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Supply of and requirements for academic medical manpower in British Columbia Barer, M.L.; Kazanjian, A.; Pagliccia, N. May 31, 1988

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Supply of and Requirements forAcademic Medical Manpower in British ColumbiaHMRU 88:6Prepared by:Health Manpower Research UnitDivision of Health Services Research and DevelopmentOffice of the Coordinator of Health SciencesThe John F. McCreary Health Sciences CentreThe University of British ColumbiaVancouver, B.C. V6T 1Z6M.L. BarerA. KazanjianN. PaglicciaMay 1988This report is one of a series describing the distribution of health careresources and manpower in the Province of British Columbia . These reports,prepared for the Health Manpower Working Group of the Ministry of Healthand for the Associations and Licensing bodies which provide the data, areworking documents and comments or suggestions are welcome .HEALTH MANPOWER RESEARCH UNITc/o OFFICE OF THE COORDI~ATORHEALTH SCIENCES CD-aREPHONE: (604) 228-4810Dr. Steve GrayActing ChairmanHealth Manpower Working GroupMinistry of Health1515 B1anshard StreetVictoria, B.C .V8W 3C8Dear Dr. Gray:4th FLOOR I.R.C BI:lLD1~GTHE l'N1VERSITY OF BRITISH COLDIEIAVANCOCVER. B.c.. CA~ADAV6T lZ6May 27, 1988It gives us great pleasure to be able to submit to the Health ManpowerWorking Group the final report of the project, "Supply of and Requirementsfor Academic Medical Manpower in British Columbia".We believe this to be the first of this type of study, at least inCanada, and we hope you share our feeling that the approach has producedsome very interesting and useful planning information.As always, we welcome suggestions. At the same time, I wish to thankyou and the other members of the Health Manpower Working Group for yourvery useful input on the earlier draft.Yours sincerely,Yl.·~~Morris L. Barer, Ph.D.DirectorDivision of Health ServicesResearch and Development;Associate ProfessorDepartment of Health Careand EpidemiologyMLB :jrEnc l..A Research Unit for the Health Manpower Working Group , Ministry of Health , British ColumbiaAcknowledgementsThis study grew out of discussions with Dr. John Ruedy, to whom we areparticularly indebted. Not only did he spawn our interest in this issue,but he served conscientiously and constructively as a member of theproject's steering committee. We are also grateful to the other members ofthe steering committee , Dr. A.D . Forward and Mr. Nick Haazen , and to DeanWilliam Webber for his ongoing support, and for his comments on an earlierdraft. Steve Gray and other members of the Health Manpower Working Groupalso provided a number of improving suggestions. Kathy Campbell and MaryBrunold converted what we wrote into what we meant, with patience and goodhumour . The financial support of the B.C. Ministry of Health is gratefullyacknowledged.TABLE OF CONTENTSList of Tables 11I.II.III.IV.V.VI.VII.VIII .IX.INTRODUCTIONLITERATURE REVIEWOBJECTIVES OF THE PRESENT STUDYRESEARCH DESIGN AND METHODSStudy PopulationStudy DesignQuestionnaire DesignPilot Survey of SupplySurvey of SupplySurvey of RequirementsDEMOGRAPHIC AND EDUCATIONAL PROFILEEMPLOYMENT PROFILE AND LEVEL OF ACTIVITYCLINICAL ACTIVITY OF ACADEMIC FTESCURRENT AND FUTURE REQUIREMENTS FOR ACADEMIC PHYSICIANSSUMMARY1244455678919354551ReferencesAppendicesAppendix A:Appendix B:Appendix C:Questionnaire and Covering LetterQuestionnaire for Future Academic RequirementsFull-Time Income Cutoffs, by Type of Practice, 1985-86iiLIST OF TABLESTable 1:Table 2:Table 3a:Table 3b:Table 4:Table 5:Table 6 :Table 7:Table Ba:Table Bb:Distributions of Faculty Listing, Initial and FollowupReturns by Appointment CategoryDistribution by Age Group by SexDistribution by Year of Graduation by SexDistribution of Period of Graduation by Place of 'GraduationDistribution by Place of Graduation by SexDistribution by Place of Graduation by GroupedTraining Specialty AreaDistribution by Appointment Category by SexDistribution by Appointment Category by Age GroupDistribution by Grouped Training Specialty Area bySex, All Appointment CategoriesDistribution by Grouped Training Specialty Area bySex, Full-Time and Part-Time Regular Appointments Only8101112131414151616Table 9 : Distribution by Specialty Area by Sex, All AppointmentCategories 17Table 10: Distribution by Appointment Category by Grouped TrainingSpecialty Area 18Table 11: Distribution by Appointment Category by Department 20Table 12: Distribution by Number of Weeks Worked Per Year by Sex,All Professional Activities 21Table l3a: Distribution by Number of Weeks Worked per Year by AgeGroup , All Professional Activities 22Table l3b: Distribution of Full- and Part-time Regular AppointmentsOnly, by Number of Weeks Worked per Year by Age Group,All Professional Activities 22Table l4a: Distribution by Number of Weeks Worked per Year byAppointment Category 23Table l4b: Distribution by Number of Weeks Worked per Year bySex , Full -Time Appointees Only 23iiiLIST OF TABLES (continued)Table 15: Distribution by Number of Weeks Worked per Year byGrouped Training Specialty AreaTable 16: Distribution by Number of Hours Worked Per Weekby SexTable 17: Distribution by Number of Hours Worked Per Week byAppointment CategoryTable 18: Distribution by Number of Hours Worked per Week byGrouped Training Specialty AreaTable 19: Distribution of Number of Hours Worked per Week byAge GroupTable 20: Proportions of Respondents by Appointment CategoryReporting Any of Each ActivityTable 2la: Average Annual Hours by Appointment Category, AllRespondents with Any Involvement in Activity (inparentheses)Table 2lb: Distribution of Total Number of Hours Spent inProfessional Activities by Appointment CategoryTable 22a: Average Annual Total Hours by Appointment Categoryand Grouped SpecialtyTable 22b: Average Annual Academic Hours by Appointment Categoryand Grouped Specialty, for Those Reporting AnyAcademic ActivityTable 22c: Average Annual Private Practice Hours by AppointmentCategory and Grouped Specialty, for Those ReportingAny Private PracticeTable 23: Total Academic Full-Time-Equivalents by AppointmentCategoryTable 24: Average Distribution of Source of Income by AppointmentCategory and SexTable 25: Clinical Full-Time Equivalence by Academic Full-TimeEquivalence, All RespondentsTable 26: Clinical Full-time Equivalence by Academic Full-TimeEquivalence, Full-Time Appointments OnlyTable 27: Total Clinical Full-Time-Equivalents by AppointmentCategory24242526262729303232323436384040ivLIST OF TABLES (continued)Table 28: Clinical Full-Time Equivalence by Academic Full-TimeEquivalence, All Respondents, Adjusted Full-TimeDesignations 42Table 29: Clinical Full-Time Equivalence by Academic Full-TimeEquivalence, Full-Time Appointments Only, AdjustedFull-Time Designations 43Table 30: Clinical Full-Time Equivalence (based on sessional rates),by Full-Time-Equivalence (excluding patient care),All Respondents 45Table 31: Total Attrition, During 1986/87 Relative to 1985/86 46Table 32: Total Requirements for 1986/87 46Table 33: Achieved Requirements During 1986/87 49Table 34: Future Net Requirements by Appointment Categoryand by Hypothetical Scenario 50I. INTRODUCTIONDespite what some might consider a plethora of physician manpowerstudies in Canada during the past decade (Lomas et a1 . I 1985) , the subjectof academic medical manpower has been generally neglected by researchersand policymakers. Information on requirements for and supply of qualifiedacademic physicians has been a missing component in most medical manpowerstatistics in Canada. This has meant two things. First, to the extentthat there are medically trained individuals pursuing largely academiccareers, clinically-based measures of physician supply have understated'true' physician supply. Second, estimates of current and future physicianrequirements which have neglected the role of medically-trained academicsin supporting medical schools have understated those requirements.One might argue that if such individuals are not counted either in thesupply or requirements side of the 'equation', no particular damage is done- net requirements (gross requirements less supply) will not be affected.The trouble with this line of reasoning is that it requires a 'staticequilibrium' (i .e. current academic physician supply and requirements arein balance), when in fact we know neither whether we have a currentequilibrium nor whether that equilibrium can be maintained in a dynamicworld in which future physician career decisions stand a good chance ofbeing quite different from those today. On the latter point, for example,it may be that much of the academic load is presently carried by physicianswhose primary careers are clinical . In such a case they would be largely'counted' already in clinical supply, and no apparent net academicrequirement would be evident. If such arrangements became less popular or2workable in the future, apparent supply would not change, but there couldsuddenly be a major increase in net academic medical manpower requirements.The 'flip' side of this, of course, is a scenario in which policies arebased on clinical targets, in innocence of academic requirements, but whereacademic career decisions leave the clinical targets unfulfilled.In short, it would seem of vital importance to the future of medicaleducation and medical manpower policy generally to have a clear picture ofacademic medical requirements, and to monitor the way in which thoserequirements are (or are not) being met .The dearth of information in British Columbia (B.C.) on academicphysician supply , let alone requirements , prompted the present study. Itsaims were relatively straightforward - to attempt to estimate the currentacademic medical manpower supply in B.C ., to compile estimates of futurerequirements under a number of alternative future University of BritishColumbia (UBC) medical school scenarios, and to examine the extent ofoverlap of clinical and academic activity among B.C.'s physicians.II. LITERATURE REVIEWA review of recent literature on academic physician manpower indicatedthat very little, if any, has been published directly addressing supply andrequirements issues. However, studies on academic medicine which broachmanpower issues only peripherally, are more readily available. Thisgeneral literature is exclusively U.S .-based and can be sorted into fourbroad categories .3The first such category comprises work that has focused on: theclinical investigator, who he is, what he does and why; the role andfunction of academic health centres; government funding of clinicalresearch and related problems; and supporting the marriage of science andmedicine (Committee on Medical Education, 1981).A second category includes work on market conditions and physicians'expectations of academic careers, focusing on job satisfaction andattitudes towards work, as well as on issues that influence and shapeattitudes, such as expected and actual mean incomes, perceived teaching andpatient care loads, etc . (Petersdorf, 1981; Linn et al., 1985) .A third focus is on work on the training needs for academic/clinicalsubspecialties (e.g. pathology , family medicine , etc .) , as well as onfaculty development, curricular development and organizational change(Anderson et al., 1986; Association of American Medical Colleges, 1985;Goldman, 1982).Finally, some literature addresses factors affecting the individual'sselection of an academic career, and is included in studies that de s : beavailability of academic physician supply (Pritchett et al., 1986; « lonand Gibson, 1984; Benson et al. , 1985). In this last category is anunpublished U.S. national study that develops a projection model toestimate net future needs of medical schools for faculty manpower usingsupply/demand components. Demand estimates are based on enrolment andresearcher (clinical investigator) income . Projected net demand isdisaggregated by the various reasons for estimated need: replacement and4new positions, reductions of current vacancies, and staffing dental andveterinary schools (National Research Council, 1982).III. OBJECTIVES OF THE PRESENT STUDYThe specific objectives of the study were:(1) To gather information by questionnaire on current academic-relatedactivities of physicians licensed in B.C.(2) To gather estimates of requirements for academic medical manpower, byspecialty area and type of activity, through solicitation ofinformation from Department and Division Heads within the Faculty ofMedicine at UBC.(3) To analyze the data collected in (1) and (2) above, and to produce areport on same.IV. RESEARCH DESIGN AND METHODSStudy PopulationThe population under study included all physicians in B.C. who had afull-time, part-time or clinical appointment at UBC during the academicyear September 1985 to August 1986. Using the then current Faculty ofMedicine mailing list (N=1568), a directory of all physicians in B.C. withany affiliation with UBC was compiled . A first screening of the listreadily identified 263 names who were not medically trained. 1 A furthercheck was achieved by linking the Faculty mailing list data for theremaining 1305 names with registration data from the College of Physiciansand Surgeons of British Columbia (CPSBC). The name and date of birthcomputer linkage produced 237 "unmatched" records which were then checked1 These individuals were faculty members affiliated with non-medicalschools and programs within the Faculty of Medicine. Examples includefaculty in the School of Rehabilitation Medicine, and non-MDs in theDepartment of Health Care and Epidemiology.5manually against other Faculty of Medicine records. Of these, 145 wereidentified as physicians (MDs) from CPSBC records, and therefore includedin the directory (N~1213).Study DesignThe data collection was carried out using two separate surveys, one toquantify academic medical manpower supply and describe in detail thevarious components that constitute the academic physician's professionalactivities, the other to estimate academic medical manpower requirements byspecialty and by type of professional activity. The former survey was sentto all MDs with UBC affiliation (N=12l3), while the latter was sent toacademic Department and Division Heads within the UBC Faculty of Medicine.Questionnaire DesignThe research instrument for measuring supply consisted of a mailedquestionnaire accompanied by a covering letter co-signed by the Dean,Faculty of Medicine (Appendix A). This questionnaire contained fivesections designed to solicit information on:(1) Personal data: [age and sex];(2) Education data: [specialty, year and place of graduation];(3) Employment data: [UBC appointment category, Department and/orDivision];(4) Time allocation data: [total time in active employment and proportionof time allocated to each of various professional activities duringacademic 1985/86];(5) Income data : [sources and distribution].Particular care was necessary in formulating the set of questionsconcerning time allocation for teaching, research and patient care since,in many cases, these activities are performed jointly. We explored the6utility and validity of providing a formulaic approach to the allocation oftime spent on joint activities, cognizant of the fact that this may be adirect function of type of appointment. However, in order to more fullycapture the variability of time allocation we adopted a subjectiveapproach. We instructed the respondents to designate as "academic" thatportion of joint activities which they would consider to be in excess ofthe time needed, had the clinical activities not involved any teaching orresearch.The research instrument for measuring requirements also consisted of amailed questionnaire (Appendix B), which was distributed to all DepartmentHeads within the Faculty of Medicine (UBC) in early 1987 . The intent ofthis questionnaire was to solicit information on requirements formedically-trained faculty, given a number of alternative future enrolmentand postgraduate complement scenarios. Respondents were asked to indicatechanges in academic staff complements in the then current academic year(1986/87) relative to the previous year , which were both "required" and"achieved", and furthermore to indicate whether these were for replacementor other than replacement purposes .Pilot Survey of SupplyA draft "supply side" questionnaire was pilot tested for clarity andvalidity. Department Heads from Surgery, Medicine, Pharmacology, andHealth Care and Epidemiology were asked to select specified numbers offull/part-time and clinical faculty, a total of 18 faculty who were MDs andwere willing to participate. The respondents were asked to return thequestionnaires directly to the Division.7All selected participants responded to the pilot questionnaire,conveying comments and observations which prompted minor changes to thequestionnaire.Survey of SupplyA mail survey of academic physician supply (N=12l3) was conducted inmid-November 1986, yielding a response rate of 49 percent (591) . Since theaverage expected response rate to this type of survey (self-administeredmail survey) is around 61 percent (Heberlein and Baumgartner, 1978), andour objective was a census rather than a sample, a second mailing wasconducted in mid-January, 1987. This increased the response rate to 78percent (950) and yielded additional information on populationcharacteristics that led to a reduction in the size of our baselinepopulation. A total of 36 respondents were found to be either retired ornot faculty members in 1985/86, and one respondent turned out not to be anMD, thus yielding an actual population of 1176, and providing 913 useablequestionnaires for analysis . Table 1 shows distributions by appointmentcategory from the Faculty of Medicine directory, the initial mailing andthe follow -up. Information on appointment category was available at theoutset from the Faculty mailing list. This information was used toestablish the previously discussed pilot survey numbers as well as toprovide a general measure for gauging the representativeness of therespondents. Not surprisingly perhaps, full-time (19.3%) and part-time(8.5%) faculty were slightly overrepresented among initial respondents;however, our final sample - subsequent to further reassessment ofpopulation characteristics - appeared to be generally representative of the8target population, at least in terms of appointment mix. A slightdiscrepancy in part-time numbers was noted.Table 1Distributions of Faculty Listing, Initial and Followup Returnsby Appointment CategoryListing compiled fromFaculty of MedicineDirectoryInitial ReturnsFollow-up Returns%%%Full-Time17.819.317.7Part-Time3.68.57.2Clinical78.572.375.2Total1212591949Upon comparing characteristics of respondents to the first mailingwith those of all respondents, it was found that distributions by age, sex,year of graduation, specialty and department were very similar.Proportionately more full-time and part-time physicians, and fewer clinicalMDs, responded to the first mailing. Nevertheless, 95 percent confidenceintervals obtained from the first mailing on number of weeks worked, numberof hours worked per week, academic time and total performance time, includethe mean values based on all respondents. This suggests that a responserate of 49 percent would have sufficed to provide good estimates, evenwithin each appointment category.Survey of RequirementsA mail survey was also conducted during early 1987 to solicitinformation on current and future requirements for academic physicians.All Departments within the Faculty of Medicine were surveyed. In addition,other Departments/Schools which may have had medically trained faculty(e.g. School of Physical Education and Recreation) were included in the9survey; however, none were identified to actually have such appointments.The questionnaire was addressed to Department Heads and contained threesections (Appendix B). Section I solicited information on facultyattrition during 1986/87 relative to 1985/86, and on subsequentrequirements, disaggregated into those needed to replace retiring orotherwise unavailable faculty, and those for changes other thanreplacement. In addition, information on requirements was supplemented byinformation on the extent to which these reported requirements wereachieved .Future requirements (1987/88 to 1990/91) under five hypotheticalscenarios were solicited in Section II. Although some respondents may havefelt that some of the scenarios were very unlikely to occur over the nextfour years, respondents were instructed to assume that each of thesescenarios was the case and to provide a best estimate of attrition andrequirements for new faculty relative to the previous year.Finally, Section III solicited the personal opinions of therespondents as to the likelihood of each of the five scenarios occurringover the following four-year period. Replies were elicited on a five­category scale ranging from Very Unlikely to Very Likely.V. DEMOGRAPHIC AND EDUCATIONAL PROFILEA brief analysis of age, sex, year of graduation, place of graduation,and specialty provides some useful perspectives from which to examineemployment activities.10Table 2 indicates that in 1985/86 about 85 percent of academic medicalfaculty were male, and that approximately half (47.4%) were over 45 yearsof age. However , those in the 35-44 age group comprised 45 percent of therespondents. Female academic physicians (15% of respondents) tended to beyounger than their male counterparts ; almost two-thirds of the femalerespondents (66%) were less than 45 years old, as compared to only half themale respondents (50.4%). Among male respondents the mean age was 46 andthe median 44; among female respondents, the comparable figures were 43 and41.Table 2Distribution by Age Group by SexSexAge % Male % Female % Total25-29 0.4 0.7 0.430-34 6.3 11.9 7.135-39 21. 2 26.7 22.040-44 22.5 26 .7 23.145-49 13.7 9.6 13 .150-54 12.8 11.9 12 .755-59 12.4 8.1 11.865-64 8.2 3.7 7.665+ 2.5 0.7 2.2Total N (100%) 765 135 900""In this and the following tables, the total N often does not equal 913.This is a reflection of non-responses to specific questions.Since female academic physicians were somewhat younger than their malecounterparts it was not surprising to find that they were also more recentgraduates (Table 3a). Fifty-eight percent of the female respondentsgraduated after 1975, in contrast to 40 percent for male respondents.While most respondents (34%) , regardless of gender, reported a graduation11date between 1966-1975 , approximately one-quarter (23 .3%) graduated before1966.Table 3aDistribution by Year of Graduation by SexSexYear ofGraduation % Male % Female % TotalBefore 1956 5.4 3.6 5.11956-1965 19.1 13.0 18.21966-1975 35.6 25.4 34.01976-1980 21. 7 29.0 22.8After 1980 18.3 29.0 19 .9Total N (100%) 765 138 903In Table 3b we superimpose information on respondents' place ofgraduation against their date of graduation. This reveals some interestingtrends. Graduates of Canadian medical schools comprise 73 percent of UBC'sacademic MD respondents. Almost 60 percent of the Canadian schoolgraduates were, in fact, graduates of UBC itself. Among the non-Canadiangraduates, about one-half graduated in the United Kingdom (U.K.) .The proportion of faculty graduating in each period who are graduatesof UBC has been increasing with time. Among the pre-1966 graduates, only27 percent are UBC graduates. In contrast, responding faculty whograduated between 1966 and 1980 are about 45 percent UBC graduates, andover half the post-1980 graduates are from UBC. Clearly there is aninverse relationship between faculty age and the likelihood of the facultyappointee to be a graduate of UBC.12Table 3bDistribution of Period of Graduation by Place of Graduation<1956 1956-65 1966-75 1976-80 >1980 TotalCanada 60.8 62.4 68.7 80.6 84.4 73.0UBC 10.9 31. 5 43.4 46.6 54.2 42.4Other West Prov 6.5 6.7 8.2 10.7 7.3 8.2Ontario 30.4 10.3 8.6 14.6 14.5 12.6Quebec 13.0 13.3 7.6 5.8 7.3 8.4Atlantic 0.6 1.0 2.9 1.1 1.3UK 26.1 21. 2 15.8 10.2 2.8 13.4Other Europe 2.2 1.2 1.3 1.5 1.1 1.3USA 6.5 12.1 11.5 5.8 7.3 9.2Other 4.3 3.0 2.6 1.9 4.5 3.0Total N (100%) 46 165 304 206 179 900% Female 10.9 10.9 11.5 19.4 22.3 15.3Among the faculty who graduated before 1956, Ontario and the U.K.represent 56.5 percent of the places of graduation. While these datareflect a single point in time, so that we cannot directly determinetemporal hiring trends, the patterns in mix of places of graduation doesallow indirect inference as to such trends. It appears that once the UBCgraduates became available in reasonable numbers (in the late 1950s andearly 1960s), the importance of Ontario as a source of faculty diminisheddramatically, while the U.K. remained a source second only to UBC itself.But since 1976, one can infer that Canadian, and particularly UBC,graduates have received preference. Of the 385 respondents who graduatedafter 1975, only 68 (17.7%) graduated outside Canada. This is undoubtedlyin large part an availability effect, resulting from the rapid expansion inthe capacity of Canadian medical schools in the late 1960s.Table 4 shows place of graduation cross-tabulated with sex of therespondents. Among the female foreign graduates, approximately equal13numbers were trained in the U.S. and the U.K., whereas the U.K. was thedominant source of male non-Canadian-graduate academic physicians in B.C .Table 4Distribution by Place of Graduation by SexSexCountry % Male % Female "% TotalCanada:Row % 84.2 15.8 100.0Column % 72.4 75.9 72.9UK:Row % 88.6 11.4 100.0Column % 14.2 10.2 13.6Other Europe:Row % 83.3 16.7 100.0Column % 1.3 1.5 1.3USA:Row % 84.3 15.7 100.0Column % 9.1 9.5 9.2Other:Row % 85.2 14.8 100.0Column % 3 .0 2 .9 3.0Total N (100%) 768 137 905Table 5 shows that UBC graduates are slightly overrepresented insurgical specialties; that is, while they comprise 42-45 percent of therespondents, they account for 49 percent of surgical specialists.Similarly, graduates from Atlantic provinces comprise 4.5 percent oflaboratory specialists, yet they represent only 1.3 percent of therespondents . 2 The U.K . and the U.S . were, together, the places ofgraduation of almost one-third of the laboratory medicine specialists.2 The specialty designations in this project are generally those ofthe Royal College of Physicians and Surgeons of Canada, except that familyand general practice have been included with the clinical specialties. SeeROLLCALL 87 for the categories used.14Table 5Distribution by Place of Graduation by Grouped Training Specialty AreaMedical % Clinical % Laboratory % Surgical %School Specialty Medicine Specialty TotalCanada 72.4 63.8 78.7 73 .1UBC 41.2 37.7 48.9 42.5Other \Vest Prov 8.7 5.8 7.4 8.2Ontario 12.5 11. 6 13.3 12.6Quebec 9.0 5.8 7.4 8.4-Atlantic 1.1 2.9 1.6 1.3UK 14.1 15.9 10.6 13.5Other Europe 1.1 2.9 1.1 1.2USA 9.0 15.9 7.4 9.2Other 3.4 1.4 2.1 3.0Total N (100%) 646 69 188 903\Yhile the respondent academic physicians were about 85 percent male,over 90 percent of the full-time academic physicians were male (Table 6).Table 6Distribution by Appointment Category by SexSexCategory % Male % Female % TotalFull-time 19.1 10.9 17.9Part-time 6.7 10.1 7.2Clinical 74.2 79.0 74.9Total N (100%) 774 138 912Male academic physicians were almost twice as likely (19%) as femaleacademic physicians (11%) to have full-time appointments (Table 6). Almost80 percent of academic appointments among the females were clinical, withthe rest being equal proportions full-time and part-time regularappointments. Our analysis of appointment category by age group (Table 7)15shows that full-time faculty (54.2% over 44 years old) were only slightlyolder than part-time (50.8% over 44 years old); clinical faculty, however,tended to be slightly younger than both (54 .5% under 45) .Table 7Distribution by Appointment Category by Age GroupAge Full-Time Part-Time Clinical TotalLess than 35 :Row % 7.4 1.5 91. 2 100.0Column % 3.1 1.5 9.1 7.535 -39:Row % 18.2 9.1 72 .7 100.0Column % 22.6 27.7 21. 3 22.040-44 :Row % 15.4 6.3 78.4 100.0Column % 20.1 20.0 24.1 23.145-49:Row % 22.0 8.5 69.5 100.0Column % 16.4 15.4 12.1 13.150-54:Row % 22 .8 6.1 71.1 100 .0Column % 16.4 10.8 12 .0 12.755-59:Row % 17.8 6.5 75 .7 100.0Column % 11. 9 10.8 12.0 11 .960 and Older:Row % 17.1 10.2 72 .7 100.0Column % 9.5 13.8 9.5 9.7Total N (100%) 159 65 677 901Tables 8a, 8b and 9 examine specialty by sex. The most markeddifference in specialization between males and females is in surgicalspecialties. Male academic physicians were almost three times as likely(22.7%) to be trained in surgical specialties as their female counterparts(8.7%). This is reflected in the fact that over 93 percent of the surgicalacademic physicians were male; among regular appointments, this percentagewas even higher (97%, Table 8b). Almost half the female surgicalspecialists (42%) were in obstetrics and gynaecology, compared to only 1416percent of male surgeons, yet even here the male specialists outnumberedthe females 5:1 (Table 9). Female academic physicians were twice as likely(13.8%) as males (6.7%) to be trained in Laboratory specialties (Table 8a),mainly in Pathology and Laboratory Medicine (Table 9). Among clinicalspecialties the female academic physicians were somewhat more likely to betrained in Paediatrics, Psychiatry, Radiology and Anaesthesio1ogy.Table SaDistribution by Grouped Training Specialty Area by Sex,All Appointment CategoriesSexSpecialtyArea % Male % Female % TotalClinical:Row % 83.6 16.4 100.0Column % 70.6 77 .5 71. 6Laboratory:Row % 73.2 26.8 100.0Column % 6.7 13.8 7.8Surgical:Row % 93.6 6.4 100.0Column % 22.7 8.7 20.6Total N (100%) 771 138 909Table Sb17Table 9Distribution by Specialty Area by Sex , All Appointment CategoriesSexSpecialtyAreaAnaesthesiology:Row %Column %Dermatology:Row %Column %Family Medicine:Row %Column %Internal Medicine:Row %Column %Medical Subspecialty:Row %Column %Ob & Gynaecology:Row %Column %Paediatrics:Row %Column %Path & Lab Medic :Row %Column %Phys & Occ Medic :Row %Column %Psychiatry:Row %Column %Pub Health & Corom :Row %Column %Radiology:Row %Column %Surgery:Row %Column %Surgical Subspecialty:Row %Column %Other:Row %Column %Total N (100%)% Male81. 38.485.71.685.515.390.59.987.611 .983.33 .274.07.470.75.3100. .65.890.63.896.815.7100.00.5771% Female18.810.914.31.414.514.59.55.812.49.416.73.626.014.529.312.321. 713. Total100 .08.8100 .01.5100.015.2100.09.2100 .011 .6100 .03 .3100 .08 .5100 .06.4100.00 .9100.09.1100 .01.4100 .06.4100 .03.5100.013 .8100 .00.490918Table 10 shows that specialists in Laboratory medicine were much lesslikely (53.5%) than the other two grouped specialties to have clinicalappointments (82.4% and 75.4% for Surgical and Clinical speciali~ts,respective1y).3 While laboratory medicine specialists comprised only 8percent (N=7l) of the respondents (N=9l0), they accounted for 14.4 percentof full-time appointments and 15.2 percent of part-time appointments.Clearly, the majority (54%) of the respondents were specialists in clinicalfields (including general practitioners) who had 'clinical' appointments.Overall, 75 percent of faculty appointments were clinical; only 18 percentwere regular full-time appointments. On the basis of this information, onecan infer that the activities of UBC's Faculty of Medicine are supported toa significant extent by individuals whose primary professional affiliationis not the University.Table 10Distribution by Appointment Category by Grouped Training Specialty Area% Clinical % Laboratory % Surgical %Category Specialty Medicine Specialty TotalFull-Time:Row % 70.6 14.4 15.0 100.0Column % 17.4 32.4 12.8 17.6Part-Time:Row % 71.2 15.2 13 .6 100.0Column % 7.2 14.1 4.8 7.3Clinical:Row % 71. 8 5.6 22.7 100.0Column % 75.4 53.5 82.4 75.2Total N (100%) 651 71 188 9103 This is undoubtedly a reflection of the fact that the Universityapplies different 'non-academic-activity' criteria to laboratoryspecialists in awarding full- and part-time appointments.19In Table 11 we examine appointment category by department. Pathology(33.9%), Paediatrics (33.3%) and Medicine (26.3%) reporteddisproportionately more than average (13.9%) full-time appointments, whileDiagnostic Radiology (28.3%) and Pathology (14.5%) used more than average(5.6%) part-time appointments. Anaesthesiology (90.8%), Family Practice(86.8%) and Surgery (85.1%) were above the Faculty average (58.1%) forclinical appointments.VI. EMPLOYMENT PROFILE AND LEVEL OF ACTIVITYBased on the 1212 faculty with MD degrees, between 20 and 23 percentof the registrants of the College of Physicians and Surgeons of B.C. in1985/86 had some involvement with the province's medical school. 4 Asimilar cross-reference with records of the Medical Services Plan (MSP)revealed that about 20 percent of those physicians receiving at least onepayment from MSP during 1985/86 were affiliated with UBC. 5 This provides a'snapshot' of the extent of involvement of the province's physicians withthe academic activities of the Faculty of Medicine. We analyze the mix ofclinical and academic activity in more detail below. In the presentsection, however, our focus is on the mix of professional activity as self-reported through our questionnaires.4 The 145 physicians identified manually were not cross-referencedagainst College records. This is the source of the range indicated.5 Of the 913 respondents, approximately 808 had received at least onepayment from the MSP during 1985/86. Assuming no non-respondent bias, thiswould imply a numerator of about 1073. From Barer and Wong Fung (1987), wehave a denominator of 5309.20Table 11Distribution by Appointment Category by DepartmentDepartment NAnaesthesio1ogy:Row % 90Column %Diagnostic Radiology:Row % 55Column %Family Practice:Row % 166Column %Medicine:Row % 237Column %Paediatrics:Row % 91Column %Pathology:Row % 80Column %Psychiatry:Row % 120Column %Surgery:Row % 157Column %Other Depts.*:Row % 177Column %%Fu11­Time3 .­Time5.36 .128.319.76.613 .65.315.28 .09 .114.513.65 .97 .64 . 64.777 .69.785.115.175.013 .2%Total100.08 .3100.05.0100.014.9100 .020.9100.08.2100.06.8100.09 .3100 .013 .3100.013.2%Non­Respondt5.33.411.517 .96.16.913 .413.721. 8%ResponseRate84.483.681. 980.282.477 . 570.877 .167.8Total N(Row %)Missing Data117339163(13.9)66( 5.6)682(58.1)911(77.7)38**262(22 .3)177.7tNon-respondents for this particular question*Anatomy, Biochemistry, Health Care and Epidemiology, Genetics, Obstetrics,Ophthalmology, Orthopaedics, Pharmacology, Physiology**36 retired or non-faculty members.While the average (mean) number of weeks worked during 1985/86 wasreported to be 45.4 (median was 48.0), and 41.8 percent of respondentsreported working 40-47 weeks of the year, more than half (51.1%) therespondents reported working 48 weeks or more during the year (Table 12).21While males were more likely to be in this category (52.2%) than females(44 .9%), mean weeks worked were quite similar : 45.6 for males, 44.2 forfemales. Similarly, median weeks worked were only slightly lower forfemales (47) than for males (48). Only 6 percent of male physicians workedless than 40 weeks/year, whereas 13.3 percent of their female counterpartsdid so.Table 12Distribution by Number of Weeks Worked Per Year by Sex,All Professional ActivitiesSexWeeks % Male % Female % Total<40 6.0 13.2 7.140-47 41.8 41.9 41.848-52 52.2 44.9 51.1Total N (100%) 764 136 900With the exception of an apparent anomaly among the 35-44 year oldMDs, the proportion of each age group working 48 or more weeks per yearfell with age. While almost 60 percent of those <35 years of age fell intothis category , this percentage dropped to a (still substantial) 45 percentamong the over-65s (Table 13a). Although the number of older respondentsis small, the percentage of the 60-64 year age group who reported working48-52 weeks a year is comparable to the overall average, indicating nomarked or sudden decrease in weeks of activity at this age . As notedabove, the 35-44 year age group was as likely as the over 65 age group andless likely than any other age group to have reported working 48-52 weeksper year. This is the age group with the highest proportion of femalephysicians , but they are insufficient in numbers to provide the entireexplanation. In fact, only 45 .9 percent of male respondents aged 35-4422reported 48-52 week work-years, whereas for both sexes combined theproportion was 45.5 percent.Table l3aDistribution by Number of Weeks Worked per Year by Age Group,All Professional ActivitiesAge% % % % % % %Weeks <35 35-44 45-54 55-59 60-64 65+ Total<40 13.4 6.7 6 .5 5.7 7.4 5.0 7.040-47 26.9 47.8 36.1 39.0 41. 2 50.0 41. 748-52 59.7 45.5 57.4 55.2 51. 5 45.0 51. 2Total N (100%) 67 404 230 105 68 20 894In an effort to explain the 35-44 year age group anomaly, we split offthe regular (full-time and part-time) appointments in Table 13b. Clearlythe phenomenon was not concentrated among clinical appointees only. Whilethe proportions reporting at least 48 work weeks a year are higher in allage groups when we focus only on regular full- and part-time appointments,the anomaly for the 35-44 age group remains.Table 13bDistribution of Full- and Part-Time Regular Appointments Only,by Number of Weeks Worked per Year by Age Group,All Professional ActivitiesAge% % % % %Weeks <35 35-44 45-54 55-59 60-64<40 6.1 1.4 4.540-47 16.7 29.3 24 .6 23.1 22.748-52 83.3 64 .6 73 .9 76.9 72.7Total N (100%) 6 99 69 26 22%65+100.02%Total3.525.970 .522423But a comparison of Tables 13a and 13b does suggest some remarkabledifferences in activity patterns by appointment category. These areexplored more fully in Table 14a. Full-time academic appointments are muchmore likely (80.6%) than part-time (47%) or clinical appointments (44 .6%)to work 48 or more weeks a year. Furthermore, the female full-timeappointees were somewhat more likely (87%) to have worked at least 48 weeks(Table 14b) .Table 14aDistribution by Number of Weeks Worked per Year by Appointment Category% % % %Weeks Full-Time Part-Time Clinical Total<40 2.5 6.1 8.3 7.140 -47 16.9 47.0 47.1 41. 7>47 80.6 47.0 44 .6 51. 2Total N (100%) 160 66 675 901Table 14bDistribution by Number of Weeks Worked per Year by Sex,Full-Time Appointees Only% % %Weeks Male Female Total<40 2.1 6.7 2.540-47 17.9 6.7 16.9>47 80 .0 86.7 80 .6Total N (100%) 145 15 160Weeks worked per year were found not to vary with specialty area(Table 15); surgical specialists were only slightly more likely (54.8%)than the others (51.2%) to have worked 48 or more weeks per year.24Table 15Distribution by Number of Weeks Worked per Yearby Grouped Training Specialty Area% Clinical % Laboratory % SurgicalWeeks Specialty Medicine Specialty Total<40 8.1 8.7 3.2 7.140-47 41. 6 42.0 41. 9 41. 7>47 50.3 49.3 54.8 51. 2Total N (100%) 644 69 186 899Of course the intensity of a work week can vary dramatically acrossindividuals. Respondents were also asked to report the number of hoursthey worked per week (Table 16). The majority (55.8%) reported that alltheir professional activities consumed 40-59 hours per week. However, malerespondents were much more likely (38.9%) than female respondents (21.6%)to report working 60 or more hours per week. Approximately one-quarter(23.1%) of female respondents reported working less than 40 hours per week,in sharp contrast to 5.1 percent of males. Nevertheless, the difference inaverage hours worked per week (53.9 for males and 47.5 for females) was notthat dramatic.Table 16Distribution by Number of Hours Worked Per Week by SexSexHours % Male % Female % Total<40 5.1 23.1 7.940-59 55.9 55.2 55.8>59 38.9 21. 6 36.3Total N (100%) 758 134 89225Interestingly, full-time appointments were much more likely to reportworking longer hours than others (Table 17) . If clinical academicappointee workloads are representative of general clinical workloads in thecommunity (and we cannot say that they are from these data), then one couldconclude that full -time university appointments involve considerably longerwork-years than those of clinical practitioners. Among specialty areas(Table 18) surgical specialists were much more likely (58.1%) than others(32.2% and 16.2% for clinical and laboratory medicine specialists,respectively) to report working, on average, 60 hours or more per week.The vast majority of laboratory medicine specialists (77.9%) reportedworking average weeks of 40-59 hours. Finally, as one might expect, lengthof work week was reportedly inversely related to age, with over 42 percentof those under 35 years of age reporting extremely long work weeks (60+hours), and this percentage declining with age, to 25 percent of the over65 group (Table 19).Table 17Distribution by Number of Hours Worked Per Week by Appointment CategoryCategoryHours % Full-Time % Part-Time % Clinical % Total<40 3.1 9.1 8.8 7.840-59 43.8 60.6 58.2 55.8>59 53.1 30.3 33.0 36.4Total N (100%) 160 66 667 893The survey asked respondents to allocate their average weeklyprofessional working time across a provided list of activities (seeAppendix A), separated into academic and non-academic activities. In Table20 we report the proportions of respondents in each appointment category26Table 18Distribution by Number of Hours Worked per Weekby Grouped Training Specialty Area% Clinical % Laboratory % Surgical %Hours Specialty Medicine Specialty Total<40 8.8 5.9 5.3 7.840-59 59.0 77.9 36.6 55.8>59 32.2 16.2 58.1 36.4Total N (100%) 637 68 186 891Table 19Distribution of Number of Hours Worked per Week by Age GroupAge Groups% % % % % % %Hours <35 35-44 45-54 55-59 60-64 65+ Total<40 7.8 7.5 6.6 5.7 11.9 30.0 7.840-59 50.0 54.0 56.1 63.2 61. 2 45.0 55.7>59 42.2 38.5 37.4 31.1 26.9 25.0 36.4Total N 64 400 230 106 67 20 887(100%)AverageHours 53.3 53.3 54.0 52.4 49.5 45.9 52.9indicating at least some time spent on the indicated activity. Theaggregated data indicate that 83.1 percent of all respondents were engagedin some teaching, 77.4 percent provided academic-related patient care aspart of their academic activities, and 53.4 percent performed someadministrative functions. Research was carried out by less than half of therespondents (45.1%). The data in Table 20 reveal clearly the differences inproclivity to different types of activities by appointment category. Thetwo cornmon threads are the universal high levels of participation in27academic-related patient care and in teaching. Even in the latter, however,Table 20Proportions of Respondents by Appointment CategoryReporting Any of Each Activity%Full-TimeActivityPatient CareTeachingResearchAdministrationOther AcademicSub-TotalAcademicPrivate PracticeOther Non-AcademicTotal N84.997.593.192.525 .8100.069.830.8159%Part-Time74.284.853.078.816.798.578.830.366% %Clinical Total75.9 77 .479.5 83.132.8 45.141.5 53.415 .6 17.596.7 97.486.3 82.843.2 40.0665 890there is a monotonic relationship between type of academic appointment andrate of participation . Virtually all full-time appointments had someteaching responsibility , whereas 85 percent and 80 percent of part-time andclinical appointments respectively were similarly involved.This relationship between participation rate and type of academicappointment is most pronounced in the areas where one would expect to findthe greatest disparity - research and academic administration. Over 90percent of full-time appointments reported involvement in each, whereas only33 percent of clinical appointees were involved in research and a slightlyhigher 42 percent in administration. The part-time appointees fell inbetween for both activities. A not surprising monotonic, but reverse,relationship was found for private clinical practice, with over 86 percentof the clinical appointees, but a still substantial 70 percent of full-time28appointees engaged in some private practice. But the relative degree ofprivate practice involvement was much less for full-time appointees (seeTables 21a and 21b below).From the solicited information on the number of weeks worked per yearand the number of hours worked per week, combined with the information ontime allocation, we estimated academic physicians' average annual academicand non-academic hours by appointment category (Table 21a). The threefigures in each cell of this table represent average hours based on allrespondents in the appointment category, average hours based on the subsetof respondents who indicated any involvement in the row's activity (inparentheses), and the number of such latter respondents. For example,clinical faculty averaged 73 hours of academic administration a year. Butfor those doing any (N=276) the average was a much more substantial 177hours. 6There are a number of striking results in this table, not the least ofwhich is that full-time appointees reported working, on average, about 20percent more annual hours than their part-time and clinical counterparts(reinforcing the earlier hours per week and weeks per year findings reportedseparately). About one-quarter of the average full-time appointee's workyear was taken up with research, with academic patient care consuming afurther 23 percent and academic administration an additional 18 percent.6 The degree to which clinical faculty with primary administrativepositions in teaching hospitals, for example, were able to separateadministration of the hospital operation from 'academic' administration is,regrettably, unknown.29Table 2laAverage Annual Hours by Appointment Category, All Respondents,and Respondents with Any Involvement in Activity (in parentheses)Full-Time Part-Time Clinical TotalAcademic-RelatedPatient Care:Average.. 634 .9 599.1 404.8 460.3Mean.... (747.8) (806 .9) (533.0) (594.6)N 135 49 505 689Teaching:Average.. 356.3 222.0 148.0 190.6Mean" " (365.5) (261.6) (186.0) (229.3)N 155 56 529 740Research:Average" 683.4 104.7 78.7 188.7Mean*. (734 .2) (197.5) (240.2) (418.8)N 148 35 218 401Administration:Average• 496.6 253 .6 73.3 162 .3Mean•• (537.1) (321.9) (176.6) (304.1)N 147 52 276 475Other:Average" 67 .4 27.1 32.1 38.0Mean"" (261.5) (162.5) (205.2) (217.0)N 41 11 104 156Academic Subtotal:Average.. 2238.7 1206.4 736.8 1040.0Mean** (2238 .7) (1225.0) (762.0) (1067 .6)N 159 65 643 867Private Practice:Average" 436.2 888.5 1399.2 1189.3Mean*" (624.8) (1127.7) (1621.0) (1436.2)N 111 52 574 737Other Non-Academic :Average.. 127.6 205.2 213.8 197.8Mean"" (414.2) (677.1) (495.4) (494.4)N 49 20 287 356Total ProfessionalActivities:Average* 2802.6 2300.1 2349.8 2427.0N 159 66 665 890**"*Denominator includes all respondents** Denominator for those with any involvement*** Excludes 23 respondents who did not provide this information30Table 21bDistribution of Total Number of Hours Spent in ProfessionalActivities by Appointment Category% % % %Full-Time Part-Time Clinical TotalAcademicPatient Care 22.7 26.0 17.2 19.0Teaching 12.7 9.7 6.3 7.9Research 24.4 4.6 3.4 7.8Administration 17.8 11.0 3.1 6.7Other 2.4 1.2 1.4 1.6AllAcademic 79.9 52.5 31.4 42.9Non-AcademicPrivate Practice 15.6 38.6 59.5 49.0Other Non-Academic 4.6 8.9 9.1 8.2Surprising (at least to us) was the fact that, on average, full-timeacademic appointees spent 22 percent more time engaged in private (non-academic-related) practice than in teaching. Fully 15 percent of theirprofessional time was spent in private practice (and, as we will see below,this activity provided close to 20% of their average incomes).The profile of the part-time appointee is quite different. 7 Hereslightly over half the work year appears to be taken up with academicactivity in aggregate, but the single largest category is private practice(39%). This is followed by academic-related patient care (26%), so thattwo-thirds of the part-time appointee's activities are directly related topatient care (in contrast to 38% for the full-time appointments).7 It was interesting to note that one part-time appointee reported noacademic activity.31As might be expected, private practice dominates the activities ofclinical appointees (about 60% of their annual hours).8 Among theiracademic activities as well, patient care was easily the most frequentactivity. The average respondent in this category reported the equivalentof about three full-time weeks of student contact a year, and 79 hours ofresearch time, although among those doing any research the figure wassubstantially higher. In fact the clinical faculty involved in someresearch averaged more time in that activity than their part-timeappointment counterparts! The activity mix proportions are reported inTable 2lb.In Tables 22a, b, and c we disaggregate the totals from the previoustable by grouped specialty for those who reported any activity. Table 22aencapsulates total average annual hours; tables 22b and 22c focus,respectively, on Academic and Private Practice annual averages.The data indicate appreciable inter-spe~ialtyvariability. Table 22ashows, for example, that while full-time faculty averaged longer hours ingeneral, part-time and clinical faculty in the surgical specialties averagedlonger annual hours than full-time faculty in the laboratory specialties .The data also show that clinical appointments in laboratory specialtiesaveraged about 9 percent more total hours annually than their part-timecounterparts. Furthermore, there were considerable differences betweenspecialties in average annual hours of full-time faculty. Surgicalspecialists average about 26 percent more hours than laboratory specialists8 Twenty-two (3 .3%) of the clinical appointment respondents reportedDQ academic activity!32Table 22aAverage Annual Total Hours by Appointment Categoryand Grouped SpecialtyAppointment Clinical Laboratory SurgicalCategory Specialty Medicine Specialty TotalFull-Time 2797.2 2477 . 5 3124.9 2802.5N III 22 24 157*Part-Time 2284.6 2060.0 2647.3 2300.0N 47 10 9 66Clinical 2268.6 2250.7 2630.7 2349.8N 478 36 151 665Table 22bAverage Annual Academic Hours by Appointment Categoryand -Gr ouped Specialty, for Those Reporting Any Academic ActivityAppointment Clinical Laboratory SurgicalCategory Specialty Medicine Specialty TotalFull-Time 2338.8 1840.3 2225.5 2251. 6N 111 22 24 157*Part-Time 1201.4 1342.0 1215.1 1225.0N 46 10 9 65Clinical 727.0 1235.9 762.6 762.0N 462 34 147 643Table 22cAverage Annual Private Practice Hours by Appointment Categoryand Grouped Specialty, for Those Reporting Any Private PracticeAppointment Clinical Laboratory SurgicalCategory Specialty Medicine Specialty TotalFull-Time 516.1 779 .3 868.9 601.8N 82 5 23 110**Part-Time 1112.3 82.5 1429.7 1127.7N 41 2 9 52Clinical 1544.3 1737.5 1817.4 1621. 0N 408 16 150 574*Two full-time respondents did not report their specialty .**One full-time respondent with some private practice activity did notreport a specialty.33private practice phenomenon, not a reflection of relative academic time(Tables 22b and 22c). Full-time clinical specialists reported the highestaverage annual academic hours; full-time surgical specialists reported about5 percent fewer average hours than their clinical specialty counterparts.The relatively high total activity time for full-time surgical specialistscan be explained by the relatively high private practice time reported bythis group. The latter reported 68 percent more average annual privatepractice hours than full-time appointments in clinical specialties (Table22c) .While the same overall specialty-specific trend exists for part-timeand clinical appointments, the variations between specialties withinacademic and private practice activities show quite different patterns .Among the part-time appointments, the laboratory specialists spent the mosttime on academic activities, although the variations were small. Laboratoryspecialists with clinical appointments also spent more time on academicactivities than their surgical and clinical counterparts, but here thedifferences were far more dramatic. Among those clinical appointmentsreporting any academic activity, the laboratory physicians reported over 60percent more of such activity than their clinical and surgical counterparts.The private practice figures are most affected by the smallerdenominators, reflecting the variable subsets of academic appointments ineach cell who engaged in any private practice activity. Among those facultywho did, the surgical specialists were the most active in this area (asnoted above), regardless of appointment category.34If we somewhat arbitrarily designate 2160 hours 9 of academic activityin the year as a 'full-time cutoff', implying that anyone who puts in atleast this many hours is one ful1-time-equivalent (FTE), and those who workfewer hours are proportions of a FTE based on a denominator of 2160, thenTable 23 provides a summary of the relationship between type of appointmentand actual (self-reported) academic activity.Table 23Total Academic Fu11-Time-Equiva1ents by Appointment CategoryAppointment # of # of # of FTECategory Faculty Academic FTE # of FacultyFull-time 157 140 0.89Part-time 66 36 0.54Clinical 679 219 0.32Total 902 394 0.44Clearly there is a direct relationship between type of appointment andnature of activity. Most full-time appointments are engaged full-time inacademic activity (although as we see below this does not seem to precludeconcurrent high levels of clinical practice activity). The full-time-academic-equivalences of the part-time and clinical appointments aresubstantially lower.Because of different implicit (or explicit) hourly rates of pay, thedistribution of income may differ in varying degrees from the distributionof hours. In an attempt to address that issue, and as a means of being ableto profile the income make-up of university-affiliated MDs, we asked9 45 hours per week, 48 weeks per year.35respondents to provide the proportionate disaggregation of their incomesources (see questionnaire, Appendix A).In Table 24 we show these average income source profiles, split out bytype of appointment category and by sex within category. As would beexpected, the dominant source of income for full-time faculty is a regularacademic salary. Yet even among these appointees, patient care (academic­related or private) was a significant source of income. As one moves acrossrows from full-time to clinical, the importance of academic salary virtuallydisappears, while that of payment through (primarily) MSP increasessubstantially. In all appointment categories, male academics receive alarger share of income from MSP or Yorkers' Compensation Board (WCB) thantheir female colleagues. With the exception of female part-timeappointments, the single major source of income in all appointment/sexcategories was either academic salary or MSP. For the former, the majorsource of income was non-university, through hospitals or other healthagencies.VII . CLINICAL ACTIVITY OF ACADEMIC FTE'SThe issue of the clinical (particularly private practice) activity ofacademic appointments is of importance both to manpower planning and touniversity administrators. As noted at the outset of this report, if asignificant segment of academic activity is provided by largely privatepractitioners, then the academic enterprise is in some senses at jeopardy,vulnerable to shifts in career decisions of the 'pr~vate sector'. On theother hand, the extent of private practice, particularly among full- and36part-time university faculty, should give pause to universityadministrators, whose concern is (or ought to be) that the university (andthe taxpayers) are receiving value for money.In this section we bring together two distinct sources of data, insearch of insight into the extent of overlap between private practice andacademic careers. Our approach was to compute two FTE values for eachacademic MD, one based on MSP payments in fiscal 1985/86, the other based onself-reported academic hours of work. 1 0 For academic time, we assigned aTable 24Ayerage Distribution of Source of Income by Appointment Category and SexAppointment CategorySource ofIncomeFull-TimeMale Female% %Part-TimeMale Female% %ClinicalMale Female% %University:Academic SalaryPatient CareTeaching HospitalOtherNon-University:Hospital/HealthAgencyMSP, WCB, etc.Other41. 716 . 35 .2 .1.011 .244 .03 .018 .95 .413 . .310 .83.04.619 .648.04.6Note :Co1umns do not sum to 100 percent because of the categorical nature ofresponses (see questionnaire, Appendix A). For the purposes of this table,interval mid-points were used. For example, if a respondent indicated 81­90 percent of income from a particular source, 85 percent was assumed.10 Beca~se the academic year referred to in our questionnaires wasSeptember 1985 - August 1986, whereas the MSP payment fiscal year was April1985 - March 1986, there may be some slippage, particularly for anyindividuals who shifted from clinical practice to a regular academicappointment in September 1985. Nevertheless, we suspect such anomalieswill not unduly affect the overall picture.37full-time cutoff of 2160 hours per year (45 hours a week, 48 weeks a year) .Anyone spending 2160 or more hours in the year on academic activity wasconsidered to be engaged in full-time academic activity. Those spendingfewer hours were assigned FTE values equal to their academic hours dividedby 2160.The measure of clinical fu11-time-equiva1ence was based on definition#4, taken from Barer and Wong Fung (1987). This defines a full-time cutoffequal to one-half the mean payments from MSP for each MD's peer group bytype of clinical practice (for details, see above ref.). Then anyone withearnings above that cutoff is counted as full-time. For those below, theirFTE value is calculated as the ratio of their MSP gross earnings to theirpeer full-time cutoff. The cutoffs by specialty are reported in Appendix C.In Table 25 we report the cross-tabulation of academic and clinical FTEvalues, for those academic MDs who responded to our questionnaire and whoseclinical type of practice was not laboratory medicine, radiology, nuclearmedicine or medical microbiology. For these, it is impossible to computemeaningful clinical FTE values because of the practice of man; physicianssubmitting MSP claims through a single practitioner number. It seems worthpointing out as well, that where activity self-reported ~ ~ "academic patientcare" (see Appendix A, questionnaire) resulted in claims paid by MSP, suchactivity is double-counted here - included in the computation of bothacademic and clinical FTE values. We undertook a number of sensitivityanalyses (below) to subject the results to alternate methods andassumptions, including treatment of this possibility of double counting .38With these caveats in mind, Table 25 shows a considerable (some mightsay remarkable) degree of "double careers". Among those who are at least0.8 FTE in clinical terms, 20 percent also appear to be engaged at least 80percent in academic careers (in fact, among those counted as one clinicalFTE, 11 percent also showed as full-time academic). Viewed in the oppositedirection, almost two-thirds of respondents who, on the basis of self-Table 25Clinical Full-Time Equivalence by Academic Full-Time Equivalence,All Respondents*Academic Clinical Full-Time-EquivalenceFull-TimeEquivalence ~.8 .5 to <.8 .2 to <.5 0 to < .2 Total~.8 126 22 11 35 194Row % 64.9 11.3 5.7 18.0Column % 19.6 61.1 42.3 35 .0 24.1.5 to <.8 89 4 5 14 112Row % 79.5 3 .6 4.5 12.5Column % 13 .9 11.1 19 .2 14 .0 13 .9.2 to <.5 159 5 4 14 182Row % 87.4 2.7 2.2 7.7Column % 24.8 13.9 15.4 14 .0 22.60 to <.2 268 5 6 37 316Row % 84.8 1.6 1.9 11.7Column % 41. 7 13.9 23.1 37.0 39.3Total N 642 36 26 100 804Row % 79.9 4.5 3.2 12.4 100 .0*Excludes those specialties such as radiology and pathology for which wecould not compute clinical FTEs.reported academic hours of work were engaged as full-time universityemployees, were also involved in enough billable clinical work to becategorized as full-time clinical as well. In fact, the mean clinical FTEvalue for those with academic FTE values of I was 0.7. This mean rangedbetween 0.7 and 0 .9, the latter being associated with those with academic39FTE values between 0 and 0.2. As one might expect, with declining academicFTE values comes an increase in the proportion who are clinical full-time,but the trend starts from a high base (50.8% of academic 'full-timers' arealso clinical full-time, and this increases to 87% of those with an academicFTE value between 0.2 and 0.5).The largest cells in Table 25 are those intersecting '0.8-1.0 clinicalFTE' with 'less than 0.5 academic FTE'. These account for over one-half therespondents. But this is a clinical appointment phenomenon, as we see whenwe move to Table 26. This table repeats the analysis of Table 25, but onlyfor full-time academic appointments. Among this much smaller group, almosthalf were at least 0.8 FTE on both clinical and academic criteria. Amongthose spending at least 2160 hours a year in academic activity, 46 percentalso earned enough through MSP to be categorized as clinical full-time (notshown in Table). Among those with MSP payments representing at least 0.8clinical FTE, 77 percent also worked at least 1728 academic hours in theyear.Part of the explanation for these findings may be the level of theclinical full-time payment cutoffs (Appendix C). While some of these seemon the low side, this method of computing a full-time cutoff was endorsed bythe Joint Committee on Medical Manpower during deliberations in 1982. Analternative explanation of Table 26 is that those who work hard in one'career' work hard in both, or that clinical practice (and with it clinicalincome) goes hand in hand with being an academic physician .40Table 26Clinical Full-Time Equivalence by Academic Full-Time Equivalence,Full-Time Appointments Only*Clinical Full-Time-EquivalenceAcademicFull-TimeEquivalence~.8Row %Column %.5 to <.8Row %Column %.2 to <.5Row %Column %a to <.2Row %Column %Total NRow %~.86660.076.71676.218.6350.03.5133.31.28661.4.5 to <.81816.494.7133.35.31913.6.2 to <.598.290.014.810.0107.1a to <.21715.568.0419.016.0350.012.0133.34.02517.9Total11078.62115.064.332.1140100.0*Excludes those specialties such as radiology and pathology for which wecould not compute clinical FTEs.Another way of vie~ing these data is in a form comparable to Table 23.In Table 27 we show the ratio of clinical FTEs to numbers of faculty, byappointment category. As one would expect, the ratio of clinical FTEs toTable 27Total Clinical Full-Time-Equivalents by Appointment CategoryAppointment # of # of # of Clin FTECategory Faculty Clinical FTE # of FacultyFull-time 141 102 0.72Part-time 50 40 0.80Clinical 619 536 0.87Total 810 677 0.84*Excludes those specialties such as radiology and pathology for which wecould not compute clinical FTEs.41numbers of individuals is highest for clinical appointments and lowest forfull-time appointments. But as the data described earlier foreshadowed,there is very little variation.In an attempt to subject these results to some sensitivity analyses. wevaried the assignment of full-time status for each of clinical and academicactivity. Tables 28 and 29 replicate Tables 25 and 26, with the followingmethodo1ogic changes:(a) before an individual's academic fu11-time-equiva1ence wascomputed. self-reported "academic patient care" time was removed.The full-time 'cutoff' of 2160 hours was then applied to theremaining reported academic time.(b) the clinical full-time cutoff was set at two-thirds of thephysician's peer type of practice mean income from MSP (seeAppendix C for levels).These adjustments were adopted in an effort to create a "most favourable" or"least overlap" set of results. That is, it becomes much less likely thatsomeone would be both clinical and academic full-time if academic patientcare (for which the physician may be paid by MSP) is treated at the otherextreme, i.e. is excluded entirely from academic time, and if the billinglevel necessary for clinical full-time designation is increased by 33percent over the base (Tables 25 and 26) case.The two concurrent adjustments have a dramatic effect. If we assumethat all academic patient care is, in fact, entirely clinical activity (withno academic content), then only 4 percent of those with clinical FTE valuesof at least 0.8 also have academic FTE values at that level (Table 28; downfrom 20% in Table 25). Among those considered as full-time academics42Table 28Clinical Full-Time Equivalence by Academic Full-Time Equivalence,All Respondents,* Adjusted Full-Time DesignationsClinical Fu11-Time-EquivalenceAcademicFull-TimeEquivalence~.8Row %Column %.5 to <.8Row %Column %.2 to <.5Row %Column %o to <.2Row %Column %Total NRow %~.82231. 93 . .,3848.76.412674.621.440482.868.559073.4.5 to <.81927.526.42126.929.2137.718.1193.926.4729.0.2 to <.5913.024.3810.321. 6105.927.0102.027.0374.6o to <.21927.518.11114.110.52011.819.05511.352.410513.1Total698.6789.716921. 048860.7804100.0*Excludes those specialties such as radiology and pathology for which wecould not compute clinical FTEs.(academic FTE value ~0.8), 31 percent still have clinical FTE values of atleast 0.8, but this too is down dramatically (from 65%).One would expect that the effect of these adjustments would show mostdramatically in movement across the (row) categories of academic FTE status.On the clinical FTE side, the only individuals affected would be those whoearned less than the two-thirds mean peer-group cutoff, and even there onewould expect at most a one column (to the right) move. In contrast, theremoval of academic patient care activity from academic time would beexpected to reduce dramatically the extent of some physicians' academicactivity. Indeed, we find as much as 100 percent increases in the column43percentages along the 0.0-0.2 academic FTE row, and a SO percent increase inthe absolute number of respondents ending up in this bottom row.Table 29Clinical Full-Time Equivalence by Academic Full-Time Equivalence,Full-Time Appointments Only,* Adjusted Full-Time DesignationsAcademic Clinical Full-Time-EquivalenceFull-TimeEquivalence ~.8 .5 to <.8 .2 to <.5 0 to <.2 Total~.8 19 18 9 16 62Row % 30.6 29.0 14.5 25 .8Column % 31. 7 48.6 52.9 61. 5 44 .3. 5 to <.8 20 15 6 3 44Row % 45.5 34 .1 13.6 6.8Column % 33.3 40 .5 35.3 11.5 31.4.2 to <.5 17 4 1 4 26Row % 65.4 15.4 3 .8 15.4Column % 28.3 10 .8 5.9 15.4 18.60 to < .2 4 1 3 8Row % 50.0 12 .5 37 .5Column % 6.7 5.9 11.5 5.7Total N 60 37 17 26 140Row % 42.9 26.4 "12.1 18.6 100.0*Excludes those specialties such as radiology and pathology for which wecould not compute clinical FTEs.A comparison of Tables 26 and 29 , in which we focus solely on full-time faculty appointees, is also revealing . Here the effect is largely toshift from the ~0.8 academic FTE category to the 0.2-<0 .5 and 0.5-<0.8groups . In particular, over two-thirds of those in the ~0.8 FTE cellonboth academic and clinical criteria in Table 26 are no longer there in Table29 . Over 20 percent end up still showing ~O .8 FTE clinical activity, butnow are categorized as only 0.2-0.5 of an academic FTE (this cell gains 1444individuals in moving from Table 26 to 29, all of whom must have come fromthe upper left-hand cell of Table 26).Even after these extreme methodo1ogic adjustments, we still find that14 percent of the full-time appointments show up as being involved in eachof clinical and academic activity, each at least 80 percent of full-time.Almost exactly one-half of these full-time respondents are at least 0.5 FTEin both clinical and academic dimension. At the other end, 24 percent ofthese respondents spent less than half-time in academic (non-patient care)activity, despite their status as full-time university faculty. We notewith some bemusement the (small number of) full-time faculty who appear tobe less than 0.2 academic FTE.As a final look at this cross-classification of clinical and academicactivity, we retained the academic FTE definition from Table 28 (i.e.excluding academic patient care), but substituted MSP's 1985/86 sessionalpayment levels ($80,640 for general practice; $99,360 for specialists) forthe two-thirds peer mean full-time clinical cutoff. A comparison of Tables28 and 30 shows that this has the effect of moving a small number ofrespondents from ~0.8 clinical FTE to lower categories. Examination of thecutoff levels (Appendix C) suggests that this must be largely a result ofmovement among the general practitioners, psychiatrists and paediatricians.For most of the other specialties, one would have anticipated movementsacross the columns from right to left rather than the reverse. In general,however, differences between Tables 28 and 30 are not dramatic.45Table 30Clinical Full-Time Equivalence (based on sessional rates), byFull-Time-Equivalence (excluding patient care), All Respondents*Academic Clinical Full-Time-EquivalenceFull-TimeEquivalence ~.8 .5 to <.8 .2 to <.5 0 to < .2 Total~.8 23 15 12 19 69Row % 33.3 21. 7 17.4 27.5Column % 4.1 18.3 23.5 17.6 8.6.5 to <.8 36 15 15 12 78Row % 46.2 19.2 19.2 15.4Column % 6.4 18.3 29.4 11 .1 9.7.2 to <.5 121 15 12 21 169Row % 71.6 8.9 7.1 12.4Column % 21. 5 18.3 23.5 19.4 21.00 to <.2 383 37 12 56 488Row % 78.5 7.6 2.5 11.5Column % 68.0 45.1 23.5 51. 9 60.7Total N 563 82 51 108 804Row % 70.0 10.2 6.3 13.4 100.0• Excludes those specialties such as radiology and pathology for which wecould not compute clinical FTEs.VIII. CURRENT AND FUTURE REQUIREMENTS FOR ACADEMIC PHYSICIANSThe purposes of the survey on requirements were threefold:(1) to document current attrition and requirements ;(2) tb estimate current net requirements;(3) to forecast future requirements using five hypothetical scenarios basedon different first year (medical school) enrolment figures.Respondents were asked to enumerate the number of faculty affiliatedwith their departments in 1985/86, but who were not so affiliated in 1986 /87(Table 31). A total of 52 appointees were so identified, the46majority being clinical faculty. Assuming that our estimate of 1212medically-trained faculty is relatively accurate, the reported overallattrition rate works out to be approximately 4 percent; that for full-timefaculty was slightly higher (approximately 7%). What were perhaps moreinteresting were the responses by Department Heads to questions regardingtheir faculty requirements in 1986/87, and the extent to whichthey were able to meet those requirements. After having indicated theextent of attrition between 1985/86 and 1986/87, the respondents thenindicated their requirements for 1986/87, both to replace faculty no longeravailable and to support new or reorganized activities or initiatives. Thesummary results are reported in Table 32.Table 31Total Attrition, During 1986/87 Relative to 1985/86Type of EstimatedAppointment N Attrition Rate (%)Full-Time 15 6.9Part-Time 7 15.9Clinical 30 3.2Total 52 4.3Table 32Total Requirements for 1986/87Type of AppointmentFull-TimePart-TimeClinicalTotalOther ThanTotal Replacement ReplacementN % N % N %46 41. 8 18 42.9 28 41. 216 14.6 2 4.8 14 20.648 43.6 22 52.4 26 38.2·110 100.0 42 100.0 68 100.047These following results must be interpreted in the context of theunderlying 'recruiting' differences pertaining to the different types ofappointments. Generally, all full-time appointments are recruited by theUniversity, Faculty of Medicine . In contrast, clinical appointments usuallyresult from individuals seeking and gaining privileges at one of theaffiliated teaching hospitals. One of the expectations associated with thegranting of privileges at these hospitals is that the physicians willinvolve themselves in teaching. In such situations, the University willroutinely offer a clinical appointment .As can be seen by a comparison of Tables 31 and 32 , there were no plansto fill ten of the positions vacated. But this aggregate picture ismisleading. Not only were all vacated full-time appointments included inthe replacement requirements, but somehow three additional positions wereincluded as being for replacement purposes. Department Heads appeared farless interested in replacing departed part-time faculty and, of course,clinical faculty are to some extent outside the direct control of therespondents .This general trend, of 'over-replacing' full-time faculty but notreplacing all part-time and clinical faculty, carried over into theresponses regarding requirements for ~ faculty. While full -time facultyaccounted for only 18 percent of respondents to the supply-sidequestionnaire (Table 6), they comprised 41 percent of new requirements for1986/87. Part-time appointments were also 'over-represented' relative tothe base stock proportions. This may, once again, largely be a reflectionof the manner in which clinical appointments come about .48Department Heads apparently preferred to make fewer total appointmentsby appointing proportionately more full-time faculty (over which they havegreatest control). These data indicate a total requirement of about 9percent, and net new requirements of about 6 percent.Of course all requirements questions of this nature are subject to'wish list' bias, particularly wit~in a financially constrained environment.As we show in Table 33, actual appointments fell considerably short of theself-reported targets. Only 50 percent of positions which became availablethrough attrition were filled (this despite the fact that three part-timeappointments were made in response to two vacancies!), while 31 percent ofrequirements other than for replacement were met. In contrast to thepreferences of the respondents, a higher proportion of the clinical than ofthe other two appointment categories were filled. Even so, the 'new'appointments (other than for replacement) were disproportionately full-time .Taken at face value, the 1986/87 appointments left a shortfall of 68positions 'unfilled' (31 full-time, 13 part-~ime and 24 clinical). Ofcourse many of those 68 positions may never have been more than gleams inthe eyes of the respondents. Our questionnaire did not seek informationthat would have distinguished between funded positions for whom incumbentscould not be found (which would reflect problems in recruiting), andpositions desired but for which funding was not secured (which would reflectthe extent of 'wish lists').Finally, future net requirements were determined from respondents'estimates of annual faculty reductions and new faculty appointments (Table34). As noted earlier, Department Heads were asked to project changes in49faculty complement by type of appointment and by '.":·'ether or not forreplacement, for the years 1987/88 to 1990/91. This task was complicatedsomewhat by the fact that we asked for these estimates given five differentscenarios regarding changes in the size of the first year medical class.These scenarios ranged from 10 percent per year reductions in thiscomplement, to 10 percent per year increases.Table 33Achieved Requirements During 1986/87Other ThanTotal Replacement Replacement% of % of % ofType of Appointment N Req'mts N Req'mts N Req'mtsFull-Time 15 32.6 5 27.8 10 35.7Part-Time 3 18.8 3 15.0 0 0.0Clinical 24 50.0 13 59.1 11 42.3Total 42 38.2 21 50.0 21 30.9In most cases, net requirements increased with the size of the firstyear class. There were a few exceptions (e.g. fewer full-time requirementsin the +5% scenario than in the status quo scenario, for 1987/88; fewerpart-time requirements in an expansionary environment than in the reverse,for 1988/89; etc.). We might attribute such anomalies to some combinationof respondent error and conscious projections of changes in the mix offaculty by type of appointment. For example, the 1988/89 result may reflecta feeling that an expanding medical school size would require more full-timeand clinical and less part-time appointments.50Table 34Future Net Requirements by Appointment Categoryand by Hypothetical ScenarioFull-TimeAcademic Year Four-YearScenarios 87-88 88-89 89-90 90-91 Total-10% 21 2 1 1 25-5% 24 3 5 2 340 26 6 5 4 415% 24 10 7 8 4910% 33 11 10 14 68Weighted· 41. 8Part-TimeAcademic Year Four-YearScenarios 87-88 88-89 89-90 90-91 Total-10% 15 3 0 1 19-5% 17 3 1 2 230 20 3 2 3 285% 21 0 5 6 · 3210% 26 -2 4 7 35Weighted· 26.4ClinicalAcademic Year Four-YearScenarios 87-88 88-89 89-90 90-91 Total-10% 9 1 1 -2 9-5% 14 1 4 -2 170 17 7 5 2 315% 21 11 11 8 5110% 27 16 15 11 69Weighted· 30.4·Four-year total weighted by the reported likelihood of the five scenarios.51The weighted total four-year requirements reflect the effect ofweighting the total requirements for each scenario by the average reportedlikelihood of the occurrence of each scenario. These data suggest that, onbalance, Department Heads thought it most likely that there would be nochange in the size of the entering class between now and 1990/91.IX. SUMMARYThe following major points emerge from the foregoing analysis:(1) During the 1985/86 academic year, 1212 British Columbia MDs had someaffiliation with the province's medical school. This represents about21 percent of non-postgraduate MDs registered with the College ofPhysicians and Surgeons of B.C. as of September 1985, and about 20percent of physicians receiving any payments from the Medical ServicesPlan of B.C . in 1985/86.(2) MDs with faculty appointments were predominantly male (85%) between theages of 35 and 44 (45%). Female academic physicians tended to beslightly younger, on average, than their male counterparts. An evenlarger proportion (90%) of full-time academic appointments were male;about 80 percent of female academic physicians held clinicalappointments.(3) About 75 percent of MD university appointments were "clinical". Only18 percent were full-time faculty appointments.(4) Over half the respondents reported working more than 48 weeks of the1985/86 academic year. Mean weeks worked for males and females werevery comparable (45.6 & 44.2 respectively). Only 6 percent of maleappointees reported working less than 40 weeks/year, while about 13percent of female respondents so reported. The proportions working 48weeks or more fell with age , with the exception of an unexpectedlysmall proportion of those 35-44 years of age (Tables 13a & l3b).(5) Full-time academic appointments were much more likely to report workingat least 48 weeks per year (81%) than were their part-time and clinicalappointment colleagues (about 45%), and among the full-time appointees,an even greater proportion of female respondents (87%) worked at least48 weeks .(6) Male MD academics were likely to work somewhat longer hours than theirfemale counterparts (average 53 .9 hours per week for males, 47.5 forfemales), although this difference could be partially traced todifferences in mix of appointments (most full-time academicappointments were male) and the fact that full-time appointees tended52to work longer hours than clinical appointees .the male respondents reported working at leastonly 22 percent of female respondents reportedAlmost 40 percent of60 hours a week, whereassimilarly long hours.(7) Over half the full-time appointments reported working average weeks ofat least 60 hours. This was significantly higher than the proportionof part-time and clinical appointments (about 33%) reporting similarhours.(8) The surgical specialty appointments were significantly more likely toreport working 60+ hour weeks (58%) than were their clinical andlaboratory medicine colleagues (32% and 16% respectively).(9) The distributions of hours worked per week were relatively similar forthe age groups up to and including 45-54, after which hours worked perweek declined with age group (Table 19).(10) Less than half the respondents were involved in research activities.In contrast, 83 percent had some teaching responsibilities, and 77percent provided academic-related patient care (e.g. rounds, studentsupervision) . Among full-time appointments , virtually all reportedsome teaching, research and academic administrative activities (Table20). Clinical appointments were significantly less likely to beinvolved in research or academic administration.(11) Over 80 percent of the respondents reported engaging in some private(non-academic) patient care activity, with proportions ranging from 70percent of full-time appointments to 86 percent of clinicalappointments . But the extent of such activity among full-timeappointees was far less than for the others, averaging 436 hours peryear as compared with 1400 hours per year for clinical appointments(Table 2la).(12) Full-time appointees reported working an average of about 2800 hours inthe year, significantly higher than the hours reported by part-time(2300 hours) and clinical (2350 hours) appointees. These totals werefor all professional activities combined.(13) Full-time academic MDs spent an average 436 hours during the year inprivate practice, but only 356 hours in teaching and relatedactivities . The two largest components of their time were academic­related patient care , and research, each consuming about 650 hours onaverage.(14) Part-time academic MDs spent about 40 percent of their professionalwork time in private practice, and slightly over 25 percent more inacademic-related patient care. In short, about two-thirds of theirwork time involved patient care . Among academic activities, patientcare was followed by administration, with teaching and researchcombined representing less than 15 percent of the average part-timeappointee's work year.53(15) The time of clinical appointments was dominated by private practice(60%), with academic-related patient care averaging an additional 17percent of annual work time.(16) Clinical appointees involved in any research activities averaged moresuch time than their part-time appointment counterparts.(17)(18)(19)(20)(21)(22)Appointees in the surgical specialties reported longer total work hoursthan in the other broad groupings, although full-time appointees in theclinical specialties averaged more academic-related time than those inthe surgical specialties . In contrast, among full-time appointeesengaged in any private practice, those in the surgical specialtiesaverage about 70 percent more private practice hours than theirclinical specialty colleagues.Among full-time male academic appointees, private practice providedclose to 20 percent of annual income. For females this source wassomewhat less important, averaging 11 percent of income. Academicsalaries represented 41 percent of full-time appointment incomes, about10 percent of part-time incomes, and under 3 percent of clinicalappointment incomes.Using our baseline definitions of 2160 annual academic hours foracademic full-time-equivalence, and patient care full-time-equivalencebased on billing activity relative to each MD's type of practice peergroup (see Appendix C), we found that almost two-thirds of thoserespondents who were at least 80 percent of an academic full-time­equivalent were also sufficiently involved in billable patient careactivity to be counted as full-time in that dimension as well. Amongthose with full-time clinical practices, 11 percent also reportedenough academic activity to be considered full-time academic as well.Among full-time academic appointees who spent at least 2160 hoursduring the year on academic activities, almost half also earned enoughthrough MSP to be categorized as clinical full-time.If self-reported academic-related patient care is not counted at allwithin academic time, and if private practice full-time income cutoffsare increased by one-third, the extent of apparent 'double careers'shrinks markedly (Tables 26 & 27). Yet 32 percent of the respondentswith academic FTE values of at least 0.8 also still have clinicalpractice FTE values of at least 0 .8. For full-time appointments, thisfigure is still over 30 percent .Faculty attrition rates from 1985/86 to 1986/87 averaged 4.3 percent,with the rates ranging from 3.2 percent for clinical appointments toalmost 16 percent among part-time appointments .(23) Recruiting efforts (self-reported) suggested a focus on replacing andexpanding the full-time complement. New appointments tendeddisproportionately to be full-time.(24) Relative to self-reported requirements for 1986/87, less than half the'positions' were filled. Half of the positions vacated through54attrition were filled, while only 31 percent of new self-reportedrequirements were satisfied.(25) Projected faculty MD requirements for 1987/88 to 1990/91, assuming nochange in the size of first year medical school enrolment, totalled 41full-time, 28 part-time and 31 clinical appointments. The requirementswere heavily loaded on the beginning of the period (1987/88).ReferencesAnderson, R.E . et a1 . (1986), "Future Needs of Academic Pathology :Viewpoints of Chairpersons and Faculty from Departments of Pathology" ,Human Pathology 17(12):1192-1195, December.Association of American Medical Colleges (1985), "Symposium - ClinicalTeaching: Three Perspectives on Faculty Development", Proceedings of theAnnual Conference on Research in Medical Educ ation 24 :329-336, October .Barer , M.L . and P . Wong Fung (1987) , Fee Practice Medical ServiceExpenditures pe r Capita, and Full -Time-Eguival ent Phys i c ians i n B.C .. 1985 ­86, HMRU 87:1 , Division of Health Services Research and Devlopment ,University of British Columbia, Vancouver, B.C., March.Benson, M.C. et al. (1985), "Career Orientations of Medical and PediatricResidents", Medical Care 23(11):1256-1264, November.Colon , V,F. and J. Gibson (1984), "The Status of Faculty in Family PracticeTeaching Programs in Ohio", Ohio State Medical Journal 80(4):317-321 ,April.Committee on Medical Education, The New York Academy of Medicine (1981),"Symposium on the Academic Physician: An Endangered Species", Bulletin ofthe New York Academy of Medicine 57(6):411-503 , Second Series, Ju1y­August.Goldman , J.A . (1982), "Faculty Development and Human Resource Management inthe Academic Medical Setting", Journal of Medical Education 57:860-865,November .Heberlein, T .A. and R. Baumgartner (1978), "Factors Affecting ResponseRates to Mailed Questionnaires: A Quantitative Analysis of the PublishedLiterature", American Sociological Review 43(4):447-462.Linn , L.S. et a1. (1985), "Health Status, Job Satisfaction , Job Stress andLife Satisfaction Among Academic and Clinical Faculty", Journal of theAmerican Medical Association 254(19):2775-2782, November 15.Lomas, J . , M.L. Barer and G.L. Stoddart (1985 ), Physician ManpowerPlanning: Lessons from the MacDonald Report, Toronto: Ontario EconomicCouncil .National Research Council (1982), Personnel Needs and Training forBiomedical and Behavioural Research, discussed in "Manpower Needs forAcademic Medicine" , Annals of Internal Medicine 97(4):611-612.Petersdorf , R.G. (1981), "Academic Medicine: No Longer Threadbare orGenteel" , New England Journal of Medicine 304(14):841-843 , April 2.Pritchett, E.L.C. et al, (1986), "Career Choices of 135 Cardiology Traineesat Duke University Medical Centre from 1970 to 1984", American Journal ofCardiology 57:313-315.APPENDIX AAcademic Medical Manpower StudySupply of Academic TimeQuestionnaire and Covering LetterTHE UNIVERSITY OF BRITISH COLUMBIA#400 - 2194 HEALTH SCIENCES MALLVANCOUVER, B.C., CANADAV6T lZ6OFFICE OF THE CO-ORDINATOR, HEALTH SCIENCESDivision of Health Services Research and DevelopmentP. A, \\'oodward Instructional Resources CentreTelephone: (604) 228 -4810November 24, 1986Dear Respondent:This questionnaire is designed to gather information for a study beingcarried out by the Division of Health Services Research and Development ,Office of the Coordinator of Health Sciences, VBC, in collaboration withthe Office of the Dean, Faculty of Medicine. The study is entitled "Supplyof and Requirements for Academic Medical Manpower in B.C."The main objectives of the study are:1 - To gather information on current academic-related activities ofphysicians in B.C.2 - To gather information on requirements for academic medicalmanpower in the province.It has been observed that one of the components missing in mostestimates of medical manpower supply and requirements in this country hasbeen information on the need for and supply of qualified academicphysicians. Thus, this study will provide important, and heretoforeunavailable, data necessary to rational physician manpower planning for theprovince and the Faculty of Medicine.The enclosed questionnaire is designed to gather information on the"supply side", that is the academic time provided by physicians in B.C. Itis being distributed to all physicians with academic appointments in theVBC Faculty of Medicine (full-time, part-time and clinical). Because ofthe anticipated wide variation among faculty in degree of academicinvolvement, an extremely high rate of response is essential to the successof this study. We will be able to infer very little about the activitiesof non-respondents, and anything less than a complete response will ofcourse create serious problems in profiling the supply situation. Inshort, we need the cooperation of all to make this project useful. Whileit goes without saying that you have every right to decline our invitationto participate, we are hopeful that you will recognize the importance ofthe study and will be willing to assist us.A-ITHE JOHN F. McCREARY HEALTH SCIENCES CENTRE. .. /2A-2 2The enclosed questionnaire should require no more than 10 minutes ofyour time. The returned questionnaire in the stamped, self-addressedenvelope will be taken as your consent to participate in this study, butwill also represent the total commitment required of you. There will be nofurther contact or questionnaires. Your information and identity will bestrictly confidential and only accessible to researchers directly involvedin the study . Results on individuals will not be published or appear inany working documents.If you have any questions please feel free to contact Morris Barer at228-5992 or Nino Pagliccia at 228-5009.Thank you in advance for your cooperation.William A. Webber, M.D .Dean, Faculty of MedicineUniversity of British Columbia: kcEncl .Morris L. Barer, Ph .D.Associate DirectorDivision of Health ServicesResearch and DevelopmentTHE UNIVERSITY OF BRITISH COLUMBIA~400 - 2194 HEALTH SCIENCES MALLVANCOUVER, B.C., CANADAV6T lZ6A-3OFFICE OF THE CO-ORDINATOR, HEALTH SCIENCESDivision of Health Services Research and DevelopmentP. A. Woodward Instructional Resources CentreTelephone: (604) 228-4810Dear Respondent:January 15, 1987Re: "Supply of and Requirements for AcademicMedical Manpower" studyIn late November 1986, a questionnaire regarding your academicactivities during 1985/86 was mailed to you. To date, over 60 percent ofyour colleagues have sent us completed questionnaires. This response hasbeen gratifying. However, it still leaves us well short of our goal. Ourrecords show that we have not yet received your completed questionnaire.We are very aware of the considerable demands placed on the time ofthose to whom this questionnaire was sent. It was with that in mind thatwe attempted to design a questionnaire that was easy to follow, and thatwould require very little respondent time. We are taking this opportunityto ask, once again, for your assistance with this project. The onlyinvolvement we ask for is the completion of the questionnaire. We wouldreiterate that the usefulness of the results from this survey will beseverely compromised by .any significant extent of non-response.On the chance that you misplaced (or our mail service misdirected) thecontents of the earlier mailing, we are enclosing another complete packagefor you (including the November letter). We look forward to your earlyresponse. (If you have responded since the time this was mailed, pleasedisregard this second mailing.)Thank you once again for your support.Yours sincerely,William A. Webber, M.D.DeanFaculty of MedicineMorris L. Barer, Ph.D.Associate DirectorDivision of Health ServicesResearch and DevelopmentTHE JOHN F. McCREARY HEALTH SCIENCES CENTREA-4ACADEMIC MEDICAL MANPOWER STUDYSUPPLY OF ACADEMIC TIMEOFFICEUSEONLYNAME (optiona1)Surname First Name Second Name1 - 4PERSONALMale 0 0 U 51- Sex: Female2- Year of birth: 19 LJ 6 - 7EDUCATION3- In which specialty or professional discipline didyou complete your training?4- From which medical school have you received themajority (more than half of the training time) ofyour training that led to the specializationabove?- If in Canada, givename of medical school- If abroad, givecountry onlyLJLJU8 - 910 - 11125- When did you comp2ete the training mostrelevant to your current professionalactivities?19(Continued ••• )LJ 13 - 142EMPLOYMENTA-5OFFICEUSEONLY6- During the last year Sept. 1985 - Aug. 1986 were youa UBC faculty member? (If you were retired check theappropriate box)Yes o No 0 Retired D u 15If No, thank you for your assistance. Please returnquestionnaire in the enclosed self-addressedenvelope.If Yes or retired, please continue.7- In which Department were you?8- In which Division were you?(if applicable)W 16 - 17W 18 - 199- What was your faculty category?- University full-time faculty- University part-time faculty- Clinical facultyTIME DISTRIBUTIONDoDu 2010- For how many weeks were you involved inprofessional activities during the yearSept. 1985 - Aug. 1986?(do not include vacation)11- How many hours per week did you work on theaverage in all your professional activitiesduring those weeks? (excluding "on call" timeduring which you were not clinically active)(Continued ••• )W 21 - 22U 23 - 25A-6 312- For the year Sept. 1985 - Aug. 1986, please indicatethe average percentage of your WEEKLYprofessional working time spent on each of theactivities listed below.[WE UNDERSTAND THE DIFFICULTY OF SEPARATING TEACHING,RESEARCH AND PATIENT CARE TIME WHEN ACTIVITIES AREPERFORMED JOINTLY, BUT WE ASK YOU TO USE YOUR BESTJUDGEMENT IN ALLOCATING THE PROPORTION OF JOINTACTIVITY THAT CORRESPONDS TO EACH OF TEACHING,RESEARCH AND PATIENT CARE.], of yourweeklytime-Private practice (excluding "oncall" time during which you werenot clinically active) ••••••••••••OFFICEUSEONLYU 26 - 28-Patient care related to teaching,research or other activities asfacul ty member .-Teaching as a faculty member ••••••-Research as a faculty member ••••••(Include administrative activitiesthat are part of research)i..;uu29 - 3132 - 3435 - 37-Administration .a s a faculty member.(Include administrative activitiesrelated to education or otheruniversity responsibilities otherthan research)-Other activities as faculty member(please specify)-Other professional activitiesother than as faculty member(please specify)-Total weekly time.................. 100\(The percentage of weekly time spenton all activities should add up to100\)(Continued ••• )U 38 - 40U 41 - 43U 44 - 464REMUNERATION13- For the year Sept. 1985 - Aug. 1986, pleaseindicate the distribution of your sources ofprofessional income by using the appropriate code(s)given below. (Please bear in mind that the totalpercentage cannot exceed 100\)A-7OFFICE. USEONLYPercentageIf the percentage ofyour total remunerationfrom a given source is •••codes••• write this numbernext to the correspond­ing source below (13a,b)1 ­11­21 ­31 ­41­51 ­61 ­71­81 ­91 -0\10\20\30\40\50\60\70\80\90%100\o1234567891013a- Professional remuneration from orthrough university:- Academic salary (teaching,research grant, administration) ••- Patient care 5 ••••••••••••••- Teaching hospit~l••••••••••••••••- Other(please specify) _13b- Professional remuneration other thanfrom or through university:- Teaching hospital and HealthAgency •••••••••••••••••••••••••••- Various agencies such as theMedical Services Plan or theWorkers' Compensation Board .•- Other(please specify) __PercentagecodeLJ 47 - 48LJ 49 - 50LJ 51 - 52LJ 53 - 54LJ 55 - 56LJ 57 - 58LJ 59 - 60A-8 5COMMENTSPlease feel free to comment on the questionnaire or the project, or toprovide any supplemental information that you feel would assist ininterpreting the responses you have provided.THANK YOU FOR YOUR COOPERATIONPlease return the questionnairein the enclosedstamped, self-addressed envelope(no stamp necessary for campus Mail)APPENDIX BQuestionnaire for Future Academic Requirements8-1HEALTH MANPOWER RESEARCH UNITc.o OFFICE OF THI: ('OORDI!':ATORHEALTH SCIENCES ('E"IREPHO~E: (6041 228-4810Dear4th FLOOR I.R .C. BUILDINGTHE UNIVERSITY or BRITISH COLUMBIAVANCOUVER, B.C., CANADAV6T IZ6April 23. 1987This is the second of three questionnaires designed to gatherinformation for a study being carried out by the Division of HealthServices Research and Development, Office of the Coordinator of HealthSciences, UBC, in collaboration with the Office of the Dean, Faculty ofMedicine. The study is entitled "Supply of and Requirements for AcademicMedical Manpower in B.C."The main objectives of the study are:1 - To gather information on current academic-related activities ofphysicians in B.C.2 - To gather information on requirements for academic medicalmanpower in the province.The enclosed questionnaire is designed to gather information on the"demand side", that is, the required number of academic physicians for UBC.It is being distributed to all department heads in the UBC Faculty ofMedicine.This questionnaire should require no more than 15 minutes of yourtime. The returned questionnaire in the self-addressed envelope will betaken as your consent to participate in this phase of the study. Yourinformation and identity will be kept in strictest confidence and will onlybe accessible to researchers directly involved in the study. Responses ofindividuals will not be published or appear in any working documents.If you have any questions, please feel free to contact Morris Barer at228-5992 or Nino Pagliccia at 228-5009.Thank you in advance for your cooperation.~~c~.~--L~William A. Webber, M.D.Dean, Faculty of MedicineUniversity of British Columbia:kcEne1.Morris L. Barer, Ph.D.Associate DirectorDivision of Health ServicesResearch and DevelopmentA Research Unit for the Health Manpower Working Group, Ministry of Health, British ColumbiaB-2QUESTIONNAIRE FOR FUTURE ACADEMIC REQUIREMENTSINTRODUCTIONThe intent of this questionnaire is to solicit information from thoseDepartment Heads at UBC who are likely to have physicians as facultymembers in their departments, on requirements for faculty with training asphysicians.You are asked to provide faculty requirements, given a number ofalternative future enrolment and postgraduate complement scenarios.PLEASE NOTE THAT ALL INFORMATION ON FACULTY MEMBER REDUCTIONS ANDREQUIREMENTS REFERS ONLY TO TRAINED PHYSICIANS; FACULTY MEMBERSWITH NON-MD TRAINING SHOULD NOT BE INCLUDED HERE.Department _I . Faculty Attrition and Requirements (1986-87)D 1-2B-31 - How many faculty members who were affiliated with yourDepartment in 1985-86 are not so affiliated (forreasons of retirement, leave, other position, etc.) in1986-877Full Time (F-t)Part Time (P-t)Clinical (Clin)2 - For the current academic year Sept. 86 - Aug. 87 pleaseindicate in the following table the addition(reduction) of full-time, part-time and clinicalacademic staff complement relative to 1985-86:1 - reguired by your Department2 - achieved by your Departmentfor(a) replacement of faculty retiring or otherwiseunavailable who were active in your departmentin 1985-86;(b) changes other than for replacement, i.e.increases or reductions in class sizes, newprograms, etc.(indicate reductions in parentheses)3-45-67-8(a). .. forReplacementF-t pot Clin .(b). . . for Changes OtherThan for ReplacementF-t pot Cl in.1 - Required in 1986-87relative to actual1985-86 . ....2 - Achieved in 1986-87relative to actual1985-86 .....8-4For sections II and III of the questionnaire we will refer to thefollowing five hypothetical scenarios, corresponding to different firstyear medical school (UBe) class size.Scenario 1Enrolment of first year medical students drops at ayearly rate of 10 percent over the period 1987/88 to1990/91Scenario 2Enrolment of first year medical students drops at ayearly rate of 5 percent over the period 1987/88 to1990/91Scenario 3There is no change in enrolment over the period 1987/88to 1990/91Scenario 4Enrolment of first year medical students increases at ayearly rate of 5 percent over the period 1987/88 to1990/91Scenario 5Enrolment of first year medical students increases at ayearly rate of 10 percent over the period 1987/88 to1990/9111. Faculty Requirements (1987-88 to 1990-91)In the following table we are seeking information on estimated annualfaculty reductions, and on estimated requirements for academic medically­trained ~ faculty during the period 1987·88 to 1990-91, in each caserelative to the previous year.Reductions are any decline in the number of faculty members in theyear in question, relative to previous year, due to retirement, leave,,e t c . , but also in this context due to reductions necessitated by class orprogram changes, etc.New faculty is the number of new faculty members required to replaceexpected reductions for each year and to support new or expanded activitiesunder each of the five scenarios.For example, if you anticipate that 10 full-time faculty will leavefor one reason or another in 1988-89, and that you will need to replacethem only partially with 5 full-time and 2 part-time faculty, you wouldenter 10 under full-time faculty reductions for that year,S under full ­time new faculty and 2 under part-time new faculty. If, instead, youanticipate a net expansion of 5 full-time faculty, you would again enter 10as before, but also enter 15 under new full-time faculty.While you may feel that some of the five scenarios are very unlikelyto occur in the next four years , we ask that, for the purposes of thisquestionnaire, you assume that each is the case and provide your bestestimate of the attrition and requirements for new faculty in yourdepartment , relative to the previous year.8-51987·88 1988 -89 1989·90 199u·91Faculty New fac ul ty New faculty New facul tv NewFirst Year Reduction Faculty Red uction faculty Reduction facult.y Reduct i on facult.yEnrolment.: full IPart 1 FulllPart I f ull IPart I Full IPart I FulllPartl FulllPartl Full IPart I FUll IPar t ITae ITiae Cl1n Tille ITille IClin Ti lle ITi lle IClin Time ITille Ien n Tilie lTilielClin Tille ITime 1Clin Ti lle ITi De Clin Ti lle ITimeICl1 nScensrio 1 I I I I I I I I I I I"Average Annual I I I I I I I I I I IDrop of 10'" I I I I I I I I I I IScenarip 2 I I I I I I I I I I I"Average AnnUAl I I I I I I I I I I IDrop of 5' I I I I I I I I I I IScenario 3 I I I I I I I I I I I"No Change" I I I I I I I I I I IScenario 4 I I I I I I I I I I I"Average Annual I I I I I I I I I I IIncreau of 5'" I I I I I I I I I I IScenario 5 I I I I I I I I I I I'Average Annual I I I I I I I I I I IIncrease of 10'" I I I I I I I I I I I1-2 ~. ~6 1-1 ..10111-12 13-1.IIS-1611l-1l 19-20I 21-22123-24 2S-Z6 I 21-281 29-30 31-321 ]]-~ 13S-36 31-3113'....01.1 ....2 43"'"I OS46I41"'"B-6III . Likelihood of ScenariosWe would like to ask your personal oplnlon on the likelihood ofoccurrence of each first year enrolment scenario over the next four year s .For each scenario, please check (j) the statement that most accuratelyreflects your opinion.Very 50-50 VeryUnlikely Unlikely Chance of Likely Likelyto Occur to Occur Occurring to Occur to Occur1 2 3 4 5Scenar io 1"Average AnnualDrop of 10%"Scenario 2"Aver age AnnualDrop of 5%"Scenario 3"No Change"Scenario 4"Average AnnualIncrease of 5%"Scenario 5"Aver a ge AnnualIncrease of 10%"4950515253APPENDIX CFull-Time Clinical Income Cutoffs,by Type of Practice, 1985-86Appendix CFull-Time Clinical Income Cutoffsby Type of Practice, 1985-86C-lType of PracticeGeneral PracticeDermatologyNeurologyPsychiatryObstetrics and Gynaeco1ogyEye (Ophthalmology)Ear, Nose and ThroatSurgery - GeneralNeurosurgeryOrthopaedic SurgeryPlastic SurgeryThoracic (to includeCardiovascular)UrologyPaediatricsInternal MedicineAnaesthesia1/2 Mean52,141.1888,569.7575,743.6653,853.4188,196.78104 ,539.0185,055.9471,048.5387,227.9684,286.2380,027 .6794,322.16105,729.4452,124.8676,930.7256,828.682/3 Mean69,521. 57118,092.99100 ,991. 5471,804.54117,595.70139 ,385 .34113,407.9194,731.37116,303 .94112 ,381. 63106,703 .55125,762.87140,972.5869,499.81102,574.2975,771. 57Full-time sessional rates (MSP)*General PracticeSpecialists$80,64099,360* Based on 10 sessions per week, 48 weeks per year.


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