1. Show Us the Money!! Kathryn Chappelle, M.A. Shawn Blanchard, M.D. William Toffler, M.D. Ana Hilde, MS4 STFM Predoctoral Meeting 2007 Oregon Health & Sciences University Mission-Based Funding as the Key to Teaching Participation

2. She and a colleague put in about 30 hours on the phone to wheedle, flatter and plead with physicians to teach a required second-year course at Massachusetts General Hospital. “It’s always down to the wire,” says Dr. Fingold, “we’re in panic mode a week before the class is supposed to start.” Diane R. Fingold has mastered the art of begging…. The Chronicle of Higher Education, Nov 28 2003, 50:14, pA18

3. Family Medicine Faculty Involvement in Pre-Clinical Years + Key innovators in 1990’s education reform in years 1 and 2 + Increased leadership/control of SOM curricula + Opportunities to obtain grant funding for dept efforts + More exposure to students who may become future FPs + Expanding FM status and influence in institution – HRSA funding disappearing – FM leaders responsible for curriculum success without sufficient funding or faculty to teach

4. OHSU Principles of Clinical Medicine: Annual Recruitment Needs 230 Clinical preceptors 12027,600 144 Small-group facilitators 202,880 72 Patient-exam tutors 201,440 72 GOSCE observers 5360 70+ Presenters/panelists 170 50 Pelvic/GU instructors 2100 12 Psychiatrists 224 12 Neurologists 448 Total =32,522 hours

5. 115 Clinical Preceptors120 hrs each 80 Clinical Issues Presenters 2 hrs each 40 OSCE Observers 4 hrs each 16 PMR Leaders 12 hrs each OHSU Family Medicine Clerkship: Annual Recruitment Total: 14,312 hours

6. Faculty Recruitment Methods  Annual flyer to all faculty members  Annual sign-ups for past participants  Word of mouth, reputation of course  Student recruitment of individual preceptors  Appeals to dept. chairs for special needs  Individual phone recruitment (“begging”!)  Careful documentation of faculty participation - Dean’s Office for P & T - Copies of PCM letters to Chairs for faculty files

7. Stop-gap measures as class size increases and faculty participation decreases Course Directors take teaching slots, leaving them unavailable to substitute Small group sizes increase One faculty member for small groups normally co-facilitated Students present fewer cases in Clerkship PMRs and have fewer didactic sessions

8. Key Concern: The decline in faculty participation is detrimental to the education of our medical students. So…

9. OHSU Teaching Surveys-- 1999 and 2003 What did we learn?

10. In both 1999 and 2003 surveys, the majority of faculty said…  Not regularly involved in medical student teaching  Teaching not valued by depts as much as status or income-producing activities  Teaching of little value in advancing careers, despite Dean’s Office attempt to factor in to P&T  Increasing pressures to produce clinically leaves less time to teach  No compensation for teaching – even financial loss due to losing clinic time RVUs

11. 2003 participation in medical student instruction (little change from 1999)

12. SOM Responses to First Survey Largely Ineffective  Tried to make teaching “count” more in P&T  Created new education awards & luncheon to honor more faculty members for teaching efforts  Dean’s Office appealed to Chairs to support courses, but did not set expectations

13. Primary job responsibilities (Teaching rated as one of top 3)

14. Teaching Disincentives at OHSU

15. Suggestions to encourage teaching participation 256 suggestions from 192/360 respondents in 2003 24.2% Money for teaching to faculty or department 22.3% Time / FTE allotted for teaching 10.2% Recognize, value and reward teaching 9.4% SOM leadership should set clear expectations 8.6% Department encouragement / support 8.2% Give teaching more weight in P & T 6.6% Advertise & inform faculty of opportunities 12.5% Other, e.g., Change the curriculum or schedule, offer faculty development, provide adm. support, etc.

16. National picture: same issues No Time No Pay No Promotion WHY TEACH??

17. National strategies 1999 - Present StanfordChairs required by SOM to put 60% SOM funds toward teaching salaries or ed expenses Harvard Task force on faculty teaching resulted in successful “productivity credit” funding. NYUInstituted minimum teaching requirements UCSFFormed “academies” that used money specifically for education FSUFull-time faculty (77) hired primarily to teach WisconsinAdopted Mission Aligned Management & Allocation Model (MOMA) for school-wide budget

18. 1999: Key article on rethinking medical school funding Academic Medicine, June 1999 “Mission-Based Budgeting: Removing a Graveyard”, by Watson MD et al Robert Watson—Senior Assoc. Dean for Educational Affairs at University of Florida College of Medicine (Also in Academic Medicine Management Series: MB Management)

19. Definition of Mission Based Management A process “to identify and account for the costs associated with each medical school function, (teaching, research, patient care, community service, administration), and to match those costs with the various revenue streams available.” -Cohen, AAMC Reporter, 1998

20. Mission-Based Budgeting Recommended by AAMC in 1999 CGEA Position Paper: Defines departmental educational responsibilities Provides basis for divisional educational responsibilities Provides the basis for individual educational responsibilities Results in deliverables/expectations for the individual Determines individual measures/criteria for $$$

21. So where are we? At level of… … OHSU School of Medicine? … Family Medicine Department?

22. At OHSU School of Medicine SOM Strategy Under Discussion: redistribution of SOM funds according to department teaching contributions gradual preparation for new funding allotments Long political process (resistance to change) Assoc. Dean reluctant to call this “mission-based funding”

23. Analysis of tuition funds available for teaching* Assumptions: Tuition of ~$25,000 per year, per student ~100 students per class ~140 faculty hours/week/per class for small groups and lecture teaching (~70 hours each week for PCM and ~70 hours for the concomitant course being taught) ~40 weeks of class per year *Based on one class (PCM & Basic Sciences) for one year only – either yr one or two (not including precepting)

24. Total hours of teaching time: 140 faculty hours/wk X 40 weeks per year = 5600 faculty-hours per year Total teaching income: 100 students X $25,000/student/year = $2.5 million/year for one class per year Analysis of tuition funds available for teaching (cont)

25. Funds per teaching hour: Funds available per hour = $2.5 million per year/5600 faculty hrs per yr = $446 hour $223/person per hourWith a 50% overhead (building, maintenance, utilities, equipment, TSO staff) funds available per faculty hour of teaching = $223/person per hour Analysis of tuition funds available for teaching (cont)

27. PCM SMALL GROUPS Department Projected Need Current Contrib.Differ.Recom’d Anesthesiology152-136 Emergency Medicine78+18 Family Medicine1226+1426 Internal Medicine369-2736 OB/Gyn93-69 Pediatrics185-1318 Public Health & Preventive Medicine519+1419 Psychiatry10 0 Surgery141-137 SOM Per Capita Faculty Request of Departments

28. PCM PE TUTORS Department Projected Need Current Contrib.Differ.Recom’d Anesthesiology1310-313 Emergency Medicine617+1117 Family Medicine914+514 Internal Medicine3017-1330 OB/Gyn201 Pediatrics2202 Public Health & Preventive Medicine0000 Psychiatry211 Surgery12 0 SOM Per Capita Faculty Request of Departments

29. In Family Medicine Dept: Attempts to Support Teaching Activities  Support of chairman for increasing FM Teaching Hours  Began collecting detailed hours of pre-doc and residency teaching hours; shared openly at faculty meeting (first 2 years)  Set expectations of 25-75 pre-doc teaching hrs based on clinician teachers’ half-day for scholarly work  Instituted annual department sign-up sheet for all core teaching opportunities  Hour tracking turned into AVU system for tracking research and scholarly work as well

30. July – Dec 2002 Jan – Jun 2003 No. of faculty with 0 hours114 No. of faculty with > 25 hrs214 No. of faculty with > 37.5 hrs07 Average # of Hours/Faculty626 Total # of teaching hours143609 Immediate Results

31. Change in Predoctoral Teaching Hours 99- 00 00-0101-0202-0303-04 04- 05 05- 06 No. of Faculty 16 1823262122 Faculty with 0 hrs 4554642 Faculty with > 37.5 hrs 555913109 Faculty with > 75 hrs 01121032 Hrs / Faculty 20252333434233 Total Teaching Hours 3204003867481122875736

32. Excludes: Toffler, Fields (99-00, 00-01), Blanchard (01-02, 02-03, 03-04) PCM Quarters Taught (132 Slots)

33. Department Results  Expectations accepted (not necessarily adhered to)  Increased teaching hours by second year of program  Enabled department to negotiate more funding from Dean’s Office  AVU program developed but not implemented for four years  Teaching participation reduced over past two years  Now planning to reward AVUs with “bonus” money according to teaching contributions

34. Irony… On the eve of mission-based funding… OHSU Family Medicine has lost ground!

35. Take Home Points SOM and department teaching missions should be consistentSOM and department teaching missions should be consistent P&T committees need to further increase value of teachingP&T committees need to further increase value of teaching Teaching recognition is nice but doesn’t change participation numbersTeaching recognition is nice but doesn’t change participation numbers Clear expectations do have an impactClear expectations do have an impact Connecting efforts to funding does change attitudes and behaviorsConnecting efforts to funding does change attitudes and behaviors