The Evolution of Earned, Transparent, and Quantifiable Faculty Salary Compensation: The Johns Hopkins Pathology Experience

Responding to the workforce crisis: consensus recommendations from the Second Workforce Summit of the American Society of Pediatric Nephrology

IMPORTANCE

Pediatric patients with complex medical problems benefit from pediatric sub-specialty care; however, a significant proportion of children live greater than 80 mi. away from pediatric sub-specialty care.

OBJECTIVE

To identify current knowledge gaps and outline concrete next steps to make progress on issues that have persistently challenged the pediatric nephrology workforce.

EVIDENCE REVIEW

Workforce Summit 2.0 employed the round table format and methodology for consensus building using adapted Delphi principles. Content domains were identified via input from the ASPN Workforce Committee, the ASPN's 2023 Strategic Plan survey, the ASPN's Pediatric Nephrology Division Directors survey, and ongoing feedback from ASPN members. Working groups met prior to the Summit to conduct an organized literature review and establish key questions to be addressed. The Summit was held in-person in November 2023. During the Summit, work groups presented their preliminary findings, and the at-large group developed the key action statements and future directions.

FINDINGS

A holistic appraisal of the effort required to cover inpatient and outpatient sub-specialty care will help define faculty effort and time distribution. Most pediatric nephrologists practice in academic settings, so work beyond clinical care including education, research, advocacy, and administrative/service tasks may form a substantial amount of a faculty member's time and effort. An academic relative value unit (RVU) may assist in creating a more inclusive assessment of their contributions to their academic practice. Pediatric sub-specialties, such as nephrology, contribute to the clinical mission and care of their institutions beyond their direct billable RVUs. Advocacy throughout the field of pediatrics is necessary in order for reimbursement of pediatric sub-specialist care to accurately reflect the time and effort required to address complex care needs. Flexible, individualized training pathways may improve recruitment into sub-specialty fields such as nephrology.

CONCLUSIONS AND RELEVANCE

The workforce crisis facing the pediatric nephrology field is echoed throughout many pediatric sub-specialties. Efforts to improve recruitment, retention, and reimbursement are necessary to improve the care delivered to pediatric patients.

Educational Relative Value Units as a Measure of Academic Productivity: A Systematic Review

INTRODUCTION

Academic Health Centers (AHCs) have complex, often competing missions. Many have developed mission-based management (MBM) systems to support their clinical and non-clinical missions. There are limited data on MBM use for their educational missions. Our scoping review explored how AHCs employed such systems.  Materials and methods: Arksey and O'Malley's six-stage framework guided our review. Based on pre-defined criteria, English language articles from PubMed, EMBASE, SCOPUS, and the Healthcare Administration Database published between 2010 and 2020 were loaded into a reference manager. The search included all health professions education schools. Articles were excluded if they were review articles, commentaries, or clearly did not involve funding for education. From the final list of selected articles, data were extracted using a data extraction sheet we developed. Two researchers reviewed each article again to ensure extracted data were reported consistently and with sufficient detail.  Results: Of the 1729 manuscripts identified, 35 met inclusion criteria. Sixteen (46%) contained data in some form but did not have a formal methods section describing the specific approach to data collection and analysis. Moreover, there was marked variability in how educational effort was quantified, what counted as educational effort (educational scholarship versus teaching) and the impacts of such quantification (departmental funding versus individual faculty incentives). None of the studies reported on the impact on faculty promotion. Faculty satisfaction with the system was reported in seven studies (20%) and was generally positive.

CONCLUSIONS

A systematic description of how systems were developed to support the educational mission was lacking. Clear goals, methods of development, uniform data on educational productivity and quality, and program evaluation were not defined by most articles. This lack of process clarity presents a challenge, but more importantly an opportunity for academic health centers to unify efforts and continue to further their educational mission.

A Review on the Use of the Educational Value Unit (EVU) among Teaching Hospitals

(1) Background: In recent years, medical institutions across the U.S. have implemented a points system based on the Educational Value Unit (EVU) to assess and reward faculty for their educational efforts. The purpose of this narrative review is to summarize the current literature on EVU systems and to evaluate their utility in the U.S. healthcare system. (2) Methods: We searched the Ovid MEDLINE, Embase, Web of Science, and PubMed databases to identify literature describing the inception of EVU systems and current systems implemented by U.S. academic medical centers and medical schools. In total, a combined 48 studies and abstracts pertaining to EVU systems were reviewed, and a combined 26 published studies and abstracts from 1999 to 2022 pertaining to EVU systems were included. (3) Results: To our knowledge, at least 40 U.S. academic medical centers have used an educational metrics system, of which 21 institutions have published studies describing EVU systems in one or more of their medical departments. The outcomes associated with these self-described EVU systems are the focus of this study. EVU systems increase the number of faculty who meet baseline educational requirements, promote educational productivity, redistribute educational burden and funding among faculty members, and shift physician priorities towards education. The monetary reward associated with EVU systems is unlikely to be a significant factor contributing to these changes; instead, intrinsic motivation and a sense of academic responsibility play a larger role. (4) Conclusions: EVU systems are an effective way to evaluate and reward individual and departmental educational efforts in U.S. academic medical centers and medical schools. The adoption of EVUs will likely become more commonplace as U.S. academic medical centers and medical schools place additional emphasis on medical education.

Gender distribution of editors and authors of reference textbooks in anatomic pathology: further edits are required

Compared to other medical specialties, pathology has a significant number of women in the academic workforce (43%). Gender disparities, particularly those disadvantaging women, are a reality in academic medicine with documented inequalities in salary, leadership opportunities, and faculty promotion. One important element of academic advancement is the recognition obtained when serving as editor or main author of reference textbooks. We aimed to document the gender distribution of editors/authors in anatomic pathology by surveying 205 subspecialty publications over a 20-year period. Gender of each editor/author was recorded after surveying their institutional or other professional biographies. When biography was non-contributory, gender was extracted from the National Provider Identifier Database. A total of 462 editors/authors were identified: 275 (59.5%) men and 187 (40.5%) women. This distribution was similar to the 2015 (39% women) and 2019 (43.4% women) Association of American Medical Colleges (AAMC) benchmark for US academic pathologists. The gender distribution in each of the main anatomic pathology subspecialties was estimated by surveying the websites of 20 North American academic pathology departments (totaling 1893 listed individuals). Compared to this benchmark, some subspecialties had more men in editor/author roles than their representation in academic departments including Dermatopathology (observed vs expected difference, ∆ = 41.3%), Genitourinary Pathology (∆ = 29.4%), Renal & Transplant Pathology (∆ = 22.4%) and Head & Neck Pathology (∆ = 21.6%). Other subspecialties had more women in editor/author roles than their representation in academic departments including Molecular Pathology (∆ = 31.4%), Gastrointestinal Pathology (∆ = 21.4%), and Bone & Soft Tissue Pathology (∆ = 19.4%). Editors/authors of multiple (>1) publications were frequent and skewed gender representation in most specialties. The overall gender distribution of editor/author roles is similar to that of the US pathology workforce. However, significant disparities exist in certain subspecialties affecting both women and men. This landscape can guide efforts by editors, publishers, and academic institutions to bring equity to the academic field by providing fair editorial and authorship opportunities to academic pathologists.

Analysis of Physician Compensation Studies by Gender, Race, and Ethnicity

Purpose:

This report investigated physician compensation studies by gender, race, and ethnicity.

Methods:

Published U.S. physician compensation studies were assessed.

Results:

Of the 47 data sets within 46 studies, 36 analyzed compensation by gender and 32 (88.9%) found disparities. Thirteen and eight analyzed for race and ethnicity, with disparities found in four (30.8%) and none, respectively. The sample sizes of the four data sets with differences by race were among the largest in the subset.

Conclusion:

Most studies demonstrate pay disparities for women, but not for people who identify with underrepresented race/ethnic groups; however, small sample sizes may affect results.

Measuring Faculty Effort: A Quantitative Approach That Aligns Personal and Institutional Goals in Pathology at Yale

US medical schools increasingly seek ways to reduce costs and improve productivity. One aspect of this effort has been the development of performance-based incentives for individual faculty. A myriad of such plans exist. Typically, they incentivize clinical revenue generation but vary widely in how teaching, investigation, and administrative contributions are recognized. In Pathology at Yale, we have developed a transparent metrically driven approach that recognizes all missions and allows faculty significant control over their career path. Although some metrics derive from traditional measures such as workload relative value units and one’s level of grant support, the key concept underpinning our approach is to define one’s contributions not in terms of the revenue generated, but rather on the effort devoted to each of our missions, benchmarked against national or local standards. Full-time faculty are paid a competitive rank-based salary and are expected to contribute at least 100% effort in support of the school’s missions: clinical, research, education, administration, and professional service. Metrics define the effort assigned to each activity. Faculty achieving greater than 100% effort receive bonus compensation in proportion to their excess effort. By codifying explicitly how such effort is recognized into a single metric (% effort), we achieve a process that better aligns the professional and personal goals of faculty with the aims of the school. To facilitate its implementation, we have developed a web-based software platform called SWAY (Standardized Workload Analysis at Yale) that enables faculty to monitor their progress and record their activities in real time.

Pathology Residency Program Special Expertise Tracks Meet the Needs of an Evolving Field

Pathologists who enter the workforce must have a diverse skill set beyond that of clinical diagnostics alone. Anticipating this need, the Johns Hopkins Pathology Residency Program developed Special Expertise Tracks to enhance training in relevant subspecialty domains. Using a combination of discussions and surveys, we assessed: (1) our current resident curriculum; (2) perceived curricular strengths and needs; (3) resident career preferences and ultimate career paths; (4) perceived barriers to implementing an advanced elective curriculum; and (5) available departmental/institutional resources. Additionally, we utilized the Accreditation Council for Graduate Medical Education Pathology Milestones as a curricular guide. Six professional residency training Special Expertise Tracks were established: Education, Physician-Scientist Research, Informatics, Quality Improvement/Quality Assurance/Value-Based Care, Health Policy/Hospital Management and Global Health. After implementation in 2017, the Education track has had 4 residents complete the curriculum successfully; the Physician-Scientist Research track has had 2 residents and the Informatics and Global Health tracks have each had one resident successfully complete their respective curricula. Currently, 5 residents are pursuing the Education track, one is pursuing the Physician-Scientist Research track, one is pursuing the Informatics track, and 2 residents are pursuing the Global Health track. Five residents have completed long-term projects including developing several e-learning modules, an online free digital cytopathology atlas, peer-reviewed articles, book chapters, and books. The Johns Hopkins Pathology Resident Special Expertise Track program provides pathology residents an opportunity to gain meaningful experience and additional skills tailored to their individual career interests.

Current and Historical Trends in Diversity by Race, Ethnicity, and Sex Within the US Pathology Physician Workforce

OBJECTIVES

This study assessed historical and current gender, racial, and ethnic diversity trends within US pathology graduate medical education (GME) and the pathologist workforce.

METHODS

Data from online, publicly available sources were assessed for significant differences in racial, ethnic, and sex distribution in pathology trainees, as well as pathologists in practice or on faculty, separately compared with the US population and then each other using binomial tests.

RESULTS

Since 1995, female pathology resident representation has been increasing at a rate of 0.45% per year (95% confidence interval [CI], 0.29-0.61; P < .01), with pathology now having significantly more females (49.8%) compared to the total GME pool (45.4%; P < .0001). In contrast, there was no significant trend in the rate of change per year in black or American Indian, Alaskan Native, Native Hawaiian, and Pacific Islander (AI/AN/NH/PI) resident representation (P = .04 and .02). Since 1995, underrepresented minority (URM) faculty representation has increased by 0.03% per year (95% CI, 0.024-0.036; P < .01), with 7.6% URM faculty in 2018 (5.2% Hispanic, 2.2% black, 0.2% AI/AN/NH/PI).

CONCLUSIONS

This assessment of pathology trainee and physician workforce diversity highlights significant improvements in achieving trainee gender parity. However, there are persistent disparities in URM representation, with significant underrepresentation of URM pathologists compared with residents.

The Johns Hopkins Department of Pathology Novel Organizational Model: A 25-Year-Old Ongoing Experiment

In 1993, the present Department of Pathology at Johns Hopkins was established with the leadership of a new chair (ie, referred to as department director at Hopkins) and upon the integration of 3 separate and independent departments at the Johns Hopkins School of Medicine (Pathology) and the Johns Hopkins Hospital (Pathology, Laboratory Medicine). This new department was organized into 17 divisions, each of which was expected to develop and maintain significant clinical, educational, and research programs of excellence. To facilitate performance and alignment across missions and parent organizations, a novel professional and administrative structure was created. Professionally, vice-chairs (ie, deputy directors) for research, teaching, and patient care were appointed to oversee and coordinate these activities across all units of the department. Likewise, to focus and enhance expertise, individual administrators were appointed for academic, clinical, and business affairs. A departmental executive committee was created consisting of the vice-chairs and administrators, which was presided over by the chair. Simultaneously, substantial effort was put into measuring and improving the organizational culture using evidence-based methods. Significant improvements were documented by the year 2000 in departmental performance in research, education, clinical service, culture, and finances. Under 2 successive leaders, the department has maintained its eminence across missions and financial performance. This 25-year experience supports the tenet that innovative and strategic organizational structures and functional alignments can provide sustainable competitive advantages in performance.