Published online March 5, 2007
PEDIATRICS
Vol. 119
No. 4
April 2007, pp.
e791-e797
(doi:10.1542/peds.2006-2207)
Performance of a Career Development and Compensation Program at an Academic Health Science Center
Hugh O'Brodovich, MDa,b,c,
Joseph Beyene, PhDd,
Susan Tallett, MB, BSa,b,
Daune MacGregor, MDa,b and
Norman D. Rosenblum, MDa,b,c
a Paediatric Consultants Partnership, Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
Departments of b Paediatrics
c Physiology
d Public Health Sciences, University of Toronto, Toronto, Ontario, Canada
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ABSTRACT
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OBJECTIVE. The academic physicians of our department developed a novel Career Development and Compensation Program to outline job expectations, enhance career development, and provide a peer-review process to assess performance. The Career Development and Compensation Program was founded on the principle that sustained achievement in education, clinical care, or research should be valued, supported, and rewarded in an equivalent manner and that reward for clinical work should not be limited by the focus of the university on research and education. The objective of this study was to determine whether the principles of the Career Development and Compensation Program were sustained during the initial 7 years of its implementation.
METHODS. The outcome of the 7 triennial reviews that occurred from 1999 to 2005 was evaluated. For the purposes of some analyses, physicians were classified as predominately clinical (clinician-specialists and clinician-teachers), predominately education (clinician-educators), or predominately research (clinician-investigators and clinician-scientists).
RESULTS. Each of the job profiles had a similar probability to increase a level within the Career Development and Compensation Program at the time of triennial review. Similarly, all 5 job profiles had a similar rate of increase in their level in relation to the total number of years of experience at an academic health science center. Neither the university academic rank nor gender of the physician affected the probability of increasing a level at the time of the triennial review.
CONCLUSION. The peer-reviewed Career Development and Compensation Program recognizes sustained achievement in each area of education, clinical care, and research in an equivalent manner with no detectable effect of academic rank or gender.
Key Words: career development • education • professional competence • clinical competence • pediatrics
Abbreviations: AHSC—academic health science center • CDCP—Career Development and Compensation Program • PCP—Paediatric Consultants Partnership • AFP—alternative funding plan • JP—job profile • FT—full-time • CAC—Clinical Advisory Committee • MEAC—Medical Education Advisory Committee • RAC—Research Advisory Committee
In the past decade, we have attempted to answer the following question: How could an academic physician's career development be supported and rewarded within the setting of an academic health science center (AHSC)? Frequently, an academic physician's career advancement is linked predominately, if not exclusively, to university-based benchmarks. This presents a significant challenge. Academic physicians at an AHSC must deliver outstanding scholarly clinical care, in addition to research and education, yet research and education usually are the only parameters that are valued by universities and their academic promotion committees. Also, the absence of a formalized career development strategy can hinder the progress of many academic physicians. This may result in the loss of talented and extensively educated physicians who have not been guided in their career development as to how best to meet the expectations of their peers. Our department developed and implemented the Career Development and Compensation Program (CDCP) to enable an academic physician's career to be developed and rewarded fairly. This CDCP is applicable to all academic medical departments wherein there is a centrally administered financial base that supports a portion or all of the physician's income.
Our department's academic physicians work within a single-payer universal health care system that is comparable, in many ways, to a single-payer health maintenance organization. One difference is that the ultimate governance is provided by the Ontario Ministry of Health, which is funded through taxation, and contrasts to a for-profit or not-for-profit private health care organization. In 1990, our partnership (Pediatric Consultants Partnership [PCP]) entered into an alternate funding plan (AFP) wherein its fee-for-service income, obtained from the Ontario Hospital Insurance Plan, was replaced by block funding from the Ontario Ministry of Health.1 A key component of the AFP agreement was the recognition by the ministry that the fees that previously were received by the PCP not only had resulted in the provision of clinical care but also had supported its research and educational activities. As a result, the PCP, the Hospital for Sick Children, the University of Toronto, and the Ministry of Health agreed that the AFP was to be allocated to clinical care (50%), research (30%), and education (20%). Although the agreement was renewed in 1998 and 2001, with concomitant changes in the level of financial support and some other modifications, the fundamental principles remain intact.
In 1996, the PCP implemented the following job profiles (JP) to define more clearly the role of each physician:
- Clinician-teacher: major (50%–65%) commitment to provide, advance, and promote clinical care; usually significant bedside teaching and some research activities
- Clinician-educator: major (
50%) commitment to education administration and educational development or research in education; participate in clinical care and bedside teaching
- Clinician-scientist: major (75%) commitment to research; participate in clinical care and education
- Clinician-investigator: significant (50%) research commitment and contributes to educational and/or research
- Clinician-administrator: major (>50%) administrative responsibilities and contributes to clinical care, education, and research
- Clinician-specialist: predominate (70%) commitment to provide, advance, and promote excellence in clinical care with contributions to education and/or research
By 1998, the PCP had established benchmarks to guide career development and a peer-review system to assess the performance of the individual full-time (FT) pediatrician. The development and subsequent implementation of the CDCP in 1998 has been published2,3 and is available at www.sickkids.ca/paediatrics.
The CDCP was founded on the principle that sustained achievement in education, clinical care, or research should be valued, supported, and rewarded in an equivalent manner and that reward for clinical work should not be limited by the university's focus on research and education. The goal of this study was to determine whether this principle was sustained during the 7 years during which the CDCP was used to guide and reward career development in our department.
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METHODS
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Site of the Study
The Hospital for Sick Children is a health care, teaching, and research center that is dedicated exclusively to children and is affiliated with the University of Toronto. Most of its patients are referred for tertiary care. In 2004–2005, there were 13819 admissions, 99037 inpatient days, 47585 emergency department visits, 165016 outpatient visits, and 127149 diagnostic visits conducted on site. The Department of Pediatrics provides approximately two thirds of all physician care to these patients, holds approximately $20 million CDN in external research funding, and is responsible for the education of 790 medical students and >200 residents and fellows each year.
The CDCP
At the time of the initial implementation of the CDCP or when hired, the physician was assigned to 1 of the 6 JPs. The assignment was based on the needs of the division and on the individual's training and achievement and was subject to final approval by the division head and chief of the department.
The CDCP divides the career of a pediatrician at a leading AHSC into 3 potential phases that are characterized by increasingly sophisticated incremental performance. These different phases of professional growth are divided into 8 levels, each of which is linked to a rate of remuneration that reflects the physician's stage of career development and the market value of various subspecialties (Table 1). If the physician was just beginning his or her academic career, then he or she was assigned to level I; however, if he or she was recruited at a later stage of his or her career, then he or she was assigned to an appropriate higher level.
The department's Clinical, Medical Education, and Research Advisory Committees (CAC, MEAC, and RAC, respectively) developed "Categories of Achievement" for clinical care, education, and research, respectively. These became the "benchmarks" that were used both as a guide for career development and for the evaluation of the individual physician's performance. Evaluations and feedback included the following: - an annual review, coupled with career development advice from the physician's division head and department chief
- career development from the CAC, MEAC, RAC, mentors, and advisors
- a major review every 3 years, termed the "triennial review," that serves as the basis for movement through the levels and additional career guidance
One third of all departmental physicians undergo a triennial review process each year (Fig 1). The physician creates and submits separate clinical, medical education, and research dossiers to the CAC, MEAC, and RAC. Each committee, using a peer-review process that is comparable to a grant review committee, assigns a "category of achievement" on the basis of the previously developed benchmarks. The resultant confidential peer evaluation of their performance then is reviewed by the chief of pediatrics, who places the category of achievement evaluation into context by considering other factors. These factors include the number of years on staff at an academic health science center; his or her JP; the amount of time allocated for clinical, education, and research activities; and other pertinent information to decide whether the pediatrician's level should be altered.
Study Population
We reviewed the results of all physicians who underwent the 7 triennial reviews that had occurred from 1999 to 2005. Overall, there were 181 physicians (100 male and 81 female) who had 1 or more triennial reviews. For the purposes of some analyses, physicians were classified as predominately clinical (clinician-specialists and clinician-teachers), predominately education (clinician-educators), or predominately research (clinician-investigators and clinician-scientists). Because we had a very small number (n < 4) of clinical administrators at any one time, they were excluded from the analyses.
Although remuneration within the CDCP is not increased on academic promotion within the Faculty of Medicine at the University of Toronto, we determined whether promotion in the CDCP was affected by professorial rank. We also reviewed the "primary platform" for promotion of departmental faculty from 2002 to 2006 inclusive to determine whether the university emphasis on research and education would negatively influence the value that is placed on scholarly clinical care in the CDCP. The primary platform for academic promotion can be 1 of creative professional activities, education, or research (see www.facmed.utoronto.ca/English/Policies-and-Guidelines.html).
Statistical Analyses
Descriptive data were summarized using proportions and mean/SD, as appropriate. The probability of advancement in the CDCP across JPs was computed and compared using a 
2 test. Furthermore, logistic regression models were used to assess potential relationships between the probability of advancement in the sublevels and demographic and other subject-specific characteristics, such as gender, age, and university academic rank. The relation between the number of years at an AHSC and the level for each JP was quantified using linear regression. Differences between the slopes of the lines for the various JPs were compared by fitting an analysis of covariance model and testing for an interaction effect between JP and number of years at an AHSC. All analyses were conducted using SAS 9.1 (SAS Institute Inc, Carey, NC).
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RESULTS
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A central principle of the CDCP is that achievements in clinical care, education, and research are valued equally. A career development and compensation model that is based on this principle predicts that equivalent achievements in these scholarly domains should result in an equivalent probability of advancement. To investigate whether this principle was sustained during 7 years of implementation of the CDCP, we compared the probability of advancement in the CDCP across JPs. We were unable to detect a statistically significant difference in the probability of physicians who were classified as predominately clinical (clinician-specialists and clinician-teachers), predominately education (clinician-educators), or predominately research (clinician-investigators and clinician-scientists) in their ability to get an increase in their level at either their first (n = 54) or second triennial review (n = 63; Table 2). Similarly, there was no statistically significant difference in the probability of individuals who held different JPs in their ability to receive an increase in their level at either their first or their second triennial review (Fig 2).
If JPs are equally valued within the CDCP, then each JP should have a comparable relation between the number of years at an AHSC and the level achieved within the CDCP. In other words, physicians with different JPs should increase their level at the same rate. To determine whether this was true, we reviewed the 103 FT physicians (58 male, 45 female) who worked exclusively at our AHSC, were present in the department during the 2005–2006 academic year, and had undergone at least 1 triennial review. We first calculated the number of years that the physician had spent at any AHSC subsequent to the initial appointment as a FT academic physician (14.6 ± 8.02 SD years). We then determined the relation between the number of years at an AHSC and the level for each JP (clinician-teacher: n = 28; clinician-educator: n = 9; clinician-scientist: n = 30; clinician-investigator: n = 19; clinician-specialist: n = 17). There was no statistically significant difference between the slopes of the lines for the various JPs, which indicated that members of each JP increased their level at the same rate (Fig 3).
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FIGURE 3 As assessed by the interaction test, there was no statistically significant difference (P = .64) between different JPs for the slope of their relation between level (Y2 axis) and the number of years at an AHSC. Clinician-educator (n = 9): y = 0.09x + 2.1; clinician-investigator (n = 19): y = 0.14x + 1.3; clinician-scientist (n = 30): y = 0.12x + 1.5; clinician-specialist (n = 17): y = 0.11x + 1.1; clinician-teacher (n = 28): y = 0.12x + 0.8. The trend for the clinician-educators to have a lower slope likely is explained by the fact that 56% of the clinician-educators had been at an AHSC for 23 years or more and were already level III.
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Because others have found that gender had effects on academic advancement,4–6 we determined whether advancement in the CDCP was affected by gender. Comparison of rates advancement in either the first or the second triennial review did not reveal a statistically significant difference between male and female members of the department (Fig 4).
Although the CDCP was designed to recognize achievements in clinical care, it is possible that the university emphasis on research and education would negatively influence the value that is placed on scholarly clinical care in the CDCP. Our results, however, demonstrated that the probability of increasing a level at a triennial review was not related to academic rank at either the first (Fig 5A) or the second triennial review (Fig 5B). From 2002 through 2006 inclusive, 43 physicians were promoted from assistant to associate professor or associate professor to professor within the Department of Pediatrics of the Faculty of Medicine. Their primary platforms for promotion (see www.facmed.utoronto.ca/English/Policies-and-Guidelines.html) were education (23%), research (44%), and creative professional activities (32%).
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DISCUSSION
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An academic department cannot be successful without the requisite financial base and infrastructure. In addition, success will be achieved only when there also is a highly skilled faculty who use the available resources in an effective manner to achieve their own and the department's goals and objectives. As such, it is our contention that a department must provide mentorship and career development to its faculty, clearly define its goals and objectives, use fair and transparent processes to evaluate the performance of its faculty, provide constructive feedback to the physician, and link the physician's rewards to these performance measures. The CDCP is our department's attempt to address some of these issues, and the long-term follow-up evaluation described in this article provides evidence that it has achieved its goal, at least in part. Specifically, regardless of the academic physician's primary role within the AHSC, his or her career development was supported, successfully developed, and rewarded.
Medical school faculty physicians who work at an AHSC must carry out clinical care, education, research, and administrative activities. A variety of approaches have been taken to document the relative activities, for example assigning a "relative value" to each of these 4 activities7 or just 1 of these activities, such as education.8 How this information was used in the long term or how successful this approach has been is uncertain, because we are unaware of outcome studies using this relative-value approach.
Our department developed the CDCP from 1996 to 1997, and the present study provides outcome information for our faculty who were evaluated by our department's various parameters. Similar to other groups,7,8 we included both quantitative and qualitative outcomes measures. One of the key design principles was that each of the JPs would be rewarded equally. This not only should encourage excellence in each of the clinical, education, and research arenas but also should enhance the morale of the department. As such, we designed the CDCP so that the rate of remuneration did not depend on the JP but rather on 2 other factors. One is the specialty or subspecialty area that reflects market forces (Table 1) and the second is the achievements of the physician relative to similarly challenging, albeit different, performance measures for the physicians whose roles are predominately clinical, education, or research,2,3 Only under rare circumstances did department members obtain changes to their remuneration outside the triennial review process. This outcome study of the CDCP provides evidence that the CDCP does value and reward equally each JP. There are physicians from each JP in within the 2 top levels (II–III and III; unpublished observations) of the CDCP and an individual physician to increase their level within the CDCP is similar for each JP (Figs 2 and 3). The findings of our study also indicate that, in contrast to documented gender bias in peer-review4 or academic advancement,5,6 male and female physicians had a similar probability of success within the CDCP (Fig 4).
This outcome study that demonstrates that the CDCP satisfied its design principles2,3 from the department's perspective is in agreement with our previous qualitative research study that evaluated the departmental physician's perception of the CDCP.9 That previous study found that our physicians thought that the CDCP was an improvement over previous methods, that they still were in agreement with the CDCP's purpose and design principles, and that they did not want the CDCP to undergo a major redesign. Taken together, these 2 outcomes studies of our CDCP should provide useful information and/or strategies to other academic departments, for example, to promote the career development and excellence of their physicians or to use as 1 parameter whereby departmental budgets might be aligned with desired academic outputs.10,11
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ACKNOWLEDGMENTS
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The CDCP represents the work of many members of our Department of Pediatrics. Special acknowledgment is made to the Department of Pediatrics' Clinical, Medical Education, and Research Advisory Committees.
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FOOTNOTES
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Accepted Oct 10, 2006.
Address correspondence to Hugh O'Brodovich, MD, Departments of Pediatrics and Physiology, University of Toronto, Hospital for Sick Children, 555 University Ave, Toronto, Ontario, Canada M5G-1X8. E-mail: hugh.obrodovich{at}sickkids.ca
The authors have indicated they have no financial relationships relevant to this article to disclose.
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PEDIATRICS (ISSN 1098-4275). ©2007 by the American Academy of Pediatrics
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