Rewards and Incentives for Nonsalaried Clinical Faculty Who Teach Medical Students

Abstract

We surveyed the clerkship administrators of pediatrics, family medicine, and internal medicine at U.S. medical schools, and of pediatrics at Canadian medical schools to determine what rewards and incentives are being offered to nonsalaried faculty for office-based teaching. Monetary payment was offered by 13% to 22% of the programs. Nonmonetary rewards like educational opportunities were offered by 70% to 89%; academic appointments by 90% to 95%; special recognition events by 62% to 79%; and appreciation letters by 74% to 84% of programs. Only 3 of 338 responders offered no rewards or incentives.

Medical schools have traditionally relied on the voluntary efforts of physicians for the clinical teaching of medical students.^1–3 Recent changes in the health care system have had the unintended consequence of making it more difficult for primary care physicians to volunteer their time.^4–7 Following the Generalist Task Force’s recommendations, medical educators increased emphasis on community-based experiences for medical students during their clinical years by requiring practicing physicians in the community to provide educational experiences.^8–11 Although studies over the past decade have identified the costs involved in ambulatory teaching, ^7,12–14 there is a paucity of information regarding the rewards and incentives offered to volunteer clinical faculty. This survey was conducted to determine what rewards, recognition, and incentives are being offered to the nonsalaried office-based faculty for teaching.

METHODS

A survey was mailed to clerkship directors or clerkship coordinators of pediatrics, family medicine, and internal medicine in all U.S. medical schools and to administrators of pediatrics clerkships in 16 Canadian medical schools. Using a yes/no format, the survey asked whether the department or the college offered office-based, nonsalaried physicians monetary payment, educational opportunities, perks, privileges, gifts, teaching awards, academic appointments, special recognition events, letters of appreciation, or other incentives.

All returned surveys were reviewed prior to data entry. Data were entered and analyzed using Microsoft EXCEL and ACCESS; statistical analysis was done with SPSS-PC.

Clerkship administrators returned 348 surveys. There were 86 responses from pediatric clerkship administrators at 77 (61.6%) of 125 U.S. medical schools and 10 responses from 16 Canadian medical schools (overall response, 87 [61.7%] of 141); multiple responses were received from 6 U.S. schools with multiple campuses or administrative units. There were 148 responses from family medicine clerkship administrators at 93 (74.4%) of 125 U.S. medical schools; multiple responses were received from 33 schools with multiple campuses. There were 104 responses from internal medicine clerkship administrators at 80 (64%) of 125 U.S. medical schools; multiple responses were received from 17 schools with multiple campuses. Even after two reminders, surveys were not returned by 38% of pediatrics programs, 36% of internal medicine programs, and 25% of family medicine programs at U.S. medical schools. It is probable that these programs were not utilizing community-based clinical faculty for clinical teaching. Ten returned surveys (three from pediatrics, seven from internal medicine) indicated that office-based, nonsalaried faculty were not involved in clerkship teaching; therefore, data were analyzed from 338 surveys.

RESULTS

Monetary payment for office-based teaching was offered by 13% to 22% of programs (Table 1) Several types of payment schemes were identified (Table 2)Table 1 also lists other rewards and incentives. Different types of educational opportunities were offered. Faculty development workshops were offered by 80% of family medicine, 63% of internal medicine, and 55% of pediatrics programs (p < .0001). Few programs offered travel or registration costs for professional meetings, while about one third provided discounted tuition at the university. Common gifts that were offered included parking stickers, discounted or priority tickets to campus events, and access to the campus health/fitness facilities. Several respondents listed free access to library and computer facilities, availability of electronic mail through the university, discounted or free registration for university-sponsored continuing medical education courses, and books, audiovisual, or computer equipment. An academic appointment was offered by most programs, and prefixed (clinical) appointments were offered by almost 90% of the programs. Special recognition was given at lunch or dinner events most of which were held annually. Appreciation letters were usually signed by clerkship directors. Only 3 (0.8%) of 338 respondents did not list any rewards or incentives for their nonsalaried teaching physicians.

Table 1.

Percentage of Family Medicine, Internal Medicine, and Pediatrics Programs Offering Incentives and Awards

Awards/Incentives Category	Family Medicine, %	Internal Medicine, %	Pediatrics, %
Monetary payment	22	13	18
Educational opportunities	89	73	70
Gifts	40	41	71
Teaching awards	45	46	53
Academic appointments	90	95	92
Special recognition events	79	62	65
Appreciation letters	84	81	74

Table 2.

Monetary Payment Structures

Quarterly to yearly arrangements

$500 per student per year

$500 per student for 4 months

$500 for 6 months

$1,000–$5,000 per year

$12,000 for taking continuous flow of students

Per session or per period arrangements

$50–$55 per hour

$50–$150 for half day

$150 per week per student

$300–$1,500 for 3- to 4-week clerkship

$1,950 for 6-week clerkship

Miscellaneous

Continuing medical education reimbursement by the college based on number of students taught

Malpractice covered by the university as reimbursement for teaching

DISCUSSION

Recent studies have described the problems medical schools have in today’s era of change compensating their faculty fairly for teaching.^15,16 Most physicians feel an obligation to return some of the education that they received as students. Under the old fee-for-service system, many physicians could afford to donate their time to teaching.¹⁷ Under current managed care and discounted fee-for-service systems, there is less flexibility in scheduling, and it is more difficult for physicians to accommodate teaching.¹⁸ Given the current emphasis on reducing health care costs, including the cost of medical education, it will be difficult to find additional funding for community-based medical educators.^5,9,17 Hence, new forms of rewards for teaching must be developed.¹⁹ We do not know which types of rewards are more effective. One study indicates that fulfillment as a teacher, interacting with students, and refining skills are important motivators, but recognition by colleagues or patients as a teacher and academic acknowledgment were of little value.²⁰ Perhaps it also will be necessary for clerkship directors to trim the roster of clinical faculty, leaving only those who contribute significantly to the teaching program, and redistribute any payments for teaching among this smaller number of teachers.