Author + information
- ∗Terrence Donnelly Heart Center, St. Michael’s Hospital, University of Toronto, Ontario, Canada
- †Cardiovascular Division, Peter Munk Cardiac Centre, Toronto General Hospital and Women’s College Hospital, University of Toronto, Ontario, Canada
- ↵∗Reprint requests and correspondence:
Dr. Akshay Bagai, Terrence Donnelly Heart Center, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada.
- ↵∗∗Dr. Jacob A. Udell, Cardiovascular Division, Peter Munk Cardiac Centre, Toronto General Hospital and Women’s College Hospital, University of Toronto, 76 Grenville Street, Toronto, Ontario M5S 1B1, Canada.
Numerous elements are required to produce a successful clinical investigator. The 3 necessary pillars include: 1) the individual candidate, their preparation and training; 2) robust scientific mentorship; and 3) an institution that provides both opportunity and connectivity (1). Although these 3 elements are essential, they are potentially insufficient. Transitioning into a productive early career investigator is not easy, nor should it be considered a part-time activity performed on weeknights and weekends. Like clinical work, it requires dedicated time. Therefore, the fourth pillar for new clinical investigators to successfully launch an independent research career is protected time. Unfortunately, peer-review salary support awards and operating grants are becoming more and more challenging to secure, especially for early career investigators without an independent track record. Thus, for the majority of early career investigators, protected time for research is unfunded and only occurs at the cost of sacrificing remunerative clinical activities. As a former cardiology chief noted, “protected time is a euphemism for income.”
Typically, clinicians in academic health science centers derive income from the practice of medicine, and many struggle to find sources of remuneration to support nonclinical academic activities. Although community-based practice generates higher income, clinician investigators are attracted to academic medicine research centers because of their interest in teaching and research. In academic centers, the primary mechanism for funding nonremunerative academic activities is the practice plan, a device that pools and then redistributes professional income. Each individual member has financial arrangements on the basis of an agreement or contract that reflects his or her job description.
Purpose and Structure of Academic Practice Plans
Academic practice plans are typically governed by hospital departments, with the university providing guidelines and principles. A division of cardiology is usually, but not always under the auspices of the department of medicine. The essence of a practice plan is that those who generate high clinical revenue agree that part of their revenues will be directed to colleagues who dedicate significant amounts of time to activities that do not generate income. Thus, clinician teachers are expected to generate higher clinical income than clinician investigators and clinician scientists. At the divisional level, procedure-oriented specialties such as cardiology, nephrology, and gastroenterology, which are reimbursed at a higher rate per unit of time, have higher revenues and typically form the donors in the system. This requirement to share clinical income for the support of colleagues clearly requires strong leadership from department chiefs to articulate the mission and earn the trust of the members of the group, while maintaining sound financial management.
There are numerous academic practice plan structures (2). We describe 3 academic practice plans at the University of Toronto hospitals. In 1 plan, there is base support determined by the job description that varies between 8% to 40% of the person’s total income (3). The amount tends to be stable from year to year and is altered gradually in the setting of promotion, job description changes, or adoption of significant administrative roles. An academic merit bonus is awarded at year-end that recognizes academic contribution in teaching or research for that year and varies from 5% to 20% of total income. The relatively stable base support and variable merit award are both designed to reward and incentivize academic work. Economic performance is also rewarded. Each physician is set a target for revenue generation that reflects their job description. The structure of the formula for this target is the same for all members of the practice plan. If a physician generates more revenue than their target (overage), that physician will receive 60% of that excess as additional revenue with the remaining 40% going to support the base and merit pools. Members who generate less revenue than their target (underage) receive less income.
In the second model, a 12.5% “tax” is collected from the clinically generated income from all physicians in the group. Thus, individuals with higher income contribute higher absolute amount. The taxed money is used to “supplement” salary for individuals doing less clinical work and more investigation as per their job description. This “top-up” income is stable year after year and determined by job description, varying between 15% and 25% of yearly income. In this model, there is no academic merit bonus. In both models, economic rewards from nonclinical sources, such as personal research awards or administrative stipends, are encouraged. Academic base support or “supplements” are kept intact when members receive external research grants or teaching stipends, thus encouraging members to apply for those payments.
A third model is essentially a blend of these 2 approaches, with a cap set on the amount of annual overage that is taxed, after which further billings are not taxed for that year, in addition to providing incentives with academic merit and a base of salary support that varies with the job description.
Application of the Academic Practice Plan
Because academic practice plans reflect the mission and vision of the institution and its leadership, when applying and interviewing for jobs, it is vital that young clinician investigators inquire in detail about practice plans at the prospective institution. Given that investigators today may not receive their first independent research grant until sometime in their 40s, it is essential that young investigators seek out academic positions that are securely financed for the initial period of their early career until their ability to secure independent funding comes to fruition (4). Often, specific details are obtained by way of conversations with junior and senior faculty with similar job descriptions. It is vital to obtain support of the chief of the department and other colleagues in securing “protected” time for research activities from the practice plan so that time and focus is spent on productive research endeavors, rather than generating salary support. Although the investigator’s aptitude, training, and mentors remain the essential 3 pillars, “protected time,” or in other words “protected income,” offered via academic practice plans is the critical fourth pillar quintessential for early career clinician investigator success.
- Alan Cheng, MD and
- Gordon F. Tomaselli, MD ()
RESPONSE: An Investment in Our Future
Academic medical centers (AMCs) are arguably one of the most complex health organizations to manage (1). The tripartite mission of the AMC includes the generation of new knowledge, training clinicians, and providing health care (particularly to the underserved). The most profound effect of the AMC on the public health is defining new and more effective treatment of disease. There has been no greater time of flux in our health care system than now, with efforts to change not only how medicine is delivered, but also how physicians and clinical centers are paid. This occurs at a time when the inflation-adjusted National Institutes of Health budget has decreased by >20% since 2003 (2,3). However, it is not an option, but an obligation of the AMC to invest in new knowledge generation, and this is done through the investment in people. In an environment that is at best uncertain for funding of researchers and continued progress in science, we must ensure availability of the resources needed to fund all of the pillars required to maintain and grow a robust, globally competitive biomedical research infrastructure.
We applaud Drs. Bagai and Udell for recognizing and calling attention to the importance of understanding the financial underpinnings of any future AMC place of employment. They illustrate the complexity of the fiscal issues and the role of leadership in providing equity and a clear vision of the AMC’s mission. We agree that understanding the importance of “protected time” is necessary, but it is not sufficient. Early career clinician scientists need to fully comprehend to what extent the AMC is committed to their development. Simply being provided 20% “protected time” (or 1 day/week) is not sufficient. What is required is investment in careers by providing very granular mentorship specific to helping identify a niche at the institution, aligning clinical duties with research interests whenever possible, regular reviews of the early career individual’s progress, and creative ways of maintaining the financial health of the center.
The academic practice plan certainly has a role to play in supporting the effort of clinician investigators, but with tight margins on the delivery of clinical care, this backing must be supplemented by other sources. AMCs and parent universities must be a part of the support of careers of physician scientists, and this activity, as well as other important societal activities, should be supported by the government and public through tax law. Funding all of the pillars of success and preparing aspiring investigators to succeed also requires direct governmental support in the form of growth of funding agencies such as the National Institutes of Health and National Science Foundation in the United States. This is not an academic practice plan problem, but instead, a larger societal concern affecting science and technology broadly. In the end, supporting the fourth pillar of success needs to be viewed through the lens of an investment in our future.
- ↵National Institutes of Health. The NIH almanac: appropriations (section 2). Available at: http://www.nih.gov/about/almanac/appropriations/part2.htm. Accessed August 22, 2015.
- ↵Kennedy JV, Atkinson RD. Healthy funding: ensuring a predictable and growing budget for the National Institutes of Health. February 2015. Available at: http://www.unitedformedicalresearch.com/wp-content/uploads/2015/02/2_18-UMR-Final-copy.pdf. Accessed August 22, 2015.
The authors are grateful to Drs. Michael Farkouh, Thomas G. Parker, John D. Parker, Gary E. Newton, and Sanjeev P. Bhavnani for their thoughtful review and critique of our paper.
- 2015 American College of Cardiology Foundation