General Medicine

(Click on title to be directed to posting, most recent listed first)

Publish or Perish: Tools for Survival
Is Quality of Healthcare Improving in the US?
Survey Shows Support for the Hospital Executive Compensation Act
The Disruptive Administrator: Tread with Care
A Qualitative Systematic Review of the Professionalization of the 
   Vice Chair for Education
Nurse Practitioners' Substitution for Physicians
National Health Expenditures: The Past, Present, Future and Solutions
Credibility and (Dis)Use of Feedback to Inform Teaching : A Qualitative
   Case Study of Physician-Faculty Perspectives
Special Article: Physician Burnout-The Experience of Three Physicians
Brief Review: Dangers of the Electronic Medical Record
Finding a Mentor: The Complete Examination of an Online Academic 
   Matchmaking Tool for Physician-Faculty
Make Your Own Mistakes
Professionalism: Capacity, Empathy, Humility and Overall Attitude
Professionalism: Secondary Goals 
Professionalism: Definition and Qualities
Professionalism: Introduction
The Unfulfilled Promise of the Quality Movement
A Comparison Between Hospital Rankings and Outcomes Data
Profiles in Medical Courage: John Snow and the Courage of
   Conviction
Comparisons between Medicare Mortality, Readmission and 
   Complications
In Vitro Versus In Vivo Culture Sensitivities:
   An Unchecked Assumption?
Profiles in Medical Courage: Thomas Kummet and the Courage to
   Fight Bureaucracy
Profiles in Medical Courage: The Courage to Serve
   and Jamie Garcia
Profiles in Medical Courage: Women’s Rights and Sima Samar
Profiles in Medical Courage: Causation and Austin Bradford Hill
Profiles in Medical Courage: Evidence-Based 
   Medicine and Archie Cochrane
Profiles of Medical Courage: The Courage to Experiment and 
   Barry Marshall
Profiles in Medical Courage: Joseph Goldberger,
   the Sharecropper’s Plague, Science and Prejudice
Profiles in Medical Courage: Peter Wilmshurst,
   the Physician Fugitive
Correlation between Patient Outcomes and Clinical Costs
   in the VA Healthcare System
Profiles in Medical Courage: Of Mice, Maggots 
   and Steve Klotz
Profiles in Medical Courage: Michael Wilkins
   and the Willowbrook School
Relationship Between The Veterans Healthcare Administration
   Hospital Performance Measures And Outcomes 

 

Although the Southwest Journal of Pulmonary and Critical Care was started as a pulmonary/critical care/sleep journal, we have received and continue to receive submissions that are of general medical interest. For this reason, a new section entitled General Medicine was created on 3/14/12. Some articles were moved from pulmonary to this new section since it was felt they fit better into this category.

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Thursday
Feb092017

Publish or Perish: Tools for Survival

Stuart F. Quan, M.D.1

Jonathan F. Borus, M.D.2

 

1Division of Sleep and Circadian Disorders and 2Department of Psychiatry

Brigham and Women’s Hospital

Harvard Medical School

Boston, MA USA

 

(Editor's Note: A downloadable PowerPoint presentation accompanies this article and be accessed by clicking on the following link "Publish or Perish: Tools for Suvival". It is 20 Mb and may take some time to download).

Success in one’s chosen profession is often predicated upon meeting a profession-wide standard of excellence or productivity. In the corporate world, the metric might be sales volume and in clinical medicine it may be patient satisfaction and/or number of patients seen. In academic medicine, including the fields of Pulmonary and Critical Care Medicine, the “coin of the realm” is demonstrable written scholarship. In large part, this is determined by the number and quality of publications in scientific journals. Unfortunately, the skills required to navigate the complexities of how to publish in the scientific literature rarely are taught in either medical school or postgraduate training. To assist the inexperienced academic physician or scientist, the Writing for Scholarship Interest Group of the Harvard Medical School Academy recently published “A Writer’s Toolkit” (1). This comprehensive monograph provides valuable information on all phases of the writing process ranging from conceptualization of a manuscript to understanding of the publication process itself. In today’s society, however, there are alternative methods of disseminating knowledge that may be better received by some learners than traditional prose. Examples include videos, podcasts and online interactive courses.

In order to provide a complementary method of presenting some of the information contained in “A Writer’s Toolkit” for more active learners, we have developed a self-paced interactive learning module to help young authors better understand the submission, review, and response to reviews stages of the publishing process. The module entitled “Publish or Perish: Tools for Survival” is downloadable from this journal’s website. We believe that providing a way for self-learners to better understand these processes will help such inexperienced authors more successfully get published and therefore share their work with others in the field.

Reference

  1. Pories S. Bard T, Bell S et al. A Writer’s Toolkit. MedEdPORTAL, Association of American Medical Colleges; 2012. Available from: www.mededportal.org/publication/9238.

Cite as: Quan SF, Borus JF. Publish or perish: tools for survival. Southwest J Pulm Crit Care. 2017;14(2):67. doi: https://doi.org/10.13175/swjpcc016-17 PDF 

Tuesday
Jan172017

Is Quality of Healthcare Improving in the US?

Richard A. Robbins, MD

Phoenix Pulmonary and Critical Care Research and Education Foundation

Gilbert, AZ USA

 

Abstract

Politicians and healthcare administrators have touted that under their leadership enormous strides have been made in the quality of healthcare. However, the question of how to measure quality remains ambiguous. To demonstrate improved quality that is meaningful to patients, outcomes such as life expectancy, mortality, and patient satisfaction must be validly and reliably measured. Dramatic improvements made in many of these patient outcomes through the twentieth century have not been sustained through the twenty-first. Most studies have shown no, or only modest improvements in the past several years, and at a considerable increase in cost. These data suggest that the rate of healthcare improvement is slowing and that many of the quality improvements touted have not been associated with improved outcomes.

Surrogate Markers

The most common measures of quality of healthcare come from Donabedian in 1966 (1). He identified two major foci for the measuring quality of care-outcome and process. Outcome referred to the condition of the patient and the effectiveness of healthcare including traditional outcome measures such as morbidity, mortality, length of stay, readmission, etc. Process of care represented an alternative approach which examined the process of care itself rather than its outcomes.

Beginning in the 1970’s the Joint Commission began to address healthcare quality by requiring hospitals to perform medical audits. However, the Joint Commission soon realized that the audit was “tedious, costly and nonproductive” (2). Efforts to meet audit requirements were too frequently “a matter of paper compliance, with heavy emphasis on data collection and few results that can be used for follow-up activities. In the shuffle of paperwork, hospitals often lost sight of the purpose of the evaluation study and, most important, whether change or improvement occurred as a result of audit”. Furthermore, survey findings and research indicated that audits had not resulted in improved patient care and clinical performance (2).

In response to the ineffectiveness of the audit and the call to improve healthcare, the Joint Commission introduced new quality assurance standards in 1980 which emphasized measurable improvement in process of care rather than outcomes. This approach proved popular with both regulatory agencies and healthcare investigators since it was easier and quicker to show improvement in process of care surrogate markers than outcomes.

Although there are many examples of the misapplication of these surrogate markers, one recent example of note is ventilator-associated pneumonia (VAP), a diagnosis without a clear definition. VAP guidelines issued by the Institute for Healthcare Improvement include elevation of the head of the bed, daily sedation vacation, daily readiness to wean or extubate, daily spontaneous breathing trial, peptic ulcer disease prophylaxis, and deep venous thrombosis prophylaxis. As early as 2011, the evidence basis of these guidelines was questioned (3). Furthermore, compliance with the guidelines had no influence on the incidence of VAP or inpatient mortality (3). Nevertheless, relying on self-reported hospital data the CDC published data touting declines in VAP rates of 71% and 62% in medical and surgical intensive care units, respectively, between 2006 and 2012 (4,5). However, Metersky and colleagues (6) reviewed Medicare Patient Safety Monitoring System (MPSMS) data on 86,000 critically ill patients between 2005 and 2013 and report that VAP rates remain unchanged since 2005.

Hospital Value-Based Purchasing (HVBP)

CMS’ own data might be interpreted as showing no improvement in quality. About 200 fewer hospitals will see bonuses from the Centers for Medicare and Medicaid Services (CMS) under the hospital value-based purchasing (HVBP) program in 2017 than last year (7). The program affects some 3,000 hospitals and compares hospitals to other hospitals and its own performance over time.

The reduction in payments are “somewhat concerning,” according to Francois de Brantes, executive director of the Health Care Incentives Improvement Institute (7). One reason given was fewer hospitals were being rewarded, but another was hospitals' lack of movement in rankings. The HVBP contains inherent design flaws according to de Brantes. As a "tournament-style" program in which hospitals are stacked up against each other, they don't know how they'll perform until the very end of the tournament. "It's not as if you have a specific target," he said. "You could meet that target, but if everyone meets that target, you're still in the middle of the pack."

Although de Brantes point is well taken, another explanation might be that HVBP might reflect a declining performance in healthcare. If the HVBP program is to reward quality of care, fewer hospitals being rewarded logically indicates poorer care. As noted above, CMS will likely be quick to point out that they have established an ever-increasing litany of "quality" measures self-reported by the hospitals that show increasing compliance with these measures (8). However, the lack of improvement in patient outcomes (see below) suggests that completion of these has little meaningful effect.

Life Expectancy

Although life expectancy for the Medicare age group is improving, the increase likely reflects a long-term improvement in life expectancy and may be slowing over the past few years (Figure 1) (9). Since 2005, life expectancy at birth in the U.S. has increased by only 1 year (10).

Figure 1. Life expectancy past age 65 by year.

The reason(s) for the declining improvement in life expectancy in the twenty-first century compared to the dramatic improvements in the twentieth are unclear but likely multifactorial. However, one possible contributing factor to a slowing improvement in mortality is a declining or flattening rate of improvement in healthcare.

Inpatient Mortality

Figueroa et al. (11) examined the association between HVBP and patient mortality in 2,430,618 patients admitted to US hospitals from 2008 through 2013. Main outcome measures were 30-day risk adjusted mortality for acute myocardial infarction, heart failure, and pneumonia using a patient level linear spline analysis to examine the association between the introduction of the HVBP program and 30-day mortality. Non-incentivized, medical conditions were the comparators. The difference in the mortality trends between the two groups was small and non-significant (difference in difference in trends −0.03% point difference for each quarter, 95% confidence interval −0.08% to 0.13%-point difference, p=0.35). In no subgroups of hospitals was HVBP associated with better outcomes, including poor performers at baseline.

Consistent with Figueroa’s data, inpatient mortality trends declined only modestly from 2000 to 2010 (Figure 2) (12).

Figure 2. Number of inpatient deaths 2000-10.

Although the decline was significant, the significance appears to be mostly explained by a greater that expected drop in 2010 and may not represent a real ongoing decrease. Consistent with the modest improvements seen in overall inpatient mortality, disease-specific mortality rates for stroke, acute myocardial infarction (AMI), pneumonia and congestive heart failure (CHF) all declined from 2002-12. However, the trend appears to have slowed since 2007 especially for CHF and pneumonia (Figure 3).

Figure 3. Inpatient mortality rates for stroke, acute myocardial infarction (AMI), pneumonia and congestive heart failure (CHF) 2002-12.

Consistent with the trend of slowing improvement, mortality rates for these four conditions declined at −0.13% for each quarter during from 2008 until Q2 2011 but only −0.03% from Q3 2011 until the end of 2013 (12).

Patient Ratings of Healthcare

CMS has embraced the concept of patient satisfaction as a quality measure, even going so far as rating hospitals based on patient satisfaction (13). The Gallup company conducts an annual poll of Americans' ratings of their healthcare (14). In general, these have not improved and may have actually declined in the past 2 years (Figure 4).

Figure 4. Americans’ rating of their healthcare.

Cost

There is little doubt that healthcare costs have risen (15). The rising cost of healthcare has been cited as a major factor in Americans’ poor rating of their healthcare. The trend appears to be one of increasing dissatisfaction with the cost of healthcare (Figure 5) (16).

Figure 5. Americans’ satisfaction or dissatisfaction with the cost of healthcare.

Discussion

Americans have enjoyed remarkable improvements in life expectancy, mortality, and satisfaction with their healthcare over the past 100 years. However, the rate of these improvements appears to have slowed despite an ever-escalating cost. Starting with a much lower life expectancy in the US, primarily due to infections disease, the dramatic effect of antibiotics and vaccines on overall mortality in the twentieth century would be difficult to duplicate. The current primary causes of mortality in the US, heart disease and cancer, are perhaps more difficult to impact in the same way. However, declining healthcare quality may explain, at least in part, the slowing improvement in healthcare.

The evidence of lack, or only modest, improvement in patient outcomes is part of a disturbing trend in quality improvement programs by healthcare regulatory agencies. Under political pressure to “improve” healthcare, these agencies have  imposed weak or non-evidence based guidelines for many common medical disorders. In the case of CMS, hospitals are required to show compliance improvement under the threat of financial penalties. Not surprisingly, hospitals show an improvement in compliance whether achieved or not (17). The regulatory agency then extrapolates this data from previous observational studies to show a decline in mortality, cost or other outcomes. However, actual measure of the outcomes is rarely performed. This difference is important because a reduction in a surrogate marker may not be associated with improved outcomes, or worse, the improvement may be fictitious. For example, many patients often die with a hospital-acquired infection. Certainly, hospital-acquired infections are associated with increased mortality. However, preventing the infections does not necessarily prevent death. For example, in patients with widely metastatic cancer, infection is a common cause of death. However, preventing or treating the infection, may do little other than delay the inevitable. A program to improve infections in these patients would likely have little effect on any meaningful patient outcomes.

There is also a trend of bundling weakly evidence-based, non-patient centered surrogate markers with legitimate performance measures (18). Under threat of financial penalties, hospitals are required to improve these surrogate markers, and not surprisingly their reports indicate they do. The organization mandating compliance with their outcomes reports that under their guidance hospitals have significantly improved healthcare saving both lives and money. However, if the outcome is meaningless or the hospital lies about their improvement, there is no overall quality improvement. There is little incentive for the parties to question the validity of the data. The organization that mandates the program would be politically embarrassed by an ineffective program and the hospital would be financially penalized for honest reporting.

Improvement begins with the establishment of measures that are truly evidence-based. Surrogate markers should only be used when improvement in that marker has been unequivocally shown to improve patient-centered outcomes. The validity of the data also needs to be independently confirmed. Those regulatory agency-demanded quality improvement programs that do not meet these criteria need to be regarded for what they are-political propaganda rather than real solutions.

The above data suggest that healthcare is improving little in what matters most, patient-centered outcomes. Those claims by regulatory agencies of improved healthcare should be regarded with skepticism unless corroborated by improvement in valid patient-centered outcomes.

References

  1. Donabedian A. Evaluating the quality of medical care. 1966. Milbank Q. 2005;83(4):691-729. [PubMed]
  2. Affeldt JE. The new quality assurance standard of the Joint Commission on Accreditation of Hospitals. West J Med. 1980;132:166-70. [PubMed]
  3. Padrnos L, Bui T, Pattee JJ, et al. Analysis of overall level of evidence behind the Institute of Healthcare Improvement ventilator-associated pneumonia guidelines. Southwest J Pulm Crit Care 2011;3:40-8.
  4. Edwards JR, Peterson KD, Andrus ML, et al; NHSN Facilities. National Healthcare Safety Network (NHSN) Report, data summary for 2006, issued June 2007. Am J Infect Control. 2007;35(5):290-301. [CrossRef] [PubMed]
  5. Dudeck MA, Weiner LM, Allen-Bridson K, et al. National Healthcare Safety Network (NHSN) report, data summary for 2012, device-associated module. Am J Infect Control. 2013;41(12):1148-66. [CrossRef] [PubMed]
  6. Metersky ML, Wang Y, Klompas M, Eckenrode S, Bakullari A, Eldridge N. Trend in ventilator-associated pneumonia rates between 2005 and 2013. JAMA. 2016 Dec 13;316(22):2427-9. [CrossRef] [PubMed]
  7. Whitman E. Fewer hospitals earn Medicare bonuses under value-based purchasing. Medscape. November 1, 2016. Available at: http://www.modernhealthcare.com/article/20161101/NEWS/161109986 (accessed 11/3/16).
  8. Centers for Medicare & Medicaid Services. 2015 national impact assessment of the centers for medicare & medicaid services (CMS). quality measures report. March 2, 2015. Available at: https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/qualitymeasures/downloads/2015-national-impact-assessment-report.pdf (accessed 11/3/16).
  9. National Center for Health Statistics. Health, United States, 2015: With Special Feature on Racial and Ethnic Health Disparities. Hyattsville, MD. 2016. Available at: http://www.cdc.gov/nchs/data/hus/hus15.pdf#015 (accessed 11/3/16).
  10. Johnson NB, Hayes LD, Brown K, Hoo EC, Ethier KA. CDC National health report: leading causes of morbidity and mortality and associated behavioral risk and protective factors—United States, 2005–2013October 31, 2014/ 63(04);3-27. Available at: https://www.cdc.gov/mmwr/preview/mmwrhtml/su6304a2.htm (accessed 11/3/16).
  11. Figueroa JF, Tsugawa Y, Zheng J, Orav EJ, Jha AK. Association between the Value-Based Purchasing pay for performance program and patient mortality in US hospitals: observational study. BMJ. 2016 May 9;353:i2214.
  12. Centers for Disease Control. Trends in inpatient hospital deaths: national hospital discharge survey, 2000–2010. March 2013. Available at: http://www.cdc.gov/nchs/products/databriefs/db118.htm (accessed 11/3/16).
  13. CMS. First release of the overall hospital quality star rating on hospital compare. July 27, 2016. Available at: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-07-27.html (accessed 11/3/16)
  14. Newport F. Ratings of U.S. healthcare quality no better after ACA. November 19, 2015. Available at: http://www.gallup.com/poll/186740/americans-own-healthcare-ratings-little-changed-aca.aspx (accessed 11/3/16).
  15. Robbins RA. National health expenditures: the past, present, future and solutions. Southwest J Pulm Crit Care. 2015;11(4):176-85.
  16. Newport F. Ratings of U.S. healthcare quality no better after ACA. November 19, 2015. Available at: http://www.gallup.com/poll/186740/americans-own-healthcare-ratings-little-changed-aca.aspx (accessed 11/3/16).
  17. Meddings JA, Reichert H, Rogers MA, Saint S, Stephansky J, McMahon LF. Effect of nonpayment for hospital-acquired, catheter-associated urinary tract infection: a statewide analysis. Ann Intern Med 2012;157:305-12. [CrossRef] [PubMed]
  18. CMS. Bundled payments for care improvement (BPCI) initiative: general information. November 28, 2016. Available at:  https://innovation.cms.gov/initiatives/bundled-payments/ (accessed 12/30/16).

Cite as: Robbins RA. Is quality of healthcare improving in the US? Southwest J Pulm Crit Care. 2017;14(1):29-36. doi: https://doi.org/10.13175/swjpcc110-16 PDF 

Monday
Aug222016

Survey Shows Support for the Hospital Executive Compensation Act

Richard A. Robbins, MD

Editor, SWJPCC

The Arizona Hospital Executive Compensation Act 2016 was an Arizona state proposition to limit healthcare executive pay to $450,000/year. An anonymous survey conducted by the Southwest Journal of Pulmonary and Critical Care (SWJPCC) from 8/1/16-8/22/16 on support for the proposition support and its possible effect on healthcare (Appendix 1). We obtained 52 responses of which 49 were from physicians and 3 from other healthcare workers. Eighty-three percent (43 of 52) supported the proposition and only 10% (5 of 52) felt if would make patient care worse. Thirty-five percent (18 of 52) felt it would make patient care better while the remaining 56% believed it would have no effect. All 5 of those who opposed the proposition felt it would make healthcare worse. These data suggest that in the opinion of those who answered a survey in the SWJPCC the vast majority supported a measure to limit healthcare executive pay and most felt it would have no effect on patient care or make it better.

Cite as: Robbins RA. Survey shows support for the hospital executive compensation act. Southwest J Pulm Crit Care. 2016;13:90. doi: http://dx.doi.org/10.13175/swjpcc080-16 PDF

Friday
Aug052016

The Disruptive Administrator: Tread with Care

Richard A. Robbins, MD

Phoenix Pulmonary and Critical Care Research and Education Foundation

Gilbert, AZ

 

Abstract

Although the extent of disruptive behavior in healthcare is unclear, the courts are beginning to recognize that administrators can wrongfully restrain a physician's ability to practice. Disruptive conduct is often difficult to prove. However, when administration takes action against an individual physician, they are largely powerless, with governing boards and courts usually siding with the administrators. As long as physicians remain vulnerable to retaliation and administration remains exempt for inappropriate actions, physicians should carefully consider the consequences before displaying any opposition to an administrative action.

Introduction

Over the past three decades there have been hundreds of articles published on "disruptive" physicians. Publications have appeared in prestigious medical journals and been published by medical organizations such as the American Medical Association and by regulatory organizations such as the Joint Commission and some state licensing agencies. Although attempts have been made to define disruptive behavior, the definition remains subjective and can be applied to any behavior viewed objectionable by an administrator. The medical literature on disruptive physician behavior is descriptive, nonexperimental and not evidence based (1). Furthermore, despite claims to the contrary, there is little evidence that "disruptive" behavior harms patient care (1).

Certainly, there are physicians who are disruptive. Most disruptions are due to conflict between physicians and other healthcare providers with which they most closely interact, usually nurses. Not surprisingly, many of the authors of these descriptive articles have been nurses although some have been administrators, lawyers or even other physicians. These articles often give the impression that administrators are merely trying to do their job and that physicians who disagree should be punished. Although this may be true, and most administrators are trying their best to have a positive impact on health care delivery, in some instances it is not.

Like disruptive physician behavior, the extent and incidence of disruptive administrative behavior is unknown. A PubMed search and even a Google search on disruptive administrative behavior discovered no appropriate articles. However, one type of disruptive behavior is bullying. A recent survey in the United Kingdom of obstetrics and gynecology consultants suggests the problem may be common. Nearly half of the consultants who responded to a survey said they had been persistently bullied or undermined on the job (2). Victims report that those at the top of the hierarchy or near it, such as lead clinicians, medical directors, and board-level executives, do most of the bullying and undermining. Pamela Wible MD, an authority in physician suicide prevention, said these results are not unique to the United Kingdom, and that the patterns are similar in the United States (3).

A major difference between physician and administrative disruptive behavior is that physician disruptive behavior usually applies to a specific individual but most of the examples detailed below are largely system retaliation against physicians who complained. Administrators typically work through committees thereby diffusing their individual responsibility for a specific action. Wible said the usual long list of perpetrators against physicians often indicates a toxic work environment (3). "I talk to doctors every day who are ready to quit medicine because of this toxic work environment that has to do with this bullying behavior. What I hear most is it's coming from the clinic manager or the administrative team who calls the doctor into the office and beats them up ..." she added.

History of the Recognition of Physician Disruptive Behavior

Isolated articles on disruptive physician behavior first appeared in the medical literature in the 1970's with scattered reports appearing through the 1980's and 1990's (4). Prompted by these isolated reports and the perception that this might be a growing problem, a Special Committee on Professional Conduct and Ethics was appointed by the Federation of State Medical Boards to investigate physician disruptive behavior. They released their report in April, 2000 and listed 17 behavioral sentinel events (Table 1) (5).

Table 1. Behavioral sentinel events (3).

As announced in 2008 in an article in "The Joint Commission Journal of Quality and Patient Safety" and a Joint Commission Sentinel Event Alert,  a new Joint Commission accreditation standard requires hospitals to have a disruptive policy in place and to provide resources for its support as one of the leadership standards for accreditation (6,7). Although not stated, it is clear these standards refer to hospital employees and not hospital administration giving the impression that any disagreement between a physician or other employee and administration are the result of a disruptive behavior on the part of the physician or employee. They imply that all adverse actions against physicians for disruptive physician behavior are warranted. However, physicians may be trying to protect their patients from poor administrative decisions while administrators view physician opposition as insubordination. The viewpoint lies in the eyes of observer.

Disruptive Administrative Behavior Involving Whistleblowing

Klein v University Of Medicine and Dentistry of New Jersey

Sanford Klein was chief of anesthesiology at Robert Wood Johnson University Hospital in New Brunswick, NJ, for 16 years (8). He grew increasingly concerned about patient safety in the radiology department and complained repeatedly to the hospital's chief of staff, citing insufficient staff, space, and resuscitation equipment. After Klein grew increasingly vocal he was required to work under supervision. He refused to accept that restriction and sued. The trial judge granted summary judgment for the defendants, and an appellate court upheld that ruling. Klein is still a tenured professor at the university, but he no longer has privileges at the hospital. "This battle has cost me hundreds of thousands of dollars so far, and it's destroyed my career as a practicing physician," he says. "But if I had to do it over again, I would, because this is an ethical issue."

Lemonick v Allegheny Hospital System

David Lemonick was an emergency room physician at Pittsburgh's Western Pennsylvania Hospital who repeatedly complained to his department chairman about various patient safety problems (8). His department chairman accused him of "disruptive behavior". Lemonick wrote to the hospital's CEO to express his concerns about patient care, who thanked him, promised an investigation, and assured him there would be no retaliation. Nevertheless, Lemonick was terminated and sued the hospital for violating Pennsylvania's whistleblower protection law and another state law that specifically protects healthcare workers from retaliation for reporting a "serious event or incident" involving patient safety. Lemonick and Alleghany reached an out of court settlement and he  is now director of emergency medicine at a small hospital about 50 miles from his Pittsburgh. He was named Pennsylvania's emergency room physician of the year in 2007.

Ulrich v Laguna Honda Hospital

John Ulrich protested at a staff meeting when he learned that Laguna Honda Hospital was planning to lay off medical personnel, including physicians (9). He claimed layoffs would endanger patient care. Ulrich resigned and the hospital administration reported his resignation to the state board and the National Practitioner Data Bank, noting that it had followed unknown to Ulrich "commencement of a formal investigation into his practice and professional conduct".  Although the state board found no grounds for action, the hospital refused to void the NPDB report. Ulrich sued the hospital and its administrators. In 2004, after a long legal battle, Ulrich won a $4.3 million verdict, and later settled for about $1.5 million, with the hospital agreeing to retract its report to the NPDB. Still, he spent nearly seven years without a full-time job, doing part-time work as a coder and medical researcher, with a sharply reduced income.

Schulze v Humana

Dr. John Paul Schulze, a longtime family practice doctor in Corpus Christi, Texas, criticized Humana Health Care in 1996 for its decision to have its own doctors care for all patients once they were admitted to Humana hospitals (9). Humana officials alleged that he “was unfit to practice medicine, and represented an ongoing threat of harm to his patients" and reported Schulze to the National Practitioners Data Bank and the Texas State Board of Medical Examiners. Schulze sued and after several years of legal battles an out of court settlement was reached.

Flynn v. Anadarko Municipal Hospital

Dr. John Flynn reported to Anadarko Municipal Hospital administrators that a colleague abandoned a patient (9). After no action was taken, he resigned from the medical staff before reporting the alleged violations to state and federal authorities. Flynn attempted to rejoin the staff after an investigation had found violations, but the medical staff denied him privileges. The public works authority governing the hospital held a lengthy hearing on the case and restored Flynn's privileges.

Kirby v University Hospitals of Cleveland

University Hospitals of Cleveland (UH) which is affiliated with Case Western Reserve University recruited Dr. Thomas Kirby to head up its cardiothoracic surgery and lung transplant divisions in 1998 (9). Not long after he joined UH, Kirby started pressing hospital executives about program changes, particularly for open heart procedures. Kirby said he was alarmed by mounting deaths and complications among intensive care patients after heart surgeries, and took his concerns to hospital administrators and board members.

When he returned from a vacation, Kirby learned he'd been demoted and the two colleagues he'd recruited to the program had been fired. During the subsequent months, acrimony within the department boiled over and eventually led to Kirby filing a slander suit against a fellow surgeon, who Kirby claimed made disparaging remarks to other staff members about his clinical competence. The hospital's reaction was to suspend Kirby. The suspension letter from the hospital chief of staff accused Kirby of being "abusive, arrogant and aggressive" with other hospital staff, including use of profanity and "foul and/or sexual language." Accusers were not named, dates were not supplied and Kirby was not offered the chance to continue practicing surgery. Subsequently, the Accreditation Council for Graduate Medical Education revoked UH's cardiothoracic surgery residency, saying the program no longer met council standards.

However, Kirby sued over another issue which may have been at the heart of the acrimony. Kirby had alleged that UH had entered into improper financial arrangements with doctors to induce them to refer patients and then billed Medicare for the services provided. The U.S. attorney for the Northern District of Ohio intervened in the suit. University Hospital eventually agreed to pay $13.9 million to settle the federal false claims lawsuit arising from alleged anti-kickback violations although they denied any wrongdoing. Kirby was awarded a settlement of $1.5 million.

Fahlen vs. Memorial Medical Center

Between 2004 and 2008, Dr. Mark Fahlen, reported to hospital administration that nurses at Memorial Medical Center in Modesto, California were failing to follow his directions, thus endangering patients’ lives (10). However, the nurses complained about Fahlen’s behavior and he was fired. A peer committee consisting of six physicians reviewed the decision and found no professional incompetence but Memorial’s board refused to grant him staff privileges. Subsequently, Fahlen sued. After four years of legal wrangling, an out of court agreement reinstated Fahlen's hospital privileges.

Disruptive Administrative Behavior By an Individual Administrator

Vosough vs. Kierce

In Patterson, New Jersey Khashayar Vosough MD and his partners sued St. Joseph's Regional Medical Center's obstetrics and gynecology department chairman, Roger Kierce MD, for profane language and abusive and demeaning behavior (11). Kierce once told a group of doctors he would "separate their skulls from their bodies" if they disobeyed him. In 2012 a Bergen County jury returned the verdict in less than an hour, awarding Vosough and his colleagues $1,270,000. However, the decision was appealed and overturned in 2014 by the Superior Court of New Jersey, Appellate Division (12).

Medical Staff Collectively Suing a Hospital Administration

Medical Staff of Avera Marshall Regional Medical Center v. Avera Marshall

In rare instances a collection of physicians comes into legal conflict with a hospital. In Minnesota the medical staff of Avera Marshall Medical Center was charged with physician credentialing, peer review, and quality assurance (13). A two-thirds majority vote was required to change the bylaws but the hospital administration unilaterally changed the bylaws in early 2012. The medical staff sued the hospital.

However, the real source of the dispute might be over patient referrals and income. Conflict arose when doctors not employed by the hospital alleged that the that the hospital was steering emergency room patients toward its own employed doctors. The case was eventually decided by the Minnesota Supreme Court who ruled in favor of the medical staff (13).

Discussion

These cases illustrate that physicians can occasionally win lawsuits against hospital administration for disruptive behavior. However, victory is often hollow with careers destroyed and years without a professional income as the wheels of justice slowly turn. As one article said, "Is whistleblowing worth it?" (8).

Dr. Fahlen was fortunate that the peer review found no professional incompetence. In many instances the reviews are conducted by physician administrators with the verdict predetermined. For example, in the Thomas Kummet case presented in the Southwest Journal of Pulmonary and Critical Care, an independent review concluded there was no malpractice (14). However, the Veterans Administration had the case reviewed by a VA appointed committee who sided with the VA administration. Kummet's name was subsequently submitted to the National Practioner Databank and he sued the VA. After the case was dismissed by a Federal court, Kummet left the VA system.

Physicians are particularly vulnerable to retaliation by unfounded accusations. Several examples were given above. In many of these cases, complaints were followed by what appeared to be a sham peer review. Sham peer review is a name given to the abuse of the peer review process to attack a doctor for personal or other non-medical reasons (15,16). The American Medical Association conducted an investigation of medical peer review in 2007 and concluded that it is easy to allege misconduct and 15% of surveyed physicians by the Massachusetts Medical Society indicated that they were aware of peer review misuse or abuse (17). However, cases of malicious peer review proven through the legal system are rare.

Huntoon (18) listed a number of characteristic of sham peer review (Table 2).

Table 2. Characteristics of sham peer review (16).

I first witnessed peer review being used as a weapon as a junior faculty member in the mid-1980's. The then chief of thoracic surgery, a pediatric thoracic surgeon, underwent peer review. It appeared that the underlying reason was that most of his operations were performed at an affiliated children's hospital rather than the university medical center that conducted the review. The influence of income as opposed to medical quality being the real motivation for an administrative action against a physician is unknown, although some of the above cases suggests it is not uncommon. Given the amount of money potentially involved and the lack of consequences for hospital administration, it is naive to believe that false accusations would not or will not continue to occur.

Most disturbing is physicians who falsely accuse other physicians. Although this behavior would clearly be covered by behavioral sentinel events such as those listed in table 1, hospital boards may deem not to act. For example, one physician accused a hospital director, a non-practicing physician, of being disruptive. The hospital board failed to act stating that their interpretation was that the term disruptive physician applied only to practicing physicians.

The federal Whistle Blower Protection Act (WPA) protects most federal employees who work in the executive branch. It also requires that federal agencies take appropriate action. Most individual states have also enacted their own whistleblower laws, which protect state, public and/or private employees. Unlike their federal counterparts however, these state levels generally do not provide payment or compensation to whistleblowers, Instead the states concentrate on the prevention of retaliatory action toward the whistleblower. Unlike California's law specifically protecting physicians most state laws are not specific to physicians.

Although beyond the scope of this review, it seems likely that administrative disruptive actions may also occur against other health care workers including nurses, technicians and  other staff. However, the prevalence and appropriateness of these actions are unclear. However, as leaders of the healthcare team and often not employed by the hospital, physicians are unique as evidenced by the National Practioner Data Bank. No similar nursing, technician or administrator data bank exists.

Although the few cases cited above suggest that legal action can be successful against abusive administrators, these cases are rare. The consequences of being labeled disruptive can be dire to physicians who lack any due process either in hospitals and often in the courts. Until such a time when administration can be held accountable for behavior that is considered disruptive, the sensible physician might avoid conflicts with hospital administration.

References

  1. Hutchinson M, Jackson D. Hostile clinician behaviours in the nursing work environment and implications for patient care: a mixed-methods systematic review. BMC Nurs. 2013 Oct 4;12(1):25. [CrossRef] [PubMed]
  2. Shabazz T, Parry-Smith W, Oates S, Henderson S, Mountfield J. Consultants as victims of bullying and undermining: a survey of Royal College of Obstetricians and Gynaecologists consultant experiences. BMJ Open. 2016 Jun 20;6(6):e011462. [CrossRef] [PubMed]
  3. Frellick M. Senior physicians report bullying from above and below. Medscape. June 29, 2016. Available at: http://www.medscape.com/viewarticle/865561?src=WNL_jumpst_160704_MSCPEDIT&impID=1143310&faf=1%23vp_2#vp_2
  4. Hollowell EE. The disruptive physician: handle with care. Trustee. 1978 Jun;31(6):11-3, 15, 17. [PubMed]
  5. Russ C, Berger AM, Joas T, Margolis PM, O'Connell LW, Pittard JC, George A. Porter GA, Selinger RCL, Tornelli-Mitchell J, Winchell CE, Wolff TL. Report of the Special Committee on Professional Conduct and Ethics. Federation of State Medical Boards of the United States. April, 2000. Available at: https://www.fsmb.org/Media/Default/PDF/FSMB/Advocacy/2000_grpol_Professional_Conducts_and_Ethics.pdf (accessed 5/3/16).
  6. Rosenstein AH, O’Daniel M. A survey of the impact of disruptive behaviors and communication defects on patient safety. Jt Comm J Qual Patient Saf. 2008;34:464–471. [PubMed]
  7. The Joint Commission. Behaviors That Undermine a Culture of Safety Sentinel Event Alert #40 July 9, 2008: 1-5. Available from: http://www.jointcommission.org/sentinel_event_alert_issue_40_behaviors_that_undermine_a_culture_of_safety/ (accessed 5/3/16).
  8. Rice B. Is whistleblowing worth it? Medical Economics. January 20, 2006. Available at: http://medicaleconomics.modernmedicine.com/medical-economics/content/whistleblowing-worth-it (accessed 5/5/16).
  9. Twedt S. The Cost of Courage: how the tables turn on doctors. Pittsburgh Post-Gazette. October 26, 2003. Available at: http://www.post-gazette.com/news/nation/2003/10/26/The-Cost-of-Courage-How-the-tables-turn-on-doctors/stories/200310260052 (accessed 5/5/16).
  10. Danaher M. Physician not required to exhaust hospital’s administrative review process before suing hospital under state’s whistleblower statute. Employment Law Matters. February 20, 2014. Available at: http://www.employmentlawmatters.net/2014/02/articles/health-law/physician-not-required-to-exhaust-hospitals-administrative-review-process-before-suing-hospital-under-states-whistleblower-statute/ (accessed 5/3/16).
  11. Washburn L. Doctors win suit against hospital over abuse by boss. The Record. January 11, 2012. Available at: http://www.northjersey.com/news/doctors-win-suit-against-hospital-over-abuse-by-boss-1.847838?page=all (accessed 5/4/16).
  12. Ashrafi JAD. Vosough v. Kierce. Find Law for Legal Professionals. 2014. Available at: http://caselaw.findlaw.com/nj-superior-court-appellate-division/1676593.html (accessed 5/4/16).
  13. Moore, JD Jr. When docs sue their own hospital-at issue: who has authority to hire, fire, and discipline staff physicians. Medpage Today. January 19, 2015. Available at: http://www.medpagetoday.com/PracticeManagement/Medicolegal/49610 (accessed 5/3/16).
  14. Robbins RA. Profiles in medical courage: Thomas Kummet and the courage to fight bureaucracy. Southwest J Pulm Crit Care. 2013;6(1):29-35. Available at: http://www.swjpcc.com/general-medicine/2013/1/12/profiles-in-medical-courage-thomas-kummet-and-the-courage-to.html (accessed 8/5/16)
  15. Chalifoux R Jr, So what is a sham peer review? MedGenMed. 2005 Nov 15;7(4):47. [PubMed]
  16. Langston EL. Inappropriate peer review. Report of the board of trustees. 2016. Available at: http://shammeddoc.blogspot.com/2010/10/american-medical-association-ama-and.html (accessed 5/15/16).
  17. Chu J. Doctors who hurt doctors. Time. August 07, 2005. Available at: http://content.time.com/time/magazine/article/0,9171,1090918,00.html (accessed 5/15/16, requires subscription).
  18. Huntoon LR. Tactics characteristic of sham peer review. Journal of American Physicians and Surgeons 2009;14(3):64-6.

Cite as: Robbins RA. The disruptive administrator: tread with care. Southwest J Pulm Crit Care. 2016:13(2):71-9. doi: http://dx.doi.org/10.13175/swjpcc049-16 PDF 

Tuesday
Jun212016

A Qualitative Systematic Review of the Professionalization of the Vice Chair for Education

Guadalupe F. Martinez, PhD 

Kenneth S. Knox, MD

 

Department of Medicine

University of Arizona

Tucson, Arizona. USA

 

Abstract

Background

Pulmonary/Critical Care physician-faculty are often in academic leadership positions, such as a department chair. As chairs are responsible for the success of their education programs, and given the increased complexity involved in evaluating learners and faculty increases, chairs are turning to colleagues with expertise in education for assistance. As such, vice chairs for education (VCE) are being introduced into the mix of academic executives to respond to the demands for accountability, training requirements, and professional development in a rapidly changing medical education climate. This review synthesizes the published literature around the VCE position.

Methods

An advanced electronic database and academic journal search was performed specific to the medical, medical education, and education disciplines. “Vice Chair for Education, Educational Leadership, (specialty) Residency Program Director” terms were used in these search processes. We conducted a qualitative systematic review of VCE literature in the English language published from January 1, 2005 to April 1, 2016.

Results

From the 6 studies screened, 4 were excluded and 2 full-text articles were eligible and retained for review. Both studies were cross-sectional and published between March and August of 2012 with response rates above 70%. Each employed quantitative and qualitative methods. The studies report important demographics and job duties of the vice chair.

Conclusion

The vice chair for education in academic medical departments has emerged as an important position and is undergoing professionalization.

Abbreviation List

AAIM-Alliance for Academic Internal Medicine

PRISMA-Preferred Reporting Items for Systematic Reviews and Meta-Analyses

VCE-Vice Chair for Education

Introduction

Schuster and Pangaro (1) introduced the pyramid of educators concept in their book chapter, Understanding Systems of Education in 2010. They designate the top of the pyramid as the institutional leaders or “academic executives” of the medical education system. These leaders include positions such as department chairs, deans, and CEOs. Pulmonary/Critical Care physician-faculty are often in leadership positions such as these. Locally, at our southwest institution and affiliate training hospital, the senior vice president for health sciences, chief medical officer, internal medicine department chair, vice chair for education, vice chair for quality and safety, internal medicine residency director, and one of the three associate residency directors are all pulmonary/critical care physician-faculty. Nationally, according to the Alliance for Academic Internal Medicine (P. Ballou, AAIM email communication, May 2016), 12% (20/172) Internal Medicine department chairs are pulmonary/critical care/allergy physician-faculty belonging to the association to date. As chairs are responsible for the educational success of their programs, and given the complexity involved in evaluating learners and faculty, department chairs are turning to colleagues with interest and expertise in education for assistance. Vice chairs for education (VCE) are now being introduced into the mix of academic executives. Although the VCE role may vary by institution, VCEs are likely to respond to the demands for accountability, training requirements, and professional development in a rapidly changing medical education climate.

According to sociologists DiMaggio and Powell (2), one way to respond to external pressures is to create and legitimize new positions intended to better manage changes and demands. They go on to define this process as a professionalization of a position. Despite the emergence of the prominent and potentially pivotal position of the VCE, the formal recognition of this position and clarity of its purview over the educational mission remains obscure. In addition to synthesizing the published literature around the VCE position, we sought to determine two points that could best inform the medical education community about this position and future directions for educational leadership. First, is the role of department VCE defined in the academic literature? Second, what evidence exists that the position has professionalized in academic medicine?

Methods

In adherence with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) (3) guidelines, we conducted a qualitative systematic review of VCE literature in the English language published from January 1, 2005 to April 1, 2016. The authors adapted the Cochrane Collaboration and developed and followed a specific search protocol a priori (4-5). The protocol is summarized below and detailed in Table 1. Institutional Review Board approval is not necessary for literature reviews.

Table 1. Search protocol in adherence to the Cochrane Collaboration

1. Text of the review

a. Background: As department chairs are responsible for the educational success of their learners and faculty in academic medical centers, changes in how they delegate and manage the educational mission are evident. VCEs are now being introduced into the mix of academic executives to respond to the demands for accountability, expertise and leadership from changing medical education climate. Despite this important role, the formal recognition of this position and clarity of their purview over the educational mission has remained obscure.

b. Objectives of the study are to:

i) review how well-defined the role of the department vice chair for education is medicine education institutions, and

ii) understand to what extent the position is professionalizing and becoming institutionalized.

iii) gain insight into the above via synthesis and appraisal of relevant literature.

2. Criteria for selected studies for review

Exclusion

Non-English works

Commentaries

Perspectives

Newsletters

Lone job descriptions

Unpublished under-review research reports

 

 

 

Inclusion

English language works

Peer-reviewed published or in press qualitative, quantitative mix-methods original research reports, or articles with a research component

Book chapters dedicated to the role solely

Written between: January 1, 2005*-April 1, 2016

*Average of Brownfield (9) and Sanfey (5y) mean years since the establishment of the position as reported in 2012 publication (12y; 8y)

3. Search strategy

a. Email outreach to national VCE- Internal Medicine and Emergency Medicine interest group and listserv for the purposes of:

i) triangulation

ii) accessing submitted, in press, and unpublished work

iii) accessing grey literature such as white papers and institutional reports.

b. Electronic search consisting of the following relevant journals:

Academic Medicine

American Journal of Medicine

Medical Education

Journal of American Medical Association

American Educational Research Association

Journal of Surgical Education

Medical Teacher

The American Journal of Surgery

e. Ancestry search of inclusive study references for snowball e-searches.

f. Relevant database search of the following:

Cochrane Database of Systematic Reviews

ERIC

MEDLINE

PubMed

Research Gate

Science Direct

Zotero

f. Search engines:

Google

Google scholar

g. Conference proceedings for specialty educational associations (Internal Medicine; Anesthesia, Surgery, Emergency Medicine, Pediatrics, Dermatology, Family Medicine, Psychiatry)

h. Word search:

Vice Chair for Education, Educational Leadership, (Specialty) Program Director

Search protocol

The first author completed an advanced electronic database and academic journal search that included those terms specific to the medical, medical education, and education disciplines. “Vice Chair for Education, Educational Leadership, (specialty) residency program director” terms were used in these search processes as well as the search engine examination. The first author also conducted an ancestry search of the references listed in the screened literary pieces. The authors reached out to a national interest group made up of primarily VCEs in Internal Medicine via a national VCE email distribution list to combat publication and database bias, and gain knowledge about any existing grey literature, conference proceedings, unpublished or recently submitted works. Hand searches were not conducted as the ancestry search found the earliest relevant and indexed piece to be in 2012. Additionally, most journals have moved historic volumes as of 2005 to an online interface.

Inclusion and exclusion criteria

Authors set inclusion criteria to be qualitative, quantitative mix-methods original research reports or articles with a research component. Reports were to be full-text peer-reviewed works published or “in press.” Additionally, book chapters dedicated solely to the VCE role were considered.

Excluded were commentaries, perspectives, newsletters, pure job description documents, unpublished research reports or articles and those in “under review” status.

Data appraisal and extraction

Framework analysis (6), citations and full-text articles were charted, indexed, identified for themes, and finally, mapped and interpreted to collect and examine text for review. Appraisal of methodological soundness, reporting, and contribution to knowledge was conducted once full-text articles were identified for review. Validated quality assessment tools for quantitative and qualitative works were implemented and are discussed later in this review.

During the ancestry search, citations were imported into Endnote. Full study documents were imported into QSR Nvivo 10 software for analysis. Data categories and coding were developed via consensus building between the authors as part of the analytical framework Figure 1.

Figure 1. Thematic coding and concept mapping. As a method of mapping methods for qualitative data structuring, this concept map illustrates themes that emerged from data. Concepts are linked to demonstrate the relationships between them. Similarities, differences, strengths, and weaknesses were identified and threaded throughout each domain-or branch of the map that focuses on a particular aspect.

The first author began the initial coding process and queries followed by member checking by the senior author to improve categorization credibility. No initial categorization discrepancies between the authors occurred.

Results

Search results

From the 6 screened studies, 4 were excluded and only 2 full-text articles were eligible for review. See Figure 2 for detailed PRISMA flow diagram.

Figure 2. PRISMA 2009 Flow Diagram. The diagram depicts the flow of information throughout the systematic review. Mapped are the number of records identified, included and excluded.

Study characteristics

Both studies were cross-sectional and published between March and August of 2012 with response rates above 70%. Each employed quantitative and qualitative methods, but each favored one method Table 2.

Table 2 List of relevant, but excluded literature and justification

Author

Month/Year Published

Literary Type/Topic

Focus/Justification for final exclusion

Sanfey et al.14

March web content and July 2012

Web-based and article based Review/VCE scope of duties and qualifications

Brief website review of the authors’ previous work that delineates VCE qualifications for MDs and PhD educators, career development opportunities, and job description with specific workloads for each mission. The authors offer sections on career advice specific to time management, acquiring a national reputation, funding for educational research activities, and resource sites to find a VCE position. Excluded as this is a review and career offerings are opinion-based. Via a surgical organization task force, the online material underwent a slight title modification. This online review of the original research was subsequently published in print with the American Journal of Surgery.

Pangaro15

August/2012

Commentary/VCE and direction for future educational leadership

Highlight gaps in nation’s overall approach to medical education. Offers a paradigm shift calling for medical education to use evidence-based data, and educational theory to inform future directions and departmental leadership. Innovation and creativity is stressed. In this spirit, there is a call for a specific leadership style (collaborative) on the side of the Chair that could likely empower the VCE role. Insightful and relevant for future directions, but excluded as the commentary is opinion-based.

Wolfsthal et al.16

 

Book Chapter/Internal Medicine Program Residency Director Job Description

Seven page chapter in the internal Medicine association’s textbook for medicine education programs. This chapter outlines the job description of Internal Medicine program directors. One paragraph with 5 bullet points articulates that the VCE role may be combined with that of the Internal Medicine Residency Program Director role. This chapter does serve as additional evidence of dual leadership roles that appear as a trend among the VCE and internal medicine departments. However, excluded as chapter is not dedicated solely to the VCE position and integrated, in-depth, with the PD position.

 

Sanfey et al. (7) is a quantitative work that provides basic descriptives with means. A job description with specific categories is the qualitative element presented. Participants were 20 MD surgeons and 4 PhD educators serving as VCEs in departments of surgery. One data collection instrument was used and consisted of an online survey with Likert scales and open-ended questions with comment sections to gather short narrative responses.

Though Brownfield et al. (8) employed both quantitative and qualitative methods, the study was dominated by an inductive qualitative approach. Participants included 59 MDs serving as VCEs in departments of internal medicine. The primary source of data was VCE responses to an online survey comprised of open-ended questions to collect narratives.

Appraisal of studies

Each report was appraised by the authors. We applied Spencer et al.’s (9) appraisal of qualitative work, the National Collaborating Center for Methods and Tools (10), and Jack et al.’s (11) quality appraisal tools for basic descriptive statistics. Post scoring and deliberation, studies were categorized into either: low, moderate, good, or high quality studies. This process helped us make an informed decision regarding the quality of the research reports. The qualitative assessment tool was applied to Brownfield et al. (8). Scores between the authors ranged from 35 to 44 (maximum score of 72) and a mean score of 39.5 (8). Sanfey et al.’s (7) qualitative scores ranged from 30 to 41 and a mean score of 35.5; quantitative scores ranged from 14-15 (maximum score of 18) and a mean score of 14.5 (7). In all, both reports were of good quality (scale consists of low-good-high categories), methodological rigor, reporting, and knowledge contribution.  Studies note sufficient and important limitations regarding relatively small sample sizes, non-responder bias potential, and limitations to just two fields: surgery and medicine.

Synthesis of study findings

Although both research reports were related to the VCE role, there was substantial heterogeneity in their study aims that allowed for a broad conceptualization of the role. One study was largely to create a career development path for VCEs on a national level, while the other sought to establish, in detail, the roles and responsibilities of VCEs.

Similarities. Both studies had VCEs as the primary data source with the Brownfield et al. (8) work implementing follow up member checking with a group of VCEs at a national conference. Both also refer to the elevated expectations from institutions and accreditation agencies for evidence driven education and administrative practices as an external force that has led department chairs to create the VCE role. However, these studies noted that the clerkship and residency director roles have job descriptions and recommended protected time established by national accreditation bodies. Notably absent is a formal job description for the VCE role. As such, informed by their data, these studies set precedent by establishing a job description by providing lists of expected duties and activities. These duties not only centered on program and director oversight, but reflected a value system that appreciated autonomy, educational expertise, promotion of educational scholarship and investment in the further development of leadership skills.

In terms of demographics, both studies found that VCEs were more likely male, senior MD professors with additional training in education. Formal establishment and recognition of the position is difficult to deduce from the studies. Each study identified the position as “relatively new.” They both cite this as a reason to explain why participants reported uncertainty in their responsibilities and the lack of a formal job description. VCEs in both studies served in the position for a widely variable number of years ranging from 6 months to 25 years. Distribution of protected time for the role was addressed. However, Sanfey et al. (7) provide a snap shot of participants’ work load distributions with ascribed percentages to each of the institutional missions. In terms of preparation for the role, they went into greater detail about expectations. The investigators note a national increase in educational graduate programs in academic medicine and suggest chairs seek VCEs with backgrounds in graduate medical education in order to meet the demands and expectations of the position.

Differences. Sanfey et al. (7) reviewed the academic preparation for the VCE position, terms of employment, expected scholarly productivity, and took inventory of participants’ job satisfaction as well as specific leadership skills they desired to acquire and improve upon. In this study there was comparison between MD and PhD educators’ time allocations, and demographics. Closing their report, Sanfey et al. (7) discussed recruitment strategies for the hiring of VCEs, and stressed the importance of education portfolios and educational research productivity among potential candidates. Furthermore, they provided recommendations to those in hiring positions to strongly consider PhD educators for the role given PhDs scholarly productivity outpaced those of their surgeon peers who often have time consuming clinical demands.

Methodologically, Brownfield et al. (8) state they ask for job descriptions in their data collection, but do not note actually triangulating these documents with survey responses. From survey responses and an in-person group follow-up meeting, Brownfield and colleagues (8) noted in-depth, dominant themes that emerged from those surveyed.  Unlike Sanfey, they include how participants experienced the role, and if metrics for assessing their success were clearly established at their institutions. Despite a relatively robust set of reported responsibilities, most striking was the theme of reported uncertainty about the role among their participants. This was as a result from vague expectations or ill-defined purview. Brownfield and colleagues (8) provided a set of guidelines for current and prospective VCEs to consider that could potentially mitigate such an experience. A few include: the importance of transparency with the Chair about expectations, delegation, priority setting, and establishing an appropriate infrastructure of support.

Two themes that answer our research questions. Both studies a) formally identified and defined VCE duties, and b) documented the establishment and professionalization of the VCE position in departments of surgery and internal medicine in the U.S. Analysis indicated a theme wherein VCE roles and duties were defined in both works. However, the purview was dauntingly broad. As expected, multiple indicators of the professionalization, as defined by DiMaggio and Powell (2), of the VCE role in academic medicine exist within these two published studies. Both studies were published in quality journals (Academic Medicine (Impact Factor 3.292 at the time their study was published) and the Journal of Surgical Education (Impact Factor 1.634 at the time their study was published) (12-13). Moreover, data in these studies contributed to a formalized job description that set a vast scope of duties, broad oversight purview, working conditions, and career development needs of this group at a national level.

Discussion

The VCE role is designed to help the department navigate an ever changing, complex and diverse academic environment in medical education. Because these studies included only two disciplines, we believe the position remains ambiguous and not well-defined. It is clear the responsibilities of the position need refinement to maximize its impact within the department.

Both studies provide specific examples of the VCE responsibilities and roles with attention to how VCEs are expected to oversee educational programs. Brownfield et al. list position expectations that include: educational program oversight, promote scholarship and serve in leadership activities. Sanfey et al. (14) provided examples by subcategorizing responsibilities by i). administration, ii). teaching, and iii) research responsibilities. Both studies defined oversight as: setting the philosophical tone and course to move programs toward institutional and/or departmental vision; defining priorities; creating initiatives that would aid in program advancement; play a key role in redesigning evaluation technologies and methods; developing faculty reward systems; designing faculty development curriculum; consultant to all the educational directors in the department; advising the chair in faculty recruitment; chairing educational committees; training education staff regarding accreditation and strategic initiatives, and identifying and securing resources. Though broad, this collective list outlines responsibilities that are different than those presented in Wolfsthal et al. (16) job description of Internal Medicine residency directors and Foster and Clive’s (17) chapter on the Program Director as Manager. Unlike the VCE oversight examples that are illustrative of executive leadership, the current program director literature offers examples of managerial responsibilities to a single program. Responsibilities include: implementing policy and initiatives; setting agendas for meetings; budgeting basics; delegating authority; office personnel management, and time management. This distinguishes the VCE role from that of other departmental education positions such as the residency director. From the reviewed studies, VCE responsibilities are more vision-driven rather than managerial in nature (18).

Finally, it was unclear if the VCE position should be bundled with other administrative leadership roles. According to Brownfield et al. (8), this was pervasive in internal medicine as well. While we do not believe this is unique to one specialty, Sanfey et al.’s (7) work did not report dual leadership in surgery perhaps because the survey question was not asked. Regardless, the complexity in the Sanfey et al. (7) article was not as rich or apparent as Brownfield et al.’s study.

Given the emerging importance of this influential leadership role, we were surprised by the lack of a VCE recruitment strategy. In fact, both studies touch on the fact that the majority of participants were thrust into the VCE role with a small minority being promoted into the position internally. Neither study solicited the perspectives of department chairs, what they expect of the VCE and why they were chosen for the role. This practice is in stark contrast to the guidance provided by the articles where they provide discussion points and items to negotiate prior to accepting the VCE position. The data suggest a formal recruitment process with negotiation for educational resources is needed for the VCE position to realize its potential.

Yielding 2 full-text studies this review is not robust and thus, limits recommendations. Other medical disciplines may have similar roles, but no data has been published. Never-the-less the information in this review is educationally significant. This review serves as a critical starting point from which to gain knowledge about more nuanced educational leadership positions and their mobilization towards legitimacy, formal recognition, and time allocations in clinical departments. This review documents the professionalization of the VCE role in the academic community in its infancy.

As many pulmonary/critical care physician-faculty make up the top administrative and educational leadership roles at our institution, we speculate that pulmonary/critical care and practice lends itself to leadership in academics. Building relationships with multidisciplinary ICU teams is much like building academic leadership teams. The skills necessary to articulate sensitive information to family members of critically ill patients provides a foundation for dealing with the most challenging aspects of administrative leadership discussions that are inherent to academe. Defining successful leaders and studying the personality traits of those from medical specialties would provide further insight and are ongoing.

Scholars are encouraged to consider research pertaining to the VCE role and to move beyond the job description to study the value the position brings to the department. Studies should include department chair perceptions of the position in the changing education and healthcare landscape, and whether these types of roles are more appropriately suited for particular medical disciplines over others. Examining the academic culture of departments to inform the desirable dynamic for the VCE is important. A starting approach can tease out how this role is impacted by departmental relationship dynamics, behaviors, and values. Finally, future studies that include robust examination of the VCE relationship with the chair would triangulate the existing body of work, and could validate what we know about educational leadership and academic executives.

Acknowledgements

The authors thank Carole Howe, MD, MLS of the Arizona Health Sciences Library for her guidance regarding database searches, and the University of Arizona College of Medicine Department of Medicine for allowing research time to conduct this review.

Authors also thank Ms. Sarah Almodovar for her time preparing and reviewing this work.

Finally, the authors thank those on the Vice Chairs for Education in Internal Medicine national interest group distribution list for responding to inquiry for grey literature knowledge, clarification questions, works in press, and unpublished works. We thank the National network of VCE responding to inquiry for grey literature knowledge, clarification questions, and unpublished works: Drs. Michael Frank, Stephanie Call, Erica Brownfield, Alan Harris, John Mastronarde, Bradley Allen, Ellis Levin, Lisa Bellini, Gerald Donowitz, Joel Thorp Katz, and Susan Wolfsthal.

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Cite as: Martinez GF, Knox KS. A qualitative systematic review of the professionalization of the vice chair for education. Southwest J Pulm Crit Care. 2016;12(6):240-52. doi: http://dx.doi.org/10.13175/swjpcc044-16