faculty time allocation in rural primary care training sites
TRANSCRIPT
CrandalL? WaLczak and Duncan 7
Education for Rural Health Professionals
Faculty Time Allocation in Rural Primary Care Training Sites * Lee A . Crandall, Alexandra A . Walczak andR. PaulDuncan
ABSTRACT: This investigation examined the allocation o f time by medical school faculty who served as attendmg physicians on a rotating basis in rural primary care centers where medrcdstudents and house stafiwere trained Two quite dzferent methods of studying faculty time adocation produced relative- ly consistent results. Travel and direct care of patients (with no medrcal stu- dents present) accounted for the largest share of faculty time. Much of the teaching time was spent in direct student contact with no patient present. Simultaneous care ofpatients by an attending faculty member anda medical student accounted for less than ten percent of faculty effort. I t appears that in a busy ruralprimary care center, faculty whose mission is intended to empha- size teaching may often be thrust into the role of care providers. Despite this problem, faculty-student contact appears to be greater than that which typic- ally occurs in the tertiary care teaching hospital environment.
Over the past twenty-five years, our society has employed a variety of devices in attempts to increase the supply of physicians in rural areas. One technique has been to utilize rural health centers as training sites for medical students. Presumptively, students who have positive experiences in such set- tings will be more likely to practice in rural areas. Furthermore, it is con- tended that exposure to settings which are geographically, medically and culturally quite different from the traditional university affiliated teaching hospital is a valuable component of medical education regardless of the eventual choices in location or type of practice. Certainly this latter conten- tion is expressed by the majority of graduates who experience such training (Crandall, Reynolds and Coggins, 1978; Pichoff, Ingall and Crage, 1977). Several medical and other health professional schools have developed and now provide training opportunities in off-campus, rural settings.
Such rural-based training opportunities, however, are expensive. In the present climate of cost containment, reduced government funding and str- ingent reimbursement review, they, like other components of medical education, are subject to scrutiny. Supporters of the programs (and their detractors) are increasingly called upon to present evidence and analysis in defense of their positions. Furthermore, it seems likely that formal
Requests for further information should be addressed to: Lee A. Crandall, Ph.D., Department of Community Health and Family Medicine, College of Medicine, Box 5-222, MSB, J. Hillis Miller Health Center, University of Florida, Gainesville, Florida 32610.
THE JOURNAL OF RURAL HEALTH VOLUME 2 NUMBER 2 JULY 1986
cost / benefit analyses of different training models will become common in the future.
There is some evidence that the key to measuring both costs and benefits in these programs will be found in analyses of facultv activities. As might be expected, salary expenses of teaching faculty and staff are the single most significant cost element in such programs (Stoddart, 1973). Benefits would presumably be measured by whether the program has the desired impact on either the attitude or the behavior of students who ex- perience the rotation. If these programs are comparable to other aspects of medical education, it is likely that the amount of “impact” on students will be significantly influenced by the faculty-e.g., their enthusiasm, commit- ment, vigor and expertise.
This investigation describes and documents the allocation of faculty time to various activities in rural primary care training sites. The implica- tions of those allocations for rural health education (and perhaps for rural health service delivery) are then discussed.
Research Setting Since 1969, the University of Florida College of Medicine has been
training medical students in rural primary care centers. The major educa- tional purpose of this rural health-care project is the provision of appropriate settings for the education of health professionals for primary care. The three primary care centers which have been employed as teaching sites also at- tempt to improve the health and health services of their rural populations. Trainees in the centers have included medical students and residents from both the family medicine and general internal medicine residency programs. At the time of data collection for this study (IgSl), three primary care centers provided a total of nearly 30,000 patient visits per year to a com- bined user population of about 15,000. The centers were located 25 to 60 miles from the medical school. Faculty traveled to and from the centers ctn a day trip basis. Students completed rotations of two weeks’ duration and resi- dent physicians completed four week rotations.
Methods Attempts to estimate time allocation have generally been based on one
of two approaches. The effort or activity report is the most common and is often the basis for administrative decisions regarding resource allocation. It requires that subjects estimate their own time allocation, typically in terms of a percentage distribution, among a set of explicitly identified tasks. Con- siderable doubt has been expressed regarding the usefulness and accuracy of this approach. The most commonly specified concerns refer to memory decay and a potential lack of objectivity on behalf of respondents.
The alternate estimation technique involves direct observation as fre- quently employed in time and motion studies. Here an observer records
Grandall. Walczak and Duncan 9
detailed information on the duration of daily activities. It has been argued that these techniques ameliorate the subjectivity problem, but introduce the issue of reactivity (the subjects may behave differently in the presence of an observer than they would otherwise). In addition, direct observation is time consuming and expensive and therefore usually impractical for administra- tive decision making purposes.
In the research described here, both techniques of data collection were employed. Initially, a single observer made extensive detailed recordings of each faculty member’s daily activities during a sample of days in the three rural sites. Information such as the length of time spent with each patient, presence of other medical personnel (including students), and procedures performed was recorded, as well as other tasks such as administration, counseling of students or self-education
Each member of the faculty was observed for entire workdays randomly selected over a period of two months in direct proportion to his or her actual assignment of time to the rural health centers. Activities were recorded to the nearest minute into one of nine separate categories or procedures. Each entry was further broken down by the percentage of effort devoted to “pa- tient care,” “education,” or “other activities” (which were those devoted neither to education nor patient care) in the following manner: If an activity was related directly to one classification such as patient care without a stu- dent present, that classification (i.e., patient care) was allocated the entire percentage and time. Where joint activities occurred (e.g., caring for a pa- tient with a medical student present) the faculty member was asked to in- dicate the percentage of time that should be allocated to patient care and the percentage that should be allocated to teaching. Thus, not oniy was the length of time spent by the faculty member observed, but the proportion of that time which could be assigned to the different functions was estimated.
The second phase of the time allocation study was conducted by way of the more traditional faculty activity involvement questionnaire. A list of the nine activities that were found to cover the range of behavior of the faculty in Phase I of the study was presented. Respondents completed the first col- umn, estimating the percentage of their time spent on each of the nine pro- cedures. They were then asked to allocate the effort related to each pro- cedure among the activities of “patient care,” “education,” and “other ac- tivities.” In some spaces no entry was allowed for purposes of the analysis. For example, the education column ailowed time to be attributed only to the education of medical students or residents; the education of patients was considered a patient care activity. Within a few weeks of the observation period, these data were collected from the same faculty members whose ac- tivities had been observed.
Results Table 1 presents direct observation data refer-
ring to 5,235 minutes of attending physician time spent in the rural Direct Observations.
Tab
le 1
: Pe
rcen
t of T
otal
Att
endi
ng T
ime
in R
ural
Clin
ics b
y T
ype o
f Act
ivity
Ba
sed
on O
bser
ved
Effo
rt (
Sam
ple o
f 5,2
35 m
inut
es of
Att
endi
ng T
ime)
Act
iviti
es:
Patie
nt C
onta
ct
Dir
ect
Adm
ini-
/N
o Stu
dent
S
tud
ea
Stud
ent
Self
G
oals
: st
rdtio
n Pr
esen
t Pr
esen
t C
onta
ct
Res
earc
h E
duca
tion
Edu
catio
n Tr
dvel
O
ther
T
otal
Med
ical
E
duca
tion
0.8
N
IA
1.8
1 0
.6
0.0
0.0
0.
0 0
.0
0.0
24
L
Patie
nt
Car
e 0
.0
1: 0
3.8
0.0
0
0 0.
0 0.
0 0
.0
0.0
21
:
Oth
er
Act
iviti
cr
8.4
NiA
N
/A
0.0
4.3
3.2
3.2
25 3
12
0
54 1
Tot
al P
erce
nt
9 2
1- 9
-6
10 6
4
3
32
3
2
25 3
12
i)
100 0
Obs
erve
d M
inut
e\
(48
1)
(936
) (3
UO)
(102
X)
(223
) (1
70)
( 17
0)
(I 3
25)
(6-2
) (5
215)
Tab
le 2
: Pe
rcen
t of T
otal
Att
endi
ng T
ime i
n R
ural
Clin
ics b
y T
ype
of A
ctiv
ity B
ased
on
Obs
erve
d Ef
fort
Allo
catio
n of
6,2
40 M
inut
es as
Rep
orte
d by
Res
pond
ents
Act
iviti
es:
Patie
nt C
onta
ct
Dir
ect
P A
dmin
i- (N
o Stu
dent
St
uden
t1
Stud
ent
self
Goa
ls:
stra
tion
Pres
ent
Pres
ent
Con
tact
R
esea
rch
Educ
atio
n Ed
ucat
ion
Trav
el O
ther
T
otal
Med
ical
Educ
atio
n 1.
3.
N/A
15
.1
15.5
0.
3 0.
6 0.
6 3.
8 0.
0 36
.6
Patie
nt
Car
e 4.
2 4.
8 13
.6
6.5
1.5
2.7
2.7
3.8
0.0
37
.1
Oth
er
Act
iviti
es
3.1
N/A
N
/A
2.0
0.0
0.1
0.1
19.1
2.
0 26
.3
Tota
l Per
cent
8.
6 4.
8 28
.7
24.0
1.
8 3.
4 3.
4 26
.7
2.0
100.
0
Rep
orte
d M
inut
es
(537
) (3
02)
(178
8)
(149
7)
(1 12
) (2
08)
(208
) (1
669)
(1
27)
(624
0)
teaching sites. The row totals demonstrate that neither medical education nor patient care consumed as much of total faculty time as did other ac- tivities (travel, self-education, research, and administration). Column totals indicate that travel to and from the clinics constituted about one-fourth of all the effort of faculty members. Direct contact with medical students (when no patient was present) was their second most frequent activity (19.6%), followed closely by direct patient care with no medical student present (17.9%). Only 7.6 percent of the observed attending faculty time was devoted to patient care in situations where both a medical student and an attending physician were present.
Administrative activities, most of which involved operation of the rural health care sites rather than the medical education program, comprised slightly more than 9 percent of observed efforts. Self-education and research (primarily data collection) involved relatively small proportions of attending time in these rural primary care centers. The final activity category, “other,” captured an aspect of faculty activity which is usually ignored in effort reports, i.e., time spent on personal conversations (weather, sports, gossip), meals and snacks, reading the daily paper and other forms of rest and relaxation. The busy schedule of attending faculty is reflected by the fact that a total of only about 45 minutes per day was spent in these activities despite the formal designation of a “lunch hour” in each primary care center. Lunch time was often spent seeing patients left over from the morn- ings or in teaching (formally or informally) the medical students. Thus, much of this personal time represented short breaks during “slack times” and personal chats with staff members during coffee breaks.
Table 2 presents analogous data from the effort reports of faculty members and is based on a typical week composed of 13 person days of attending time (6,240 minutes). Several of the estimates by faculty members were quitt similar to the observational data presented above. Faculty estimates for travel, administration and self-education were nearly identical to those recorded by the observer. The faculty overestimated somewhat the amount of time that was spent in direct student contact. However, the most striking differences between the reported and observed efforts of faculty were in the two categories of patient contact. Faculty estimated that 28.7% of their time was spent in patient care with medical students present whereas only 7.6% of the time observed had been classified in that designation. In contrast, effort devoted to direct patient care, with no teaching component was substantially underestimated by the faculty.
It should be noted that the effort reports showed only 2 % of time devoted to “other” activities. No doubt, most faculty members “mentally subtract” time spent on personal business when estimating effort for repor- ting purposes. Thus, direct comparison of Tables 1 and 2 may be problem- atic.
Removal of the “Other” Activities from Calculations. Table 3 removes this “other” category from both the observed and the reported ef- fort of faculty members and compares the percent of time devoted to each of
Effort Reports.
Tab
le 3
: Pe
rcen
tage
Com
pari
son o
f Obs
erve
d Effo
rt a
nd S
elf R
epor
ted
Effo
rt w
ith “
Oth
er”
Act
iviti
es R
emov
ed fr
om C
alcu
latio
n
Act
iviti
es:
Paae
nt Contact
Due
ct
Adm
ini-
No
Stud
ent
Stud
ent
Stud
ent
Self
stra
tion
Pres
ent
Pres
ent
Con
tact
R
esea
rch
Educ
atio
n Tr
avel
Perc
ent o
f Obs
erve
d 10
6
20 6
8
7
22 5
4
9
37
29
0
Effo
rt (
4,56
3 min
utes
)
Perc
ent o
f Rep
orte
d Ef
fort
(6.1
13 m
inut
es)
29 3
88
4
9
29 3
24
4
18
3
5
27 3
34 2
14 ?’he Journd of R u r d Neuith
the remaining activities. The differences within the two patient contact categories remain. Observed effort shows that most patient contact was pro- vided with no medical student present and, thus, represents a direct service effort with no teaching component. However, faculty reported that most of their patient contact occurred in the presence of medical students and therefore could, at least in part, be considered a teaching activity. Faculty tended to overestimate slightly the total percentage of their time devoted to patient contact (34 .2% versus 29.3% observed) and the minor difference in estimated versus observed percent of time devoted to research persisted when the “other” activities category data were removed from the analysis. Overall, however, the results produced by the two methods were remarkably similar, with nearly identical results for the activities of self education, travel, and direct student contact; and highly consistent results for other categories.
One weakness of the observation technique employed in Phase I of the study is the difficulty of attributing a given activity to the appropriate goal. While some activities by definition apply to only one goal (e.g., patient contact with no student present is by definition related to patient care) others were not always entirely clear to the observer. Thus, administrative efforts (e.g., personnel, recruitment, policy formulation) might appear to be related to solving problems in the primary care centers, but these activities, in fact, might be intended to improve pa- tient care or to increase the quality of instruction for medical students. Hence, while the observation method might be expected to produce more precise data on the amount of time spent in various activities, the attribu- tion of effort within these activities to various goals could be expected to be more accurate in the self report data. Therefore, the most valid description of faculty effort in this rural teaching program may be one derived from a synthesis of data from the two techniques.
Table 4 presents synthetic estimates of faculty effort in the rural clinics (which removes the “other” category in the caiculation). Column totals are based on observed data and are identical to row 1 of Table 3 . However, within each column the total effort has been apportioned as in the self report data of Table 2 . For example, Table 2 shows that 15.1 % of all admin- istrative efforts (1.3% /8.6%) were estimated to be devoted to medical education goals; thus, 15.1 Oh of the observed administrative efforts were also attributed to the medical education goal (10.6% x 15.1% = 1.6% in Table 4 ) . Table 4 shows that nearly half of all administrative effort is devoted to patient care topics rather than issues in medical education.
Surprisingly, faculty attributed a portion of their travel time to patient care and medical education noting that they listened to continuing medical education audiotapes and dictated correspondence and classroom materials while driving to and from the rural sites. Overall, the synthetic estimates show that nearly half of all faculty attending efforts in the program were devoted to patient care goals with the balance almost equally divided be- tween medical education goals and other goals.
Synthesis of the Two Techniques.
Tab
le 4
: Sy
nthe
tic E
stim
ates
of F
acul
ty T
ime A
lloca
tion
Act
iviti
es:
Patie
nt C
onta
ct
Dir
ect
Adm
ini-
'No
Stud
ent
Stud
en2
Stud
ent
Self
Goa
ls:
stra
tion
Pres
ent
Pres
ent
Con
tact
Research
Educ
atio
n Ed
ucat
ion
Trav
el To
tal
Med
ical
Educ
atio
n 1.
6 N
IA
4.6
14.6
0.
8 0.
7 0.
7 4.
1 26
.4
Patie
nt
Car
e 5.
2 20
.6
4.1
6.1
4.1
2.9
2.9
4.1
47.1
Oth
er
Act
iviti
es
3.8
N/A
N
/A
1.8
0.0
0.1
0.
1 20
.8
26.5
Tota
l Per
cent
10
.6
20.6
8.
7 22
.5
4.9
3.7
3.7
29.0
10
0.0
10
Discussion
The data reported here clearly demonstrate that faculty travel to and from remote teaching sites can represent a major time and cost component in rural primary care medical education. Nearly one fourth of faculty time was spent in commuting. This is a cost component which does not exist when an urban primary care teaching site is close to the medical school or when preceptors in private practice in rural communities provide training for medical students. When combined with the lower revenue potential of rural primary care settings, these higher travel costs no doubt provide support for those who argue that this form of education for the provision of rural pri- mary care is inefficient. Such a conclusion can be drawn only if one directs attention to the cost side of the equation and ignores information regarding benefits.
For example, our data also indicate that despite the travel time, patient care, and administrative obligations, each faculty member devotes an average of 25-30 percent of total effort to the teaching of medical students. Hence the students in this program receive eight to ten hours per week of one to one or small group contact with attending faculty members. This is in marked contrast with the experience of students on many services in the ter- tiary care teaching hospital, where most training is provided by the house staff and intensive interaction with the attending physician may be relatively rare. This may in turn deliver an important message to students: the value of rural primary care education is such that attending faculty are involved. It would not be too surprising if those same students should in turn decide that the delivery of rural health care merits their attention.
With regards to methodology, it seems clear that the two approaches to estimating faculty time allocation produce relatively consistent results. They are probably of comparable reliability when th: objective is to estimate the amounts of time actually spent in various activities. The effort report is of additional value when one is also concerned with measuring the relationship between those activities and less obvious goals, and is clearly a less expensive method of acquiring data on faculty activities. The observational technique is probably superior in estimating time allocation in situations where there are clear expectations regarding how time is “supposed” to be spent. In ad- dition, the study makes it clear that the cost factors specifically associated with faculty activities can be estimated with a reasonable level of precision and reliability. If we are to make rational decisions regarding the provision of this type of education for rural primary care, similar attention must also be focused on measurement of the benefits which can be accrued.
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