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To train or not to train
Editorial
To train or not to train Alexis H. Tilley, MBA, MHSA, and Gary L. Stiles, MD Durham, NC
See related article on page 414. How many cardiologists are enough? The answer, by and large, depends on who is asking the question and to whom the question is being posed. For rural Americans who would like access to high-quality cardiovascular care in their community, the answer is likely to be “we need more.” For an employee in a large, affluent metropolitan area, the answer is likely to be “There are so many cardiologists, I don’t know how to chose. I would like a few high quality cardiologists to choose from and you can eliminate the extra physicians who are driving up the cost of medical care.” For a managed care company or an independent practice association, the answer is likely to be “The minimum number of cost-effective, outcome-driven cardiologists to serve our enrolled population.” This same question can be asked of society, the government, or any other interest group with fairly predictable answers. The article by Franzini et al1 in this issue of the Journal poses the question to the University of Texas-Houston Cardiology department. In particular, the article focuses on the cost of training cardiology fellows. This component can then be used to help address the larger questions of how many cardiology fellows should be trained, what is the quality of the product that is being produced, who should be providing the training, and just who is responsible for making all these decisions. A fundamental question at many academic medical centers today is whether training programs are, in actuality, a cost or a benefit to the medical center. Although it is universally believed that the funding received for training programs does not support the cost of the training program, the benefit received through the additional clinical productivity of trainees has not been accurately quantified. The paper by Franzini et al1 attempts to quantify this benefit and assess the full impact of training cardiologists on the University of Texas-Houston Medical Center. The financial approach taken is very reasonable and sound. However, there are a number of methodologic and model assumptions made that need to be scrutinized before the results can be validated or exported to
From the Private Diagnostic Clinic and the Division of Cardiology, Duke University Health System. Reprint requests: Gary L. Stiles, MD, Division of Cardiology, Box 3681, Duke University Medical Center, Durham, NC 27710. Am Heart J 1999;138:390-1. 0002-8703/99/$8.00 + 0 4/4/95078
other academic or nonacademic training programs or can be considered generalizable. First, although “surveys and effort reports have been used extensively in medical education cost studies,” they have an inherent reporting bias in them depending on how the faculty member perceives the information will be used. For example, if the survey is sent out with the intent of documenting how much work is being done to support the academic mission of the medical center (ie, teaching and research), which is not funded or compensated, the surveys will be returned with a great amount of time spent in these academic endeavors. If, on the other hand, the survey is sent out with the intent of assessing productivity, the effort might look very different. In addition, given the variation in activity that occurs at most academic medical centers, accurately capturing an “average” workweek through a single survey is very difficult. One has to be very careful with this type of self-reported data and really assess the motivation behind the documentation of effort. Second, it is surprising that 3 (18%) of 17 of the fellows could not be reached or did not respond to the survey instrument. This is of particular concern when it appears that fellows completed a survey only for a single month of service taken during May/June 1997. How representative are single rotation assessments by a single fellow? The variation in time spent or consciousness noted in our training program among different fellows on a given rotation leads us to believe input from several fellows per rotation would be important. Another component potentially missing from the faculty cost estimates is the decreased or perhaps increased faculty productivity associated with fellows on service (inpatient, outpatient, or during procedures). These costs or revenue would not be transferable back to senior faculty when junior faculty replace fellows because these junior faculty would be presumably billing for services, so the cost or revenue would not be attributed to senior faculty. A method to account for this will need to be incorporated into the model, such as separating time into billable and nonbillable and correcting for enhanced/impeded services and type of billable activity, such as fee-for-service or capitated services. Finally, appropriately, the model uses a fully loaded cost for supporting resources and documents the fixed costs and the variable costs. What needs to be further defined and clarified is what percentage of the total costs is attributable to teaching versus research cost, administrative cost, clinical cost and other overhead. In addition, it would be imperative to know where all these costs are currently being borne—by the department? By
American Heart Journal Volume 138, Number 3, Part 1
Tilley and Stiles 391
the institution? By the hospital? By the clinical practice? Although separating expenses by which mission they are supporting is not easy at an academic medical center, it will be necessary to be able to use this model in any meaningful fashion across multiple institutions. The replacement cost issue is likely to remain a very important “hot button” concern. Above and beyond the debate about how many fellows should we be training to meet the national health care needs looms the practical issue of “if we train fewer fellows, who does the extra work and who pays for it?” A recent analysis at Duke University by the Department of Medicine estimates that to replace a medical resident with either a faculty member or a midlevel provider would add an additional $60,000 or $42,000 in cost, respectively, for providing services for the department. This would make the total cost of replacement in the range of $100,000 to $115,000 per resident (Sykes M, personal communication, 1997). The article by Franzini et al1 likewise documents that the replacement cost per cardiology fellow is in the range of $100,000. Beller and Vogel2 have recently discussed the entire issue of fellow training, personnel needs, and what the future may hold. They have clearly articulated some of the challenges ahead. Specifically, they have identified the difficulties in reducing the numbers of cardiology fellows,
including antitrust issues, the dependence on cardiology fellows to provide clinical services by hospitals and physician groups, the use of fellows to provide care for the indigent in major metropolitan areas, and the fact that cardiology trainees are less costly than the alternatives—namely, cardiologists or midlevel providers. These are all issues that will need to be resolved in the near future. Not addressed by a cost analysis are many intangibles, including the prestige value of having a training program associated with your hospital or cardiology practice and the negative impact of not having young inquisitive physicians around to ask probing questions and keep all concerned intellectually challenged and honest. Franzini et al1 are to be commended for their approach to cost accounting cardiology fellowship programs. These types of data are going to be a major component in the decision analysis of how many fellows we need and what we can afford.
References 1. Franzini L, Chen SC, McGhie AI, et al. Assessing the cost of a cardiology residency program with a cost construction model. Am Heart J 1999;138:414-21. 2. Beller GA, Vogel RA. Are we training too many cardiologists? Circulation 1997;96:372-8.
BOUND VOLUMES AVAILABLE TO SUBSCRIBERS Bound volumes of American Heart Journal are available only to subscribers from the Publisher at a cost of $112.00 for domestic, $142.31 for Canadian, and $133.00 for international subscribers for Vol. 137 (January-June) and Vol. 138 (July-December), shipping charges included. Each bound volume contains subject and author indexes, and all advertising is removed. Copies are shipped within 60 days after publication of the last issue in the volume. The binding is durable buckram, with the Journal name, volume number, and year stamped in gold on the spine. Payment must accompany all orders. Contact Mosby, Inc., Subscription Services, 11830 Westline Industrial Dr., St. Louis, MO 63146-3318, USA; (800)453-4351, or (314)453-4351. Subscriptions must be in force to qualify. Bound volumes are not available in place of a regular Journal subscription.
To train or not to train Alexis H. Tilley, MBA, MHSA, and Gary L. Stiles, MD Durham, NC
See related article on page 414. How many cardiologists are enough? The answer, by and large, depends on who is asking the question and to whom the question is being posed. For rural Americans who would like access to high-quality cardiovascular care in their community, the answer is likely to be “we need more.” For an employee in a large, affluent metropolitan area, the answer is likely to be “There are so many cardiologists, I don’t know how to chose. I would like a few high quality cardiologists to choose from and you can eliminate the extra physicians who are driving up the cost of medical care.” For a managed care company or an independent practice association, the answer is likely to be “The minimum number of cost-effective, outcome-driven cardiologists to serve our enrolled population.” This same question can be asked of society, the government, or any other interest group with fairly predictable answers. The article by Franzini et al1 in this issue of the Journal poses the question to the University of Texas-Houston Cardiology department. In particular, the article focuses on the cost of training cardiology fellows. This component can then be used to help address the larger questions of how many cardiology fellows should be trained, what is the quality of the product that is being produced, who should be providing the training, and just who is responsible for making all these decisions. A fundamental question at many academic medical centers today is whether training programs are, in actuality, a cost or a benefit to the medical center. Although it is universally believed that the funding received for training programs does not support the cost of the training program, the benefit received through the additional clinical productivity of trainees has not been accurately quantified. The paper by Franzini et al1 attempts to quantify this benefit and assess the full impact of training cardiologists on the University of Texas-Houston Medical Center. The financial approach taken is very reasonable and sound. However, there are a number of methodologic and model assumptions made that need to be scrutinized before the results can be validated or exported to
From the Private Diagnostic Clinic and the Division of Cardiology, Duke University Health System. Reprint requests: Gary L. Stiles, MD, Division of Cardiology, Box 3681, Duke University Medical Center, Durham, NC 27710. Am Heart J 1999;138:390-1. 0002-8703/99/$8.00 + 0 4/4/95078
other academic or nonacademic training programs or can be considered generalizable. First, although “surveys and effort reports have been used extensively in medical education cost studies,” they have an inherent reporting bias in them depending on how the faculty member perceives the information will be used. For example, if the survey is sent out with the intent of documenting how much work is being done to support the academic mission of the medical center (ie, teaching and research), which is not funded or compensated, the surveys will be returned with a great amount of time spent in these academic endeavors. If, on the other hand, the survey is sent out with the intent of assessing productivity, the effort might look very different. In addition, given the variation in activity that occurs at most academic medical centers, accurately capturing an “average” workweek through a single survey is very difficult. One has to be very careful with this type of self-reported data and really assess the motivation behind the documentation of effort. Second, it is surprising that 3 (18%) of 17 of the fellows could not be reached or did not respond to the survey instrument. This is of particular concern when it appears that fellows completed a survey only for a single month of service taken during May/June 1997. How representative are single rotation assessments by a single fellow? The variation in time spent or consciousness noted in our training program among different fellows on a given rotation leads us to believe input from several fellows per rotation would be important. Another component potentially missing from the faculty cost estimates is the decreased or perhaps increased faculty productivity associated with fellows on service (inpatient, outpatient, or during procedures). These costs or revenue would not be transferable back to senior faculty when junior faculty replace fellows because these junior faculty would be presumably billing for services, so the cost or revenue would not be attributed to senior faculty. A method to account for this will need to be incorporated into the model, such as separating time into billable and nonbillable and correcting for enhanced/impeded services and type of billable activity, such as fee-for-service or capitated services. Finally, appropriately, the model uses a fully loaded cost for supporting resources and documents the fixed costs and the variable costs. What needs to be further defined and clarified is what percentage of the total costs is attributable to teaching versus research cost, administrative cost, clinical cost and other overhead. In addition, it would be imperative to know where all these costs are currently being borne—by the department? By
American Heart Journal Volume 138, Number 3, Part 1
Tilley and Stiles 391
the institution? By the hospital? By the clinical practice? Although separating expenses by which mission they are supporting is not easy at an academic medical center, it will be necessary to be able to use this model in any meaningful fashion across multiple institutions. The replacement cost issue is likely to remain a very important “hot button” concern. Above and beyond the debate about how many fellows should we be training to meet the national health care needs looms the practical issue of “if we train fewer fellows, who does the extra work and who pays for it?” A recent analysis at Duke University by the Department of Medicine estimates that to replace a medical resident with either a faculty member or a midlevel provider would add an additional $60,000 or $42,000 in cost, respectively, for providing services for the department. This would make the total cost of replacement in the range of $100,000 to $115,000 per resident (Sykes M, personal communication, 1997). The article by Franzini et al1 likewise documents that the replacement cost per cardiology fellow is in the range of $100,000. Beller and Vogel2 have recently discussed the entire issue of fellow training, personnel needs, and what the future may hold. They have clearly articulated some of the challenges ahead. Specifically, they have identified the difficulties in reducing the numbers of cardiology fellows,
including antitrust issues, the dependence on cardiology fellows to provide clinical services by hospitals and physician groups, the use of fellows to provide care for the indigent in major metropolitan areas, and the fact that cardiology trainees are less costly than the alternatives—namely, cardiologists or midlevel providers. These are all issues that will need to be resolved in the near future. Not addressed by a cost analysis are many intangibles, including the prestige value of having a training program associated with your hospital or cardiology practice and the negative impact of not having young inquisitive physicians around to ask probing questions and keep all concerned intellectually challenged and honest. Franzini et al1 are to be commended for their approach to cost accounting cardiology fellowship programs. These types of data are going to be a major component in the decision analysis of how many fellows we need and what we can afford.
References 1. Franzini L, Chen SC, McGhie AI, et al. Assessing the cost of a cardiology residency program with a cost construction model. Am Heart J 1999;138:414-21. 2. Beller GA, Vogel RA. Are we training too many cardiologists? Circulation 1997;96:372-8.
BOUND VOLUMES AVAILABLE TO SUBSCRIBERS Bound volumes of American Heart Journal are available only to subscribers from the Publisher at a cost of $112.00 for domestic, $142.31 for Canadian, and $133.00 for international subscribers for Vol. 137 (January-June) and Vol. 138 (July-December), shipping charges included. Each bound volume contains subject and author indexes, and all advertising is removed. Copies are shipped within 60 days after publication of the last issue in the volume. The binding is durable buckram, with the Journal name, volume number, and year stamped in gold on the spine. Payment must accompany all orders. Contact Mosby, Inc., Subscription Services, 11830 Westline Industrial Dr., St. Louis, MO 63146-3318, USA; (800)453-4351, or (314)453-4351. Subscriptions must be in force to qualify. Bound volumes are not available in place of a regular Journal subscription.