well as review and editing of this document.

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References 

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