Beyond the Ivory Tower: Solutions for Faculty Development, Research and Education in Community-based Tertiary Care Centers

1
Beyond the Ivory Tower Solutions for Faculty
Development, Research and Education in
Community-based Tertiary Care Centers

• Jedd Roe, MD, MBA, Chair, Department of Emergency
  Medicine,
• William Beaumont Hospital, Royal Oak, MI
• Brigitte M. Baumann, MD, MSCE, Head, Division of
  Clinical Research, Department of Emergency
  Medicine, Cooper University Hospital, Camden, NJ
• Christopher A. Lewandowski, MD, Residency
  Program Director,
• Department of Emergency Medicine, Henry Ford
  Hospital, Detroit, MI
• Arvind Venkat, MD, Director of Research,
  Department of Emergency Medicine and Ethics
  Consultant, Allegheny General Hospital,
  Pittsburgh, PA

2
Disclosures

• Jedd Roe None to disclose
• Brigitte M. Baumann Member of SAEM BOD
• Christopher Lewandowski None to disclose
• Arvind Venkat Editor, Challenging and Emerging
  Conditions in Emergency Medicine,
  Wiley-Blackwell Publishing, August 2011

3
Introduction

• Community-based tertiary care centers are an
  important locale for clinical care, research and
  education in emergency medicine.
• However, establishing the academic mission in
  this setting can be challenging.
• At the same time, there are potential advantages
  to the academic endeavor in this setting that are
  unique and contribute significantly to the field.

4
Definition and Epidemiology

• Community-based tertiary care centers with an
  academic mission in emergency medicine have the
  following characteristics
• Clinical revenue stream that is independent of
  and not shared with a larger university.
• May not be independent of parent corporation
• Research enterprise that is not reliant upon
  larger university infrastructure and support.
• Primary training site for an emergency medicine
  residency program.
• A rough estimate reveals that 50 of 155
  accredited allopathic emergency medicine
  residency programs fall within these centers.

5
Theoretical Challenges to the Academic Mission

• How does the department attract resources for and
  incentivize academic productivity in faculty
  where revenue is primarily from the clinical
  stream?
• How is research conducted effectively in a
  resource-limited environment when compared to the
  larger infrastructure of the university setting?
• How does the department attract high quality
  medical students and residents to train in this
  environment?
• How is academic productivity incentivized among
  medical students and residents?

6
Theoretical Advantages to the Academic Mission

• Independence to model the academic mission of the
  department in novel ways compared to the more
  traditional model of the university setting.
• Broader range of research questions which are
  feasible to pursue in comparison to the
  university setting where funding feasibility is
  paramount.
• Wider range of academic output that carries
  currency in this type of institution in
  comparison to the university setting.
• Training environment that is more easily
  translated to a broader range of practice
  settings upon graduation from residency.

7
Goals

• Provide examples of addressing challenges in
  faculty development, research and education in
  the community-based tertiary-care setting.
• Show how these solutions can take advantage of
  opportunities unique to the academic mission in
  the community-based tertiary care environment.
• Discuss how these solutions can be tailored to
  different practice settings that are part of
  community-based tertiary care centers.

8
Supporting the Academic Mission at a
Community-based Tertiary Care Center

• Jedd Roe, MD, MBA
• Chair, Emergency Medicine
• William Beaumont Hospital, Royal Oak, MI
• Professor and Chair, Department of Emergency
  Medicine
• Oakland University William Beaumont School of
  Medicine

9
Objectives

• Background
• Organizational Structure
• Department Finances
• Challenges
• Strategies for Community-based Centers

10
My Training

• Williams College, BA
• Royal College of Surgeons in Ireland
• Kern Medical Center
• EM residency 1986-90
• University of Denver
• MBA / MS (Finance) 1999-2001

11
Currently

• Chair, Department of Emergency Medicine, William
  Beaumont Hospital
• Professor and Chair, Department of Emergency
  Medicine, Oakland University William Beaumont
  School of Medicine

12
Organizational Structure
Dean
13
Organizational Structure
14
How to sort this out?
15
How is the Department funded?

• Employed model
• Contracted, fee-for-service
• How is the academic mission supported?
• You need and time
• Who pays?

16
Faculty Compensation

• Base compensation
• Incentive Plan (meaningful amount, transparent
  measurable metrics, MD can influence)
• Model (Earn points / Total points) Incentive
  incentive payout
• Annual distribution
• Entry criteria
• The basics
• e.g. medical record completion, annual testing,
  etc

17
Incentive Plan Categories

• Productivity
• Quality
• Patient Satisfaction
• Align with hospital / department goals
• Academic
• Academic value units?
• Annual goals

18
Mission Conflict

• Institutional
• Department

Academic
Clinical Service
Culture
19
Whats at Risk?

• All non-clinical MD funds flow
• Residency
• Positions over cap?
• Research Support
• Department fund
• How is this generated?
• CME, Faculty Development

20
Beware of
21
Potential Strategies

• Build institutional credibility
• not the only useful currency
• Sell value of emergency medicine
• Do you know of admits that come through ED?
• Downstream revenues?
• Who knows flow better than we do?
• Manage transitions of care
• Gain control over your funds flow
• Mission-based budgeting?
• Cross-subsidize from clinical ?
• Philanthropy

22
Potential Strategies

• Network
• AACEM
• ABEM
• ACEP
• Recruitment / Retention
• Technology
• Resources
• Clinical Population

23
Research at a Community-based Tertiary
Care Center

• Brigitte M. Baumann, MD, MSCE
• Head, Division of Clinical Research
• Associate Professor of Emergency Medicine
• Cooper University Hospital, Camden, NJ

24
Objectives

• Background
• Opportunities at Community-based Centers
• Challenges Mine, and probably yours
• Solutions Mine, and hopefully yours

25
My Background

• Harvard College, BA
• Cornell University Medical College
• University of Pennsylvania
• IM residency 1995-97
• EM residency 1997-2000

26
My Current Affiliation

• Cooper University Hospital
• Tertiary care center
• Level 1 trauma center
• Adult ED with a nested pediatric ED
• Southern NJ
• Across the Delaware River
• 2 miles from Philadelphia

27
Current Affiliation
Brigitte M. Baumann, MD, MSCE UMDNJ-RWJMS at
Camden
28
My New Affiliation
Brigitte M. Baumann, MD, MSCE Cooper Medical
School of Rowan University First class
anticipated 2012
29
Challenges T0

• Fairly small department (faculty10)
• RD had just departed No on site mentorship
• No ongoing research
• No federal funding
• No industry funding
• No support staff
• No statistician
• No practical training/experience with
  IRB/protocols

30
Lay of the Land
31
T0 Resources at my CBTC Center

• Faculty and resident s increasing
• Didnt know that I was supposed to fail
• Anything is better than nothing (research)
• Masters in Clinical Epidemiology
• IRB was conservative but turnover was pretty quick

32
Challenges TNOW

• Select faculty interested in research
  (faculty25)
• Few true mentors for federal grants
• Maintain 100 financial support of research staff
• Balancing home grown studies with fiscal
  realities?
• Lack of grants office infrastructure/resources
• Limited collaboration within the system

33
Solutions Lack of Training

• Pros
• Completed majority of Masters coursework in 1 yr
• Statistical methods, epidemiology, stats programs
• Excellent feedback on my thesis
• Cons
• First outside and first EM masters applicant
• Multiple mentors
• Dissuaded from the grant pathway
• Unaware of NIH educational loan repayment awards
• Conflicting responsibilities led to 3 yr hiatus
  from completion of masters degree

34
Solutions Support Staff

• Started an Academic Associate Program
• Pilot data used for federal grant applications
• Eventually built up enough momentum for a FT
  Research Coordinator
• Now able to handle industry projects

35
Academic Associate Program

• Service to the Institution
• Data collection for departmental projects
• Assist with other departmental studies
• Allows students to shadow
• Now, may serve as a conduit for prospective
  medical students for new medical school
• HUGE time investment, but now paying off

36
Solutions Practical Knowledge

• Member of IRB
• Basics on how to write a protocol
• Consent forms / HIPAA
• In contact with other researchers
• In contact with statistician (hired 5 yrs later)

37
Solutions Mentorship

• Maintained prior mentors from U Penn
• Established new ones
• Our dept hired a PhD (Federal funding)
• Made contacts at SAEM and ACEP
• Research directors interest group
• Public Health interest group
• Program Committee (SAEM)
• Other organizations - American Society of HTN

38
Resources at other CBTCCs

• Physician extenders may be interested in research
• Data collection
• Subject enrollment
• Co-investigators
• Part of their advanced degree requirements
• IRB may be a central one or, if local, may also
  have fast turnover
• If MS or residents are present, they may also
  want to participate in research efforts
• IT personnel, MBAs different skill sets

39
Types of investigations CBTCCs

• Case reports ? novel findings, consider a pilot
  study
• EMLA cream for pediatric abscesses
• Investigations that focus on ED throughput and
  patient satisfaction (Press Ganey Scores)
• Scribes
• Fast tracks
• Physician-based triage
• Elimination of waiting room
• Clinical decision units

40
Types of investigations CBTCCs

• Focus may be more systems-based
• If residents are primarily interested in clinical
  jobs, then give them projects that will help them
  advance
• Scholarly tracks Simulation Track
• Reduction in medical errors
• Improving pain
• Improving documentation
• RVUs

41
Types of investigations CBTCCs

• Fit the study to your resources
• Medical Record reviews
• Use established databases
• Electronic medical records
• Improve your resources
• Enlist undergrads or medical students
• Develop a medical student elective (co-author)

42
Challenges Protected time/staffing

• Funding
• Ongoing industry projects -- recovery of indirect
  
• Small institutional grants
• Federal funding
• http//www.grants.gov
• Cons
• Working on projects that do not interest you
• Too many simultaneous projects
• Project brings in revenue but no publications
• What happens when the project is over?

43
Challenges
Home-grown study
Resident or MS study
Staff turnover
44
Challenges

• Few people are doing research in my department
• No one is interested in my research area
• Solutions
• Look outside your department
• Collaborate with others from other institutions
• Join EM and other national organizations
• Expect some failures before success

45
Challenges

• Theres no tenure at my institution, so few
  people are interested or motivated to publish.
  Why bother?
• Always approach your career as if you are working
  up the academic ladder
• Surprise! We now are going to have a medical
  school ? major changes and expectations from
  administration

46
Challenges

• My chair wants more service to the institution
  but I want to focus on CV building
• See if you can pick responsibilities that mesh
  with your interests (IRB, lab committee)
• Medical student mentor (recruit students)
• Id love to do more academic work (research,
  book chapters, teaching) but where to find the
  time?
• Pick an area of interest and focus on that
• Salami projects

47
Conclusion

• Set goals for yourself
• 1, 3, 5 and 10 year goals
• If you meet them, wonderful
• If not, time to reassess

48
Beyond the Ivory TowerSolutions for Faculty
Development, Research, and Education in
theCommunity Based Tertiary Care Center(CBTCC)

• Christopher A. Lewandowski, MD,
• Residency Program Director
• Department of Emergency Medicine
• Henry Ford Hospital, Detroit, MI

49
Henry Ford Hospital

• Established in 1914
• Provides primary health care to the community
• Referral Center
• Academic Medical Center
• Research Center

50
Goals

• Discuss how to structure educational programs for
  residents and students
• Review options for incentivizing clinical
  educator productivity
• Review the strengths of education in the
  community based tertiary care center (CBTCC)

51
Educational Programs in the CBTCC

• Understand your environment
• Why is medical education important to your
  institution?
• Mission
• Vision
• What is the organizational structure?
• How does the money flow?

52
Educational Programs in the CBTCC

• What components of medical education are a
  priority?
• Allied health care professional
• Medical students
• Residents
• Fellows
• Who does the institution value the most?

53
Educational Programs in the CBTCC

• Where do you fit in?
• What are your interests?
• How well do your interests align with the
  institutions?
• What are the opportunities for advancement?
• Role models
• How does your department fit in?

54
Educational Programs in the CBTCC

• Why does my department want students or
  residents?
• What is the commitment for their support?
• What is the role of the chair?

55
Building an Educational Programin a CBTCC

• What benefits the department the most?
• Residency program often come first
• Use institutional resources
• Create institutional resources
• Know the rules of the road for residencies
• The RRC is your friend
• CORD is a major ally

56
Building an Educational Programin a CBTCC

• Medical students
• Layered on top the residency
• Require a very organized approach
• Make the rotation fun, not stressful
• Provide direct faculty direction and contact
• Allied Health Care Professionals
• EMT programs
• US tech programs

57
Building an Educational Programin a CBTCC

• The Role of the Chair
• Needs to view education as a core mission
• Sets the tone, creates the environment in the
  institution
• Financial support
• PD, APDs, Coordinators
• Residents
• Faculty development
• Facilities
• Incentives

58
Building an Educational Programin a CBTCC

• Core faculty vs Key faculty
• Core faculty meet RRC requirements for scholarly
  activity
• Key faculty you cant run the day to day
  operations without them
• Create a program that plays to your strengths
• Critical care
• Peds
• Trauma

59
Building an Educational Programin a CBTCC

• Recruitment for residency
• Take the long view
• Recruit medical students as future faculty
• Invest in their development
• Help them create a vision of their own future
• Recruit faculty with specific educational roles
  in mind

60
Building an Educational Programin a CBTCC

• Define Productivity
• Clinical Supervision and Evaluation of Residents
• Formal Teaching
• Classroom
• Simulation
• Scholarly Activity
• Development of new knowledge
• Dissemination of existing knowledge
• Administrative Work

61
Building an Educational Programin a CBTCC

• Faculty
• Must have adequate clinical staffing
• Recruit with clear expectations and live up to
  them
• Develop goals for each faculty
• Career Tracks
• Needs chair buy-in
• Clearly defined roles
• It takes a village
• Clinicians
• Educators
• Researchers
• Operations / Administration

62
Incentivizing Clinician Educator Productivity in
a CBTCC

• Money Talks
• Clear Incentive plan
• Fair
• Metrics
• Measurable
• Reinforce desired behaviors
• Base pay structure
• Pooled incentive fund
• Baseline Requirements
• Competitive structure

63
Incentivizing Clinician Educator Productivity in
a CBTCC

• EVUs
• Educational Value Units (points)
• Similar to RVUs,
• Directed for non-RVU generating educational
  activities
• Funding from Incentive pool and GME
• Reward both Resident and Medical Student
  Activities
• Need an internal committee to define what
  activities are valued and how many points are
  assigned

64
Incentivizing Clinician Educator Productivity in
a CBTCC

• EVUs
• Eligibility
• Faculty without protected time for education
• Activities
• Didactic Lectures
• Interactive Educational Activities
• Residency Responsibilities
• Remediation
• Professional Development
• Medical Student Responsibilities

65
Incentivizing Clinician Educator Productivity in
a CBTCC

• EVUs
• Auditing and Tracking
• Criteria are chosen a priori
• Choose verifiable activities
• Create method of monitoring outcomes, reporting
• Quality measures
• Evaluations
• CME
• Scholarly output
• Roll out to all faculty

66
Educational Programs in a CBTCCStrengths

• Faculty can choose their career track
• Flexibility to modify track based on personal
  goals
• Less pressure toward tenure
• Self selection for each track
• Can provide time to develop interests

67
Educational Programs in a CBTCCStrengths

• Faculty growth through various stages of life
• Work life balance
• University affiliations
• Provide academic titles
• Provide other avenues of development and
  involvement

68
Educational Programs in a CBTCCWeaknesses

• Requires great internal motivation
• Difficult to keep the playing field even
• Tension between faculty on different career paths
• Requires parity in compensation

69
Conclusion

• Community-based tertiary care centers are an
  important locale for clinical care, research and
  education in emergency medicine.
• However, establishing the academic mission in
  this setting can be challenging.
• Achieving solutions to promote faculty
  development, research and education in
  community-based tertiary care centers require
  institutional commitment and departmental
  flexibility and creativity.