An overview of the history of medical education shows that addressing compensation for teaching is not a new challenge. Abraham Flexner recognized that teachers of medicine could not be solely compensated from student tuition and many models of cross subsidization of the teaching mission from the clinical practice have occurred in the evolving health care system during the last century.1 Medical school-wide efforts to measure the quantity and quality of the academic activities—including education—of faculty were undertaken in the later part of the last century in an effort to rationally allocate funds that had been intended for the educational mission of the medical school2,3 and to create faculty compensation programs that included educational activities.4 Departmental-level compensation efforts developed concurrently with these school-wide efforts and a systematic review of the impact of these programs showed that faculty members were generally satisfied with them and that the impact on the educational mission was negligible in the few instances where it was evaluated.5 One evaluation of compensation in an internal medicine program that was solely focused on clinical outcomes found that the faculty expressed less interest in engaging in teaching.6
Efforts to measure surgeon contribution to education were motivated by the sense that teaching was undervalued by most departments of surgery.7 An early effort to catalogue important surgical education activities was developed to assist surgeons who were seeking promotion and tenure.8 A more detailed effort to measure contributions to the educational mission in a department of surgery was developed for the purpose of giving faculty awards.9 One department of surgery developed a system designed to measure and reward financially academic activities related to teaching and educational leadership. The program was evaluated after three years of implementation, finding that the majority of faculty members were satisfied with the program and faculty reported decreasing involvement in the designated academic activities over time. This may have been due to the fact that the actual compensation that faculty derived from their participation in academic activities was low compared to compensation derived from clinical activities.10
Efforts to measure educational activities for the purpose of creating faculty compensation have been motivated by the genuine and pragmatic concern of protecting one of the fundamental missions of academic medicine. What has been absent in academic medicine scholarship about faculty satisfaction with these programs is a conceptual framework drawn from theories that inform compensation satisfaction research outside of academic medicine.
The major theories in use in compensation satisfaction research are equity theory and discrepancy theory.11 Equity theory posits that individuals evaluate the fairness of their compensation based on their perception of the effort required to complete and the compensation associated with them compared to this input/output of peers. Discrepancy theory hypothesizes that pay satisfaction is a result of the employee’s sense of fairness when comparing what they are paid with how they believe they should be compensated.
Another reason cited as a motivation to create academic faculty compensation programs is that they incentivize faculty to perform activities they would not otherwise perform. This is challenged by the finding that extrinsic rewards do not serve as a powerful motivator for innovative individuals doing complex work.12 This weak relationship between compensation as an extrinsic reward has been shown in a study of teaching activities amongst primary care faculty.13 Another major gap in the published experience with efforts to quantitate and compensate educational contributions is the cost of the system that must be developed to create and manage this process.
