If you are a physician and not questioning your professional value, you should be.
“What is my professional value?”
Value Versus Worth
This is an important question. Exploring individual professional value guides personal growth strategies and helps to define desired conditions of employment, especially compensation. As physicians, we should actively participate in these professional value assessments.
Value and worth are often confused. What something is worth is practically defined as what price another person is willing to pay to acquire that something. Value is a more far-reaching idea and goes beyond worth. Value encompasses concepts like significance and impact, and often has emotional connotations. For example, a family heirloom may have no monetary worth but great personal value.
Unfortunately, employers and payers frequently conflate value with worth. The default for defining a physician’s worth has been to add up the annual revenue they generate for their employer. Revenue is determined by how much a payer is willing to reimburse a physician and/or their employer for the services they provide. While the formula for those service-to-dollar reimbursement conversion rates remain one of world’s greatest unsolved mysteries, those relative value units (RVUs) are used to define what each patient interaction is worth. RVUs determine my employer’s financial success which, in turn, determines what my employer is willing to compensate me. Ironically, a physician’s value – her significance and impact to her practice, colleagues and patients – is ignored entirely in the Relative Value Unit measure, the default construct used to determine how she is compensated.
The Big Questions
Is annual revenue an important driver of value? Of course it is. Is it the only driver of value? Absolutely not. Procedures are not part of my practice, as a result, my per patient revenue, annual revenue, and associated clinical compensation are low. Missing from my annual RVU report, however, are the hundreds of imaging studies, blood work, and other tests I order. That RVU report also fails to account for driving engagement with other subspecialists, and the procedures they perform. My employer is reimbursed for these activities, but none of it is attributed to me. Why is that?
What about the value of activities which may not be revenue generating and fall outside of the RVU analysis? Consider the role of the physician-educator. Becoming an effective educator requires time to train, develop expertise, and gain experience, just like any other specialty. The challenge is no one has been able to value the physician-educator or appropriately compensate physicians for the time spent teaching. In many instances, physicians are forced to sacrifice revenue to teach, and this is not sustainable. Who will teach and train the next generation of physician and health care professional?
The Physician-Scientist Conundrum
The physician-scientist is another endangered species. Here is a common scenario: during your training you developed an interest in research, worked on small projects, published a paper, and did a few poster presentations at local and national meetings. Now you are an attending and negotiating your first job contract. You ask for protected time to try and make a go at being a physician-scientist. The answer you receive introduces you to the reality of medicine: you are highly encouraged to do research, but reminded your salary is based on revenue generation. When you get home and decode the message from your potential employer, you realize that anything outside of seeing patients and generating RVUs is a high financial risk endeavor. You ask yourself what the NIH funding rates are for new investigators, who will mentor you, and what commercial entity will give a grant or contract to someone with little research experience? In the end, you forego the likely disappointment and the aspiration to be a scientist.
It is not hard to connect the dots: the importance of the physician-educator or physician-scientist has been eclipsed by the importance of the institutional financial spreadsheet. I am not naïve and appreciate hospitals’ perilously thin operating margins and persistent proximity to the cliffs’ edge. Of course, revenue must be generated or a community resource will fold. But in the broader picture, sacrificing a major source of innovation or research and development will cost us much more.
We Need to Improve Transparency in Physician Valuation
So where does this leave us? In my opinion, we need to reset and reframe the physician value discussion. All drivers of physician value, not just the few examples discussed here, need to be put on the table and assigned monetary figures. Once established, we need a timely and accurate national accounting for how physicians, physician-educators, physician-scientists, physician-leaders, and others are being supported. This panoramic view of physician value – creating measures we can legitimately label as Value units – and associated worth needs to happen, or our profession will stray even further from our legacy as healers, teachers, and scientists.