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A changing medical climate and heightened financial pressure have made it increasingly difficult for the administration of Harvard Medical School (HMS) to get its clinical faculty to spend time teaching, according to many at the school.
The school’s dean, Joseph B. Martin, has created a task force to study the issue and even mentioned it at a faculty meeting early this year.
At a February 26 meeting of the school’s Faculty Council, the task force reported that “it is increasingly difficult to recruit faculty to participate in medical student education.”
According to Lecturer on Neurobiology David L. Cardozo, who is head of the Task Force, HMS has nearly 9,000 faculty and a policy stating that each of those faculty must contribute 50 hours a year to teaching “if asked.” Under the current system, however, some said that because of financial incentives, doctors spend too little time teaching and more time seeing patients.
“The people who teach now do so out of sheer commitment,” Cardozo said. “The remunerations are a very small fraction of what they would make in clinical practice.”
Cardozo added that hospitals are under increased pressure to see more patients due to dropping reimbursements from insurance companies.
“The hospitals are always under pressure to make ends meet financially,” he said.
HMS’s effort to increase incentives for its clinical faculty to teach is part of a broader effort of curricular reform.
According to Professor of Medicine George E. Thibault, the current problem with the clinical faculty is a negative result of the evolution of the field of medicine over the last fifty years.
“We want to renew the educational process,” Thibault said, “to deal with changes in the delivery system of healthcare and the explosion of scientific knowledge.”
He went on to explain that the problem of decreased teaching participation is one faced by medical schools throughout the country and not specific to HMS.
“It’s been happening for a long time, a decade or more,” he said. “This is not because people don’t care, it’s because complex changes have occurred in the [medical] environment. It’s a national phenomenon.”
Cardozo said that the problem has manifested itself in three ways. First, courses often have fewer tutors than they are budgeted for, resulting in larger class sizes than normal.
“If a course budgeted for 24 tutors can only find 20, the class size might increase from 7 to 9,” Cardozo said.
Next, several courses are forced to use non-Harvard faculty to fill in the holes.
“They’re good faculty, but they’re making up a gap that oughtn’t to be,” he said.
Finally, several courses have been “scrambling” as little as a week before they are scheduled to start, searching for teachers.
“We always find a way to put the course on, so you don’t see the effects,” he said, “but this year, a third to half of the first- and second- year courses had fewer than the budgeted-for number of faculty.”
Some students say they have been noticing problems with clinical faculty—but not because of understaffing.
“The problem is more accountability because the med school is separate from its teaching hospitals,” said HMS student Kevin King, who served as the school’s student council president from 2001-2002, “There’s nothing definite to coerce [the clinical faculty] to teach, and nothing bad the school can do to them if they’re really atrocious to students.”
While the problem King sees is different from that of Cardozo and Thibault, his solution is the same: more incentives for faculty to teach.
A significant incentive is to tie teaching more closely to promotion through the HMS ranks, according to Cardozo.
“The primary faculty loyalty is at the level of the department. You have people who want to teach, but...in the current system it’s very rarely seen as bringing benefit to the department [and] the heads of the department really do control promotions,” he said.
Another possible incentive to persuade faculty to teach may lie in providing more funds to departments to increase pay for clinical faculty.
According to HMS Dean for Faculty Affairs Eleanor G. Shore, health plans will reimburse clinicians for time spent seeing patients but not for time spent teaching.
“Teaching is the fiscal orphan that no one wants to pay for,” she said. “[and] when you teach someone, that physician moves more slowly because he has to stop and explain and demonstrate.”
Another issue is the focus of many faculty on research, rather than teaching.
“Part of the dean’s initiative has been to restore education at a higher plane of value,” Thibault said. “A number of initiatives have been started to restore that balance, but it’s not going to be a quick fix.”
—Staff writer Michael A. Mohammed can be reached at firstname.lastname@example.org.
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