Anesthesia & Analgesia:
Letters To The Editor: Letters & Announcements
Whitten, Charles W. MD
M. T. “Pepper” Jenkins Professor in Anesthesiology
Department of Anesthesiology and Pain Management
University of Texas Southwestern Medical Center at Dallas
To the Editor:
I applaud Feiner et al. (1) for the excellent report of their department’s system of measuring the clinical productivity of the faculty. This is an important issue for our specialty in general and for academic anesthesiology in particular. If academic departments are to survive in the future, systems for accounting for faculty time will need to be in place. Any system must be capable of assigning value to the clinical, academic, research, teaching, and administrative limbs of our academic mission. As Feiner et al. (1) point out, clinical time is a valuable commodity; however, anesthesia time-based units may not work in all academic institutions as a measure of faculty clinical responsibility.
I have struggled with this issue in a county hospital and have looked carefully at many “parts of the equation.” At a Level One Trauma Center we are asked to “have the capability to run X number of rooms at any particular time,” 24 hours a day/365 days per year. I use the analogy of the fire station—I have no idea if there will be a fire, but I must be able to put it out. This is currently an institutional mandate. Availability for the potential delivery of anesthesia services is the essence of a Level One Trauma Center. Many hospitals are now providing set fees for anesthesia provision in 12- or 24-h increments, where payment is made by the institution to a group of providers for in-house availability, as productivity cannot be guaranteed.
I understand the methodology of Feiner et al. (1) in evaluating their billable hour system. I am concerned that part-time faculty were omitted from their analysis and that only faculty taking full call were included in their investigation. In the future, we as a specialty must be flexible enough to allow part-time staff the opportunity to function in an academic setting (individuals who desire a part-time appointment). If our methods for monitoring productivity are not applicable to part-time individuals, or those not taking call, we are risking the loss of an important part of our workforce, particularly in this time of manpower shortage in anesthesiology.
A difficult concept to grasp in the billable hour methodology, one that administratively generates significant challenges, is the concept of not giving credit for staffing more than one clinical site. I have a hard time determining in a given interval of time, that staffing an experienced senior resident in a complex case is “worth the same” as staffing two seasoned CRNAs in less complex cases, or is the same as doing a case with an inexperienced resident or a surgery rotator, or doing a case by yourself. From my perspective, these unique challenges must be better understood as we develop metrics to address faculty productivity.
I agree with Feiner et al. (1) that availability alone in a large department with multiple subspecialty groups is difficult to use, especially when confused by coverage at multiple hospitals. Ultimately, large departments with numerous subspecialty divisions may need to implement a modification of the system described by Abouleish et al. (2) for services that require immediate availability (OB/Level One trauma units), while divisions with out of hospital call coverage may require a modification of the productivity formula as outlined by Feiner et al. (1).
Charles W. Whitten, MD
1. Feiner JR, Miller RD, Hickey RF. Productivity versus availability as a measure of faculty clinical responsibility. Anesth Analg 2001; 93: 313–8.
2. Abouleish AE, Zornow MH, Levy RS, et al. Measurement of individual clinical productivity in an academic department. Anesthesiology 2000; 93: 1509–16.