Incentives for Teaching Psychiatry

David Bienenfeld, M.D., Ronald Markert, Ph.D. John Rudisill, Ph.D., Paulette Gillig, M.D., Ph.D. James A. Bourgeois, M.D., William Klykylo, M.D.

Brenda Roman, M.D., Barbara Warner, M.D. ]erald Kay, M.D.

A questionnaire was sent to chairs and faculty in 137 academic departments of psychiatry regarding the methods used to promote teaching and their perceived value. The incentives most often used included promotion and retention, nomination to committees, and peer rec­ognition. Least often used were bonuses and a designated teachers' career track. Chairs and their faculty often disagreed as to whether some incentives were being used at all. Recogni­tion of teaching excellence was generally most highly valued as a useful incentive. Clarifica­tion of the nature and purpose of teaching incentives would likely improve their effectiveness. (Academic Psychiatry 1997; 21:91-97)

Economic pressures on schools of medi­eine, sponsoring hospitals, and depart­

ments of psychiatry make the commitment to teaching a struggle. Research brings grant money that teaching does not. Educators must devote increasing fractions of their time to clinical activities that generate reve­nues, and the accelerating pace of patient care drains ever more time and energy from the teaching task (1,2).

At the same time, the need for academic departments to provide quality teaching is becoming more profound. The expansion of the scientific and clinical knowiedge base to be conveyed to students and residents re­quires more of the educator than ever before. Even as the knowiedge base is growing, the number of applicants to psychiatrie resi­dency programs has been shrinking (3). The 1992 Recruitment Conference issued a num­ber of recommendations to enhance recruit­ment of students into the fieId; most of these encouraged more attention to teaching (4).

Good teachers are both bom and made (1). Although motivation for teaching is

primarily intrinsic, a function of individual taste and temperament, departments can do a great deal to encourage teaching by their faculty (5,6). With the endorsement of the American Psychiatrie Association's Counci1 on Medical Education and Career DeveIop­ment, the American Association of Directors of Residency Training, and the Association of Directors of Medical Student Education in Psychiatry, we sought to examine the role of

Dr. Bienenfeid is associate professor, vice chair, and director of residency training, Department of Psy­chiatry; Dr. Markert is professor, Department of Medi­eine; Dr. Rudisill (at the time of the study) was professor, Department of Psychiatry; Dr. Gilligis associate pr0fes­sor, Department of Psychiatry; Dr. Bourgeois (at the time of the study) was resident, Department of Psychi­atry; Dr. Klykylo is associate professor, Department of Psychiatry; Dr. Roman is assistant professor, Depart­ment of Psychiatry; Dr. Wamer is associate clinical pr0-fessor, Department of Psychiatry; Dr. Kay is professor and chair, Department of Psychiatry; all at Wright State University School of Medieine. Address reprint requests to Dr. Bienenfeid at Department of Psychiatry, Wright State University School of Medieine, Box W, Dayton OH 45401-0927.

Copyright e 1997 Academic Psychiatry.

\l \1)1 \1/1. I''>HI!I \11\\ 'I

1'\ l 1 '\ 1 1\ 'I .., 1 l ) I~ 11 \ l 111 '\ ( ,

psychiatric departments in providing incen­tives for teaching. Our first aim was to com­pile an inventory of those mechanisms and processes currently in use. Our second aim was to assess the perceived value of those mechanisms to both faculty and department chairs.

METHOOS

A survey was designed listing 27 incentives (listed in Table 3) for teaching psychiatry to medical students and residents. These were grouped into five clusters: salary and promo­tion, status and authority, perks, recognition of teaching exceUence, and facilitation of teaching. Respondents were asked to rate each incentive as "not at aß useful," "a little useful," "moderately useful," "very useful," or "not used," to foster teaching.

The survey was sent to the chairs, as the representatives of the academic leadership of their departments, and to directors of resi­dency training (ORT) and directors of medical student education (OMSE) as representatives of the teaching faculty at the 137 departments of psychiatry in the United States and Canada whose chairs are members of the American Association of Chairmen of Departments of Psychiatry. Questionnaires were eoded for eonfidentiality, still aßowing a secretary to send one reminder letter to eaeh ehair or faculty member who did not respond.

To comPare the perceived value of the ineentives, ratings were assigned values from 1 for "not at aß useful" to 4 for "very

useful." Responses of "not used" were not included in these ealculations. The chi­square test was used for eomparisons involv­ing eategorieal data; the McNemar test, for eomparisons of ehairs and their own faculty for the presenee or absence of a particular incentive; and the paired t-test and Spear­man eorrelation for eomparisons between chairs and their faculty on the pereeived value of ineentives. Inferences were made at the P:S; 0.05 level of signifieanee, with Bonferroni adjustment for multiple com­parisons.

RESULTS

Respondents

Of 137 departments surveyed, responses were received from 74 chairs (54%),72 direc­tors of residency training (52.6%), and 88 direetors of medical student edueation (64.2%). By use of the chi-square test, re­sponding ehairs, ORTs, and OMSEs did not differ significantly from their nonre­sponding colleagues with respect to public vs. private affiliation, nor to geographie loca­tion (Northeast, Midwest, South, and West) (Table 1).

Demographie charaeteristies of the re­spondents are displayed in Table 2. Chairs were 98.4% male and %.6% tenured; 92.1% carried the rank of professor, with a mean of about 15 years of faculty experienee. Diree­tors of residency training were 81.5% male, 50.8% tenured, most commonly associate

TADLEt. Ratio oi respondel'8:noru:espondel'8 by position, institution type, and region

Otairs ORTs OMSEs

Public 60:40 x2 = 1.42, df = 1, 55:45 x2 = 0.44, df = 1, 61:39 x2 = 0.50, df = 1, Private 18:19 P = 0.234 18:19 P = 0.508 25:12 P = 0.480

Northeast 18:16 x2 = 1.42, df = 3, 14:20 x2 = 3.34, df = 3, 17:17 x2 = 3.73, df = 3, South 22:21 P = 0,702 24:19 P = 0.342 29:14 P = 0.292

Midwest 24:15 23:16 24:15

West 12:7 12:7 14:5

Note: ORT = director of residency training; OMSE = director of medical student education.

'I.'. \ l \1 l \11 .~I. '\l \11'1 "2. "l \1\111\ 1<1<17

1111 '\1 '\11111" \,

TABLE2. Demographics of respondents

Chair ORT OMSE

Number male (%) 60161 (98.4) 51'65 (815) 61/85 (72.9) Number tenured (%) 56158 (96.6) 32/63 (50.8) 27/81 (33.3) Academic rank, number (%)

Professor 58 (92.1) 22 (32.4) 22 (25.3) Associate professor 5 (7.9) 25 (36.8) 27 (31.0) Assistant professor 18 (26.5) 34 (39.1) Other (Instructor, 0inica1 Assistant/

Associate Professor) 3 (4.4) 3 (45)

Years on facu1ty (mean ± SO) 15.0 ± 8.2 9.9±6.4 9.6 ± 6.6

Note: ORT = director of residency training; OMSE = director of medica1 student education.

professors, and served a mean of 9.9 years on faculty. Directors of medical student educa­tion were 72.9% male, 33.3% tenured, more commonly assistant professors, with a mean of 9.6 years of faculty experience.

Incentives Used

The first objective of the survey was to catalog the frequency with which various incentives are used to foster teaching. For this purpose, the response of the chair was taken as the standard for each institution. Results are shown in Table 3. Of the 27 incen­tives listed, chairs indicated they were used with the same frequency to promote resident and medical student education, with a differ­ence of 2% or less, except for two items: awards by residents were used to encourage resident teaching at 91 % of the responding institutions and to foster medical student teaching at 66%. Nominations for college or university teaching awards were used to re­ward medical student teaching at 78% of institutions and resident teaching at 73%.

Most commonly used to reward teach­ing were formal provision of student feed­back; academic promotion; peer recognition; promotion to positions of authority within the department; nomination to college, university, and departmental committees; retention and recruitment; and inclusion in the socia1 sphere of influence within the de­partment. Least often used were bonuses, a

designated career track for teachers, and raises.

Without regard to the perceived value of a given incentive, it might seem that there would be consensus between chairs and their faculty about whether a given method was used at all. This assumption was, how­ever, not universally supported by the re­sponses (Table 4). By use of the McNemar test (Bonferroni-adjusted), chairs did not dif­fer to a statistically significant extent from ORTs or OMSEs regarding the use of any incentive to promote teaching of residents and students, respectively. The Bonferroni adjustment demands a very large effect size from such a small sampie and may underes­timate the degree of disagreement between chairs and faculty. It is thus intriguing that the agreement between chairs and faculty was modest in many instances. In nearly half the comparisons (25 of 54) agreement was less than 70% regarding whether the chair uses a specific teaching incentive.

Perceived Value of Incentives

The size of the sampie did not permit separate analysis of the perceived value of the 27 individual incentives. More stable es­timates were calculated by collapsing the in­centives into five broad clusters (Table 5).

Mean ratings spanned a narrow range from 2.31 to 3.16 (where 2 = "a little useful" and 3 = "moderately useful"). Recognition

\l,\IJI:-"lll 1".,)(111\11'" 'I~

I\:CT\ 11\'1 c, FOI\ [I \U II\:C

TABLE 3. Number (%) ofprograms using each incentive (as rated by chairs)

A. SaIary and Promotion 1. Raises 42 (61) 2. Bonuses 20 (31) 3. Academic promotion 68 (98) 4. Academic tenure 58 (87) 5. Academic retention 62 (91) 6. Facu1ty recruited on basis

of teaching skills 64 (91) 7. Designated track for teachers 34 (SO)

B. Status and Authority 1. Promotion to positions of

authority within the depamnent 68 (94) 2. Nomination to committees:

a. National (e.g., APA) 56 (79) b. RegionaVLocaI 58 (84) c. CollegelUniversity 63 (92) d. Depamnental 66 (93)

3. Indusion in sodal sphere of influence within the depamnent 64 (90)

4. Peer recognition 70 (97)

C. Peru 1. Travel funds 45 (73) 2. Office space 44 (70) 3. Support staff 51 (82) 4. Computers 46 (74)

D. Recognition 1. Teaching awards within the

depamnent a. By Residents •

b. By Chair/Facu1ty 2. Nomination for extra

depamnental awards a. College'University·

b. National

E. Fadlitation 1. Protected time for teaching

and preparation 2. Support for development of

teaching skills (e.g., courses) 3. Indusion in depamnental

writing projects 4. Promotion of presentations to

other institutions 5. Formal provision of

student feedback

Res 57 (91) Med 38 (66)

41 (68)

Res 45 (73) Med49 (78)

44 (76)

53 (86)

46 (79)

SO (84)

52 (86)

58 (99)

• Incentives for which Res differed from Med by more than 2%; Res = percent of programs using this incentive for resident teaching; Med = percent of programs using this incentive for teaching of medical students.

for teaching excellence was generally rated as the most useful incentive for promoting teachin& but there were no statistically sig­nificant differences for chair vs. ORT or chair vs. OMSE eomparisons. For all incentive clusters, the chairs' ratings were higher than those of their ORTs and OMSEs. Differences between chairs and ORTs reached statistical significance for the cluster of salary and pro­motion. Chairs differed significantly from OMSEs in their valuation of the salary and promotion and the status and authority clus­ters. Similarly, Spearman correlations be­tween chairs and their ORTs and OMSEs were modest with only the salary and pro­motion cluster surpassing 0.30.

DISCUSSION

Two features of this study restrict our ability to draw ambitious conclusions. First, the re­sponse rate was moderate, about 50%-60% for chairs, ORTs, and OMSEs. Although there were no important differences be­tween nonresponders in terms of program type or geographie Iocation, there may be unidentified factors that make the respond­ers less than completely representative. (For example, the respondents seem to be quite senior, with aImost 10 years of faculty experience; 25%-32% were full professors.) Second, we did not compare respondents' ratings of similar incentives for research or clinica1 work, so that there is no 11 control" for their attitudes about teaching incentives. Generalizability of the findings may thus be limited, but some conclusions may be ven­tured with confidence.

Within departments of psychiatry, the existence of a particular incentive for teach­ing may be an equivocal observation. Al­though chairs and faculty did not differ in their perception of the presence or absence of anY incentive when compared by statisti­cal standards, there were a number of items for which agreement was surprisingly low. This seeming paradox is most readily ex­plained as a difference in perception of the

<l I \ ( lJ l \ J 1 .'.1 • "l \ 11)J I, 2 • c, L \ J \ 11 1\ 1 'il);-

purpose of the method. For example, chairs may believe their departments award raises on the basis of teaching skills, while faculty, most of whom are not directly involved with the sa1ary process, may perceive that faculty are rewarded on the basis of clinical or scien­tific productivity. Similar differences in attri­bution of motive may account for the responses to questions regarding committee nominations, assignment of support staff,

1111 \:1 \:1·111) I/ \/

and promotion of extramural presentations. Committee nominations in particular may be seen by chairs as an incentive, but by faculty as a burden. It remains puzzling, however, how there could be a substantial disparity between chairs' and ORTs' or OMSEs' per­ceptions of whether or not, for example, awards by the chair or faculty are given for teaching quality.

The perceived value of an incentives, as

T ABLE 4. Chair and faculty perceptions of teaching incentives used

Chair and ORT Chair and OMSE n % agree·

A. SaIary and Promotion 1. Raises 36 61.1 45 55.6 2. Bonuses 34 70.6 43 67.4 3. Academic promotion 36 94.4 46 82.6 4. Academic tenure 35 82.9 43 81.4 5. Academic retention 34 76.5 43 79.1 6. Faculty recruited on basis of teaching skills 35 77.1 47 78.7 7. Designated track for teachers 35 57.1 46 60.9

B. Status and Authority 1. Promotion to positions of authority

within the department 37 91.9 48 83.8 2. Nomination to committees:

a. National (e.g., APA) 36 69.4 45 55.6 b. RegionaJ/Local 36 77.8 43 62.8 c. CollegelUniversity 35 80.0 43 83.7 d. Departmental 36 80.6 44 88.6

3. IncIusion in social sphere of influence within the department 37 81.1 47 78.7

4. Peer recognition 36 97.2 48 91.7 C.Perks

1. Travel funds 30 60.0 39 69.2 2. Office space 30 70.0 41 63.4 3. Support staff 30 56.7 41 78.0 4. Computers 30 60.0 41 75.6

O. Recognition 1. Teaching awards within the department

a. By Residents 29 82.8 34 61.8 b. By ChairlFaculty 27 55.6 39 56.4

2. Nomination for extra-departmental awards a. CollegelUniversity 29 62.1 40 57.5 b.National 27 70.4 38 65.8

E. Facilitation 1. Protected time for teaching and preparation 29 51.7 40 67.5 2. Support for development of teaching skills

(e.g., courses) 28 53.6 37 75.7 3. IncIusion in departmental writing projects 29 75.9 38 65.8 4. Promotion of presentations to other

institutions 28 67.9 37 67.6 5. Formal provision of student feedback 26 96.2 39 89.7

Note: ORT = director of residency training; DMSE = director of medicaI student education . • No McNemar test was significant at Bonferroni-adjusted a = 0.002 (0.05127 tests = 0.002).

'\( ,\1>1 \lll 1'<"'1'(,111.\ 11\\ 'I,

1'\ l I '\ 1 1 \J '-, I l ) I, 11 \ l I 11 \. ( ,

~~~~! V

r:::~~~~ ""<'4""';00

~~f:!~8 rt'i ~ ....1 ~ N

measured by our survey, was modest, span­ning a narrow range from slightly more than "a little useful" to IImoderately useful." This response may indicate that there is little dif­ference among the clusters we defined, and that none of them is a very powerful motiva­tor. Indeed, many educators believe that teaching is its own reward and that external incentives have only limited influence (7,8). Alternatively, the modest perception of the value of the incentive measures may reflect the same ambiguity of purpose discussed above. That is, if it is unclear to the facu1ty that a particular action is intended as a re­ward for teaching, it will not be perceived as a very useful incentive for teaching quality.

The education literature reports that promotion and pay can encourage specific goals and behaviors but not general motiva­tion to teach more or better (9). The relative effectiveness of financial incentives de­creases further at higher levels of education. Carter reported that psychiatry chairs rate teaching as the second most important of eight criteria for the promotion of tenure track facu1ty, and the most important for non-tenure track (10). In our study, chairs rated salary and promotion as most valuable for rewarding medical student teaching and second most valuable for resident teaching. The recipients of these incentives, however, had different impressions. ORTs perceived salary and promotion as only the third most valuable reward, and OMSEs found it the least useful incentive for teaching medical students. These differences between chairs and their facu1ty were statistically significant and appear to reflect an inaccurate percep­tion by chairs of the value of this cluster to their teaching facu1ty.

Recognition of teaching effort or excel­lence was rated by all three groups as the most valuable cluster of incentives. Yet chairs listed teaching awards within and out­side the department as methods used only to a moderate extent. Further, items in this clus­ter yielded fairIy Iow agreement between chairs' and faculty' s perceptions of their

'11' \ l)1 L \11 21. \.L \11l1 I,'::. ~l \1\11" 1')'1;'

presence or absence. At one level, these data would support

the further use of formal recognition of teaching excellence as a means to promote psychiatrie education. It is acknowledged by all respondents as highly valuable, and it entails very low cost to the department. At another level, the results suggest that chairs could accomplish much by improving com­munication with their faculty about the in­centives being used, and their purpose. Reward mechanisms become incentives for teaching when they are direct1y linked in the teachers' perceptions to the teaching task and when there is a dear linkage between the activity and the reward (7,8). Oarifica­tion of the availability and goals of promot­ing extramural presentations, and consensus about what constitutes protected teaching time, could allow for more direct linkage between methods and purpose, promoting the intended reinforcement.

An incentive generally works best when

References

1. Pardes H, Pincus HA: Challenges to academic psy­chiatry. AmI Psychiatry 1983; 140:1117-1126

2. BorusJ:Teachingandleamingpsychiaby.Academic Psychiatry 1993; 17:3-11

3. National Resident Matching Program: NRMP Oata, March 1994. Washington, oe, National Resident Matching Program, 1994

4. Weissman SH: Recommendations from the May 1992 conference to enhance recruitment of U.S. medical graduates into psychiaby. Academic Psychi­aby 1993; 17:180--185

5. Herzberg F: One more time: how do you motivate employees1 Harvard Business Review 1968; 46:56-57

6. Cook EP, Kinnetz P, Owens-Misner N: FacuIty per­ceptions of job rewards and instructional develop-

1;11 '.1 '.11111

it is framed in the context of the organization rather than the individual (7,8). A depart­ment that seeks to promote teaching must do so not only by rewarding particular activities by individual faculty members but also by incorporating education into the mission and value structure of the organization. Fi­nally, the findings of this study reveal an expectable heterogeneity of responses, con­sistent with the diversity of types of institu­tions sampled: public and private, from many geographie areas, reflecting a variety of academic missions and philosophies. In fact, disparate incentives are likely to appeal to different departments (6,7). Within the principles outlined, the best solutions to pro­moting psychiatrie teaching are likely to re­mainlocal.

The opinions expressed herein are solely those of the authors and da not represent the officiIll views of the Department of the Air Force, the Department of DeJense, or other federal agencies.

ment activities. Innovations in Higher Education 1990; 14:123-130

7. Johnson SM: Incentives for teachers: what moti­vates, what matters. Educational Administration Quarterly 1986; 22:54-79

8. Mitchell OE, Ortiz FI, Mitchell TI<: Work Orientation and Job Performance: The CulturaI Basis ofTeaching Rewards and Incentives. Albany, NY, SUNY Press, 1987, pp. 183-205

9. Azumi JE, Lerman JL: Selecting and rewarding mas­ter teachers: what teachers in one district think. Eie­mentary School Iournall987; 88:189-202

10. Carter RE: Criteria for the academic promotion of medical school-based psychiatrists. Academic Psy­chiaby 1992; 16:147-152

\( \[)[ \ll( [''-.) l III \ 11'1 q-