임상실습 교육에 참여해준 것에 대한 보상으로 돈(Money)이 얼마나 중요할까?

How Important Is Money as a Reward for Teaching?

Antoinette S. Peters, PhD, Kathleen N. Schnaidt, Kara Zivin, PhD,

Sheryl L. Rifas-Shiman, MPH, and Harvey P. Katz, MD

배경

현재, 대부분의 미국 의과대학은 외래에서 이뤄지는 일차진료 기반 임상실습을 진행하고 있다. 그럼에도 불구하고 일차의료의사는 이같은 학생 교육에 대해서 - 완전히 못해먹겠다는 수준은 아니더라도- 상당한 부담을 느끼고 있다. 따라서 지속적으로 본과3학년 학생에게 적절한 학습경험을 심어줄 수 있는 일차의료의를 찾아서 모집할 필요가 있다.

Currently, almost all U.S. medical schools offer office-based primary care clerkships. Yet, primary care doctors are under such great pressure for productivity that teaching becomes a burden, if not a downright impossibility. Thus, there is an ongoing need to identify and recruit primary care physicians who can provide a sound educational experience for third-year medical students.

교육과 임상 생산성간의 긴장관계는 어떻게 동기부여를 하고 어떻게 보상을 줄 것인지에 대한 관점을 지배하고 있으며, 학교는 교육에 대해 "돈을 주는" 방법을 사용함으로서 학생 교육때문에 감소하는 임상수입을 경제적으로 보상해주고자 하고 있다. 비록 의과대학에서는 교육에 참여하는 일차의료의에게 보상을 해주는 경우가 많긴 하지만, 의과대학과의 관계를 보여주는 현판을 붙여준다거나, 무료 CME프로그램을 제공한다거나 하는 것 중에서 임상 수입을 대체할만큼 충분한 것은 거의 없다.

This tension between teaching and clinical productivity has led to changes in perspective on motivators and rewards for teaching, and to recommendations that schools pay “hard” money for teaching 1 to relieve faculty from the burden of financially supporting themselves through clinical dollars.2 Although medical schools commonly reward primary care physicians who teach in their offices with academic appointments, plaques identifying their relationship to the medical school, and access to free CME programs, few have been able to pay enough for teaching to replace clinical income.3,4

 

지금까지의 연구를 살펴보면, teaching practice는 nonteaching practice보다 비용이 30~40%정도 더 들어가며, 학생이 있으면 환자를 두 배 정도 더 길게 보게 된다. 따라서 하루에 보는 환자 수가 줄거나, 의사는 더 오랜 시간 진료를 하게 된다. 따라서 교육의 비용은 개별 의사가 감당하게 되는 것이다. 그럼에도 불구하고 많은 의사들은 교육을 통해 개인적 만족을 얻는다고 보고하고 있으며, 돈의 가치보다 교육의 기쁨을 더 높은 가치로 평가하기도 하기 때문에, 우리는 교육에 대한 보상으로서의 금전적 지급이 과연 필요한지 생각해볼 필요가 있다.

Research has shown that teaching practices cost between 30% and 40% more to operate than nonteaching practices,4–6 patient encounters are approximately twice as long when a student is present,6,7 and either fewer patients are seen and/or the physician’s day is extended.4 Therefore, both the practices and the individual physicians absorb the costs of teaching. Despite this, because many physicians report that they teach for personal satisfaction and rate the value of money lower than the pleasure of teaching,3,7–11 we must ask whether payment for teaching is necessary.

 

동기부여를 하는 요인과 보상이 갖는 효과는 복잡하다. 심리학자들은 외적 보상이 과연 필요한가, 그것이 내적 동기를 오히려 손상시키는 것이 아닌지, 만약 필요하다면 얼마나 즉각적으로 또는 자주 또는 직접적으로 지급되어야 효과적인지를 연구해왔다. 대표적인 연구를 보면 Herzberg는 금전적 인센티브의 효과성을 연구한 바 있는데, 직무만족도와 동기부여는 직무불만족을 야기하는 요인들과 분리되어 있으며 별개의 것(separate and distinct)한 것이라고 밝혔다. 동기부여와 만족을 유도하는 Needs는 내재적인 것이며, "인간의 고유한 특성으로, 성취를 달성하고, 이러한 성취를 통해서 심리적 성장을 경험하는" 것이라 했다. 불만족을 야기하는 것은 "직무 외적인(extrinsic to the job)"것으로 "근무조건, 봉급, 직위, 안정성" 등이라고 하였다.

The effect of motivators and rewards is complex. Psychologists have asked whether extrinsic reward is necessary at all, whether it undermines intrinsic rewards,12 and, if it is needed, how immediate, frequent, and direct it must be to be effective.13 In a seminal article on how to motivate employees, Herzberg 14 explored the effectiveness of monetary incentives. He concluded that job satisfaction and motivation stem from needs “separate and distinct” from those leading to job dissatisfaction. Needs leading to motivation and satisfaction relate to an intrinsic and “unique human characteristic, the ability to achieve and, through achievement, to experience psychological growth.” Those leading to dissatisfaction are “extrinsic to the job”—negative “working conditions, salary, status and security.”

 

오늘날의 일차의료는 이 두 가지를 모두 필요로 한다. 환자 및 학생을 위한 폭넓은 정보와 긴밀한 관계를 필요로 하면서, 더 많은 시간 근무하여 환자를 봐야 한다. 따라서 일차의료의들이 교육의 만족과 보상의 요구 사이의 균형을 어떻게 맞추는지 볼 필요가 있다.

Today’s practice of primary care involves both sets of needs: a breadth of content and close relationships with patients and students (achievement and recognition), but also long work hours during which one must see many patients to meet the demands of insurers.15 It is important, then, to understand the complex nature of how primary care physicians balance the need for satisfaction of teaching with the need for compensation.

하버드 의과대학은 지난 10년간 Longitudinal한 9개월짜리 일차의료 임상실습을 도입해서 진행해왔다. 1997년 이것이 처음 도입되었을 때, 학생을 지도해주는 의사에게 600$를 지급하였다. 그러나 4시간짜리 세션을 27번 하는 것을 감안하면 이것은 그 시간의 비용에 대한 보상 치고는 보잘것없는 것이었다. 또한 임상실습을 담당하고 있는 입장에서 항상 지도해줄 의사를 모집하는 것은 쉬운 일이 아니었고, 그래서 보상금을 올려줌으로서 지도 의사들의 재정 부담을 덜어주고, 우리 입장에서의 모집 부담을 줄일 수 있을 것을 기대했다. 2003년에는 900달러, 2004년에는 2500달러로 높였다.

Harvard Medical School has offered a longitudinal, nine-month primary care clerkship for the past 10 years.16 From its inception in 1997, the clerkship paid preceptors a $600 stipend. However, for 27 four-hour sessions, this was more a token of appreciation than compensation for lost revenue. Because those of us in charge of the clerkship have always found it difficult to recruit enough preceptors to teach between 120 and 150 students each year, we hoped that raising the amount of the stipend would ease the financial burden for preceptors and, consequently, help us retain them as faculty. With cooperation from our deans, we raised the stipend to $900 in 2003 and then to $2,500 in 2004.

이 연구에서, 보상금의 증액과 faculty의 retention사이의 관계를 보고자 하였으며, 추가적으로 이 faculty들을 대상으로 (1)외적 보상 및 동기부여와 내적 보상 및 동기부여의 가치, (2)직접 받는 것과 간접적으로 받는 것의 가치를 보고자 했다.

In this study, we examine the association between the rise in stipend and retention of faculty. Additionally, we explore faculty members’ perceptions of the relative value of (1) an external reward or motivator (the stipend) and internal rewards and motivators, and (2) receiving the stipend directly or indirectly.

방법

Analyses

Because we informed faculty of the stipend upon recruiting them, and because we paid them at the end of the clerkship, we assume that the stipend is both a motivator and a reward. Therefore, we computed the annual retention rates and the average retention rate for each stipend period (i.e., when the stipend was $600, $900, and then $2,500) as well as in the year after the rise in stipend (i.e., when the stipend changed from $600 to $900, and again when it changed from $900 to $2,500). We examined the relationship between change in stipend and the proportion of faculty we lost each year either because they were unavailable or they declined to teach versus the proportion of those who were willing to teach, whether or not they were matched to a student. Then, on the basis of physicians’ availability to teach, we conducted logistic regressions to estimate the odds of returning after each rise in stipend using general estimating equations to account for correlation within physician.18,19

 Further, we examined the frequency of rankings as well as the mean rank-order of factors involved in decisions to continue teaching and sources of satisfaction with teaching; we conducted t tests to determine the relationship between these rankings to teaching status (declined versus retained), and directness of payment (direct versus indirect). All statistical tests were conducted with a significance level of P < .05.

결과 : 

retention rate는 2006년에 91%로 높았고, 2000년에 69%로 낮았다. faculty들은 가장 적은 보상이 주어졌던 시기보다 가장 많은 보상이 주어졌던 시기에 2.66배 더 많이 교육을 지속하고자 했으며, 직접적으로 보상을 받은 경우에 더 교육을 지속하고자 했다. 응답한 170명의 faculty중 8%만이 교육을 지속하는 요인으로 있어서 보상금이 가장 중요하다고 응답했으며, 만족을 주는 근원 중 1순위로 보상금을 뽑은 의사는 아무도 없었다. 그러나 73%는 좋은 학생을 받는 것이 교육을 지속하는 첫 번째 요인이라고 응답했고, 82%는 이것이 만족의 제1 요인이라고 응답했다.

Results: Retention rates varied from a high of 91% in 2006 to a low of 69% in 2000. Faculty were 2.66 times more likely (P < .0001) to return to teach in the highest pay period than the lowest, and faculty receiving direct payment were more likely to continue teaching than those receiving it indirectly. Only 8% of the 170 responding faculty ranked receiving the stipend as the most important factor in their continuing to teach; no one ranked it first as a source of satisfaction. However, 73% ranked having a good student first as a factor in continuing to teach; 82% ranked it first as a source of satisfaction.

결론 : 

보상금을 올리는 것이 retention을 높이는 것과 상관관계가 있었으나, 교육을 하는것에 대한 동기부여 요인으로서 보상금은 낮은 순위에 있었다. 

Conclusion: Raising stipends was associated with increased retention, although faculty ranked stipend low in terms of what motivates them to continue teaching.

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Acad Med. 2009 Jan;84(1):42-6. doi: 10.1097/ACM.0b013e318190109c.

How important is money as a reward for teaching?

Peters AS1, Schnaidt KN, Zivin K, Rifas-Shiman SL, Katz HP.

Author information

Abstract

PURPOSE:

To examine the effect of increases in payment for teaching on retention of primary care faculty, and to compare those faculty members' needs and rewards for teaching with objective data on retention.

METHOD:

In 2006-2007, the authors compared retention rates of primary care clerkship preceptors at Harvard Medical School (1997-2006) when their stipends were raised from $600 to $900 (in 2003) and to $2,500 (in 2004), and when faculty received payment directly versus indirectly. A survey was sent to all 404 present and past living preceptors, who were asked to rank-order six factors in terms of (1) how much they needed each to continue teaching, and (2) each factor's contribution to their satisfaction with teaching.

RESULTS:

Retention rates varied from a high of 91% in 2006 to a low of 69% in 2000. Faculty were 2.66 times more likely (P < .0001) to return to teach in the highest pay period than the lowest, and faculty receiving direct payment were more likely to continue teaching than those receiving it indirectly. Only 8% of the 170 responding faculty ranked receiving the stipend as the most important factor in their continuing to teach; no one ranked it first as a source of satisfaction. However, 73% ranked having a good student first as a factor in continuing to teach; 82% ranked it first as a source of satisfaction.

CONCLUSION:

Raising stipends was associated with increased retention, although faculty ranked stipend low in terms of what motivates them to continue teaching.

PMID:

 

19116476

 

[PubMed - indexed for MEDLINE]