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

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

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

19. What�s 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

28. My New Affiliation

29. Challenges: T0 Fairly small department (faculty=10) 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 Didn�t 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 (faculty=25+) 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

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 �There�s 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) �I�d 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 Tower:Solutions 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 institution�s? 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 can�t 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.