Unintended Consequences? Unanswered Questions?

Miller, Ronald D. MD

Anesthesia & Analgesia:
doi: 10.1213/01.ANE.0000215145.64532.EE
Letters to the Editor: Letters & Announcements
Author Information

Department of Anesthesia and Perioperative Care; University of California; San Francisco, CA; millerr@anesthesia.ucsf.edu

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In Response:

Current economic conditions dictate that academic anesthesia departments shift from a traditional salary-based compensation plan to that which is incentivized. The fundamental issue of the Abouleish et al. letter (1) revolves around “how many unanswered questions need to be answered before implementing such a plan?” Certainly, an academic anesthesia department should carefully assess the impact of any change in its compensation plan on its overall academic program. Furthermore, if a more formal retrospective analysis can be performed, even more information will be available to the department to guide its future actions. If the new plan “makes things worse,” of course, the plan should be modified or eliminated.

Virtually all of the important questions outlined by Abouleish et al. are impossible to objectively predict (except by educated guesses) and difficult to analyze retrospectively. Even in our simple study (2), the time period during which we had a “pure salary-based compensation plan” was many years (1965–1997) before implementing an “incentive compensation plan” (1997–present). Anyone familiar with study designs knows the dangers of comparing a variable (e.g., compensation plan) that existed in different periods of time. For example, our basic research program significantly increased when we implemented our incentive program. Would the research have increased independent of the compensation plan? An adventurous dreamer might even postulate that research would have increased even more, if we had retained our “salary-based compensation.” In other words, is there a “cause and effect” relationship between decreases and increases in quantity and quality of a department's academic programs? Because more changes are compared during differing time periods, precise answers to Abouleish et al.'s concerns are difficult to answer objectively.

We are puzzled by the question in the second paragraph in the letter by Abouleish et al. (1), “What was the impact of the incentive system on the total quantity of clinical work done in the operating rooms?” The total volume of cases in the operating room is usually controlled by surgeons. How does anesthesia influence “quantity of clinical work”? Yet, there is no question that volunteer incentive programs increase the general productivity of an anesthesiology group overall, without the department having to pay the additional benefits. Yet, we clearly stated that the purpose of our study was to define the impact of an incentive system on the distribution of the moneys collected. We think the conclusions are clear. The purpose of the study was not to answer all of the other questions asked by Abouleish et al. We certainly would welcome any group that attempts to study those questions in a meaningful and objective manner.

Most universities, including the University of California, San Francisco, analyze the quality of their departments approximately every 5 yr. In that regard, our educational accomplishments and research were viewed as excellent and gradually increasing in quality. Is there a “cause and effect” relationship between these observations and our compensation plan? Who knows? Abouleish et al. suggest that there should be a “concomitant survey of the quality of the perceived quality of teaching.” Independent of the presence of a new compensation plan, all departments ideally perform a continuous assessment of all their academic programs, including research and education. After 1 yr of prediction, conjecture, and apprehension, we started. The danger of extensive conjecture regarding the impact of such a program is that it is never implemented. The pursuit of excellence requires new innovative approaches to perplexing problems.

In our case, the problems that we had in the operating rooms were so severe (e.g., who works harder? Equal pay for poor performers, etc.?) that a change in compensation was needed rather rapidly. After a year of discussion, the faculty apprehensively agreed to implement such a program. Although our plan is not without problems, it has been extremely successful overall. It has been in place for nearly 8–9 yr. We are now in a position of making some revisions, but the general principles will be retained.

Any time a new system is implemented, the department should be flexible enough to make changes and adjustments according to new evidence that evolves. We believe that answering all of Abouleish et al.'s questions before implementing a plan runs the risk of not implementing the plan on a timely basis. The alternative is to implement a plan with a commitment to flexibility and responsiveness to new information. That is what we have done. As indicated in our article, we hope that our study will provide an “incentive” for a reasonable, scholarly discourse based on data, rather than opinion and fear, regarding the conditions under which academic departments should implement incentive-based systems (and which one).

Ronald D. Miller, MD

Department of Anesthesia and Perioperative Care

University of California

San Francisco, CA


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1. Abouleish AE, Prough DS, Lubarsky DA. Unintended consequences? Unanswered questions? Anesth Analg 2006;102:xxx.
2. Miller RD, Cohen NH. The impact of productivity-based incentives on faculty salary-based compensation. Anesth Analg 2005;101:195–9.
© 2006 International Anethesia Research Society