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Create a Surgical Faculty Compensation Plan that Supports the Educational Mission

David A. Rogers, MD, MHPE, FACS, FAAP

May 1, 2017

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

Measuring Surgeon Contribution to Education

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

Measuring Educational Activities

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.


  1. Barzansky B, Kenagy G. The full-time clinical faculty: what goes around, comes around. Academic Medicine. 2010 Feb 1;85(2):260-5.
  2. Johnston MA, Gifford RH. A model for distributing teaching funds to faculty. Academic Medicine. 1996 Feb 1;71(2):138-40.
  3. Watson RT, Romrell LJ. Mission-based budgeting: removing a graveyard. Academic Medicine. 1999 Jun 1;74(6):627-40.
  4. Mallon WT, Jones RF. How do medical schools use measurement systems to track faculty activity and productivity in teaching? Academic Medicine. 2002 Feb 1;77(2):115-23.
  5. Andreae MC, Blad K, Cabana MD. Physician compensation programs in academic medical centers. Health care management review. 2006 Jul 1;31(3):251-8.
  6. Summer R, Wiener RS, Carroll D, et al. Physician perception of the impact of productivity measures on academic practice. Archives of Internal Medicine. 2012 Jun 25;172(12):967-9.
  7. Dayton MT. A modest proposal regarding the orphan child of academic surgery—teaching. The American journal of surgery. 1995 Mar 31;169(3):324-8.
  8. Sachdeva AK, Cohen R, Dayton MT, et al. A new model for recognizing and rewarding the educational accomplishments of surgery faculty. Academic Medicine. 1999 Dec 1;74(12):1278-87.
  9. Schindler N, Winchester DP, Sherman H. Recognizing clinical faculty's contributions in education. Academic Medicine. 2002 Sep 1;77(9):940-1.
  10. Williams RG, Dunnington GL, Folse JR. The impact of a program for systematically recognizing and rewarding academic performance. Academic Medicine. 2003 Feb 1;78(2):156-66.
  11. Dulebohn JH, Werling SE. Compensation research past, present, and future. Human Resource Management Review. 2007 Jun 30;17(2):191-207.Baer M, Oldham GR, Cummings A. Rewarding creativity: when does it really matter? The Leadership Quarterly. 2003 Oct 31;14(4):569-86.
  12. Peters AS, Schnaidt KN, Zivin K, et al. How important is money as a reward for teaching? Academic Medicine. 2009 Jan 1;84(1):42-6.
  13. McMahon LF. Academic Practice—Against All Odds: Comment on “Physician Perception of the Impact of Productivity Measures on Academic Practice”. Archives of Internal Medicine. 2012 Jun 25;172(12):969-70.
  14. Holm EA. A view from the top: general internal medicine form the perspective of a chair and dean [interview of Lee Goldman, MD]. SGIM Forum. 2007;30(4):2-13.
  15. Pink DH. Drive: The surprising truth about what motivates us. Penguin; 2011 Apr 5.
  16. Heneman III HG, Schwab DP. Pay satisfaction: Its multidimensional nature and measurement. International Journal of Psychology. 1985 Jan 1;20(2):129-41.


General guidelines for developing a compensation program that protects and enhances the surgical education mission can be offered based on reported experience in academic medicine:

  1. The overall compensation program will substantially influence whether or not an educational component should be developed. Faculty activity is influenced by what is measured and rewarded and so it may be rational to develop a detailed educational measurement system if compensation based on clinical care is heavily influenced by work relative value units.
  2. Developing the metric used to measure educational contributions should be done by consensus and requires considerable time and effort. Most reported experiences have only sought to measure the quantity of educational effort but measures of quality should also be included.
  3. Medical schools have expanded their clinical effort so as to fund education and research missions.14 This has caused an expansion in clinical faculty which, combined with resident work hour reform, has produced a subset of faculty who have been described as “taxpayers” in that their only involvement with educational missions is to generate the clinical revenues that will fund them.15 A compensation program will need to recognize this valuable, albeit indirect, contribution to the educational mission.
  4. The administrative costs required to develop and manage these systems are not well described and the actual effect on incentivizing faculty to engage in teaching and other educational activities is not compelling. A good case can be made that extrinsically rewarding the creative work required to teach surgical learners will likely produce many negative consequences.16 Therefore, the case can be made that a better model requires some contribution to the educational mission as a part of the “citizenship” of belonging to the faculty with the details of that contribution being left to the departmental leadership and the individual faculty member.
  5. The educational value unit model is an adaptation of the clinical relative value unit system. The progressive surgical educator leader should begin to contemplate the best way to finance the surgical education mission as the fee-for-service model is disrupted by new population health finance models.

About the Author

David A. Rogers, MD, MHPE, FACS, FAAP, is a professor of surgery, pediatrics, and medical education as well as the senior associate dean of faculty affairs and professional development at the University of Alabama School of Medicine in Birmingham.