Physician Staffing for the VA Volume I (1991) / Chapter Skim
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5 - EXPERT JUDGMENT APPROACHES TO PHYSICIAN STAFFING
5 - EXPERT JUDGMENT APPROACHES TO PHYSICIAN STAFFING
Pages 151-220
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From page 151... ...
To implement this mandate, the committee was to appoint Advisory panels to broaden the base and range of experience and competence brought to bear in the development of the methodology. In response, the committee established 11 advisory panels: data and methodology (central to the analyses in chapters 4, 7, and 8~; affiliations (see chapter 9~; nonphysician practitioners (see chapter 10~; and six specialty and two clinical program panels, to serve as sources of professional judgment in the methodology development.
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From page 152... ...
2. In a physician requirements methodology calling for a more balanced reliance on statistically based and expert judgment-based approaches, the panels would serve as the principal source of independently derived quantitative assessments of appropriate physician staffing.
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From page 153... ...
However, this chapter focuses principally on the development of two alternative expert judgment approaches to estimating physician requirements: the Detailed Staffing Exercise (DSE) and the Staffing Algorithm Development l'~strument (SADI)
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From page 154... ...
More often, expert judgment is used to reach decisions either about the advisability of particular decisions that are intermediate to a final policy outcome, or about the advisability of the outcome itself. Scheme for Eliciting Judgments Although there are a number of variations on the theme, methods to elicit expert judgment in a way that leads (eventually)
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From page 155... ...
.. Modified Delphi Approaches Several recent expert judgment applications have drawn selectively from both the Delphi and the group interactive approaches to evolve hybrid processes for eliciting information toward consensus clevelopment.
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From page 156... ...
physician requirements, by specialty, conducted initially by the Graduate Medical Education National Advisory Committee (GMENAC)
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From page 157... ...
On the other hand, all other expert judgment applications cited earlier do use explicit decision rules to map individual judgments into a consensus position. Nearly all decision rules apply to one of three types of choice problems.
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From page 158... ...
Committee's Proposed Approach to Eliciting Expert Judgments and Reaching Consensus In light of these studies and policy applications, the committee initially determined that the specialty and clinical program panels' own estimates of appropriate physician staffing levels would be obtained through a process with the following operating characteristics. A modified Delphi approach would be developed in which panel members would independently estimate appropriate physician staffing levels (in the applicable specialty or program area only)
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From page 159... ...
The primary focus here will be on the DSE and SADI because they are new vehicles for deriving expert judgment estimates of appropriate physician staffing; as such, they played central roles in most of the panels' recommendations for how the VA ought to determine physician requirements. Although the planning for panel operations began early in the study and their interactions with the committee and the staff continued through the first six
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From page 160... ...
It was understood from the beginning that the study would focus on the major specialty and program areas prominent in the VA; hence, the committee was constituted so as to have representation in these areas. It was natural that the chairs of the six specialty and two clinical program panels be drawn directly from the committee membership.
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From page 161... ...
In the course of these meetings, written communications, and phone calls, panel members contributed numerous suggestions on improving the empirically based models (including the sentiment, expressed on occasion, that the models be discarded entirely in favor of an expert judgment approach)
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From page 162... ...
An "Ideal" Mechanism Suppose an expert panel is charged with determining physician requirements for a given specialty or program area at some VAMC. An ideal expert judgment mechanism is one that yields the same staff physician FTEE levels that would be derived if the panel had made the assessment with "complete information about
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From page 163... ...
After discussions, the committee concluded two things: First, determining physician requirements by an expert judgment process was feasible, from a cognitive as well as a group dynamics standpoint. Second, the initial instruments needed revision, aimed primarily at providing enough contextspecific information that panel members could assess, with confidence, physician requirements for a given ward, clinic, or program at a given VAMC.
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From page 164... ...
Also presented were some summary statistics: the panel's high, low, mean, and median estimates of total physician FTEE. Following discussion of these results, the panels reassessed physician requirements for VAMCs I and II, working from copies of the staffing exercises they originally submitted.
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From page 165... ...
, its CDR-recorded physician FTEE level in FY 1989, and the corresponding FTEE calculation derived from the PF model. As time permitted, there was general discussion about determining physician requirements through the DSE approach.
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From page 166... ...
, considerable dispersion may remain. Committee Evaluation In surveys completed during the postmeeting period, a majority of the members of all eight panels concluded that the DSE offers a technically feasible and methodologically acceptable expert judgment approach for denying physician requirements.
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From page 167... ...
For illustration, the medicine panel's SADI is presented, and that panel's physician activity and time estimates are summarized. Following that, the SADI approach is applied to derive physician requirements in medicine at a given facility (VAMC I)
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From page 168... ...
A Closer Look As with the DSE, the best way to understand the SADI is to examine a completed instrument, then study how it can be applied to determine physician requirements at some VAMC. In Figure 5.2, the medicine panel's SADI is presented in its entirety, indicating for each function or task that panel's high, low, mean, and median estimates of the amount of physician time required for good-quality care.
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From page 169... ...
and other contextual factors. Total physician hours required per day is the sum of hours required for all patient care and non-patient-care activities.
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From page 170... ...
The projected ADC for a given ward at a VAMC may not match exactly any of the ADC levels for which time estimates are available in the SADI, as evident in the Routine Daily Patient Care portion of Figure 5.2. For example, if the projected ADC is 35 and the highest ADC shown in the SADI is 30, an extrapolation is required to estimate physician time for 35.
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From page 171... ...
to produce new distributions reflecting both types of information. Similarly, physician time estimates from the DSE can be treated in a probabilistic fashion.
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From page 172... ...
Committee Evaluation Considering the factors noted thus far, the committee concurs with its specialty and clinical program panels that any expert judgment component in the VA physician requirements methodology should be built around application of the SADI approach, across specialties, programs, and facilities. The SADI is capable of capturing almost as much clinical detail as the DSE and is better suited for systemwide application.
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From page 173... ...
In each case, the challenge is to construct a SADI with enough detail to capture significant distinctions, while omitting factors that have little influence on physician time allocations. External Norms One other major issue that the committee asked the specialty and clinical program panels to investigate was whether there exist non-VA physician staffing standards or pattems that could be usefully applied to help determine appropriate VA physician staffing.
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From page 174... ...
secondary data on staffing available from other types of providers, the process for calculating VA physician requirements on the basis of external norms was technically straightforward and basically similar for all panels. Specifically, an organization's staffing standard for inpatient or long-term care was generally defined in terms of its ADC per physician FTEE (ADC/phy)
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From page 175... ...
When these ratios are applied to the fictitious workload data above, the physician FTEE required for inpatient and ambulatory care are 14.3 and 14.1, respectively, for a total FTEE requirement of 28.4. When the DoD and New York Health and Hospitals Corporation ratios were in fact applied to the FY 1989 workload data (suitably aggregated)
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From page 176... ...
1990. Format and conduct of consensus development conferences.
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From page 177... ...
1981. Summary Report of the Graduate Medical Education Natio''nl Advisory Committee to the Secretary, Department of Health arid Huma'' Services, September 30, 1980.
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From page 178... ...
3.6 3.64.9 2.3 1.3 2 Radiation Oncol. 4.3 4.34.3 4.3 0.0 1 Ambulatory Care 71.0 81.4129.4 20.4 41.9 6 Long-Term Care 12.4 13.922.3 8.7 3.8 4 tMean absolute deviation about the median.
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From page 179... ...
3.6 3.64.3 2.9 0.7 2 Radiation Oncol. 4.3 4.34.3 4.3 0.0 1 Ambulatory Care 95.7 93.1108.8 72.1 9.9 4 Long-Term Care 2.7 2.93.4 2.4 0.4 4 _ Mean absolute deviation about the median.
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From page 180... ...
80 PHYSICIAN STAFFING FOR THE VA TABLE 5.3 Specialty and Clinical Program Panels' SADI-Based Assessments of Physician FTEE Requirements at VAMC II Total Physiciani Panelists Panel FTEE Completing SADI Medicine 54.0 7 Surgery 37.8 6 Anesthesiology 36.9 2 Psychiatry 55.6 6 Neurology 8.6 4 Rehabilitation Medicine 6.4 5 Other Physician Specialties Laboratory Medicine 5.2 1 Diagnostic Radiology 25.0 1 Nuclear Medicine 3.1 3 Radiation Oncology 3.1 1 Ambulatory Care 52.8 8 Long-Term Care 3.1 6 tBased on panel median estimates for all SADI-included physician activities.
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From page 181... ...
EXPERT JUDGMENT APPROA CHES TABLE 5.4 Major Organizations for Exten~al-Norm Exploration 181 American Board of Internal Medicine American College of Physicians American College of Surgeons American Group Practice Association American Health Planning Association American Hospital Association American Medical Association American Society of Internal Medicine Association of American Medical Colleges Association of American Physicians Association of Professors of Medicine Cleveland Clinic Foundation Commission on Professional and Hospital Activities Department of Defense Good Samaritan Health System Group Health Association of America Group Health Cooperative of Puget Sound Harvard Community Health Plan Health Insurance Plan of Greater New York Henry Ford Health System Humana Indian Health Service Joint Commission on Accreditation of Healthcare Organizations Kaiser Permanente Medical Care Program Marshfield Clinic Matthew Thornton Clinic (Dartmouth Health Plan) Mayo Clinics Mercy Health Se~vices-Professional Services National Association of Public Hospitals New York City Health and Hospitals Corporation Ochsner Clinic Palo Alto Medical Clinic RAND
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From page 182... ...
This highly affiliated VAMC participates in a moderate amount of research and is large with total operating beds of 978 and an average daily census of 772. Your task in section A is to calculate the physician hours required from the Medicine Service for each Patient Care Area (PCA)
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From page 183... ...
time spent interactively with residents in patient care and/or teaching on the PCA Do NOT include in section A: · Night call and weekend coverage. · Physician time spent in non-patient-care-related activities such as: research off the PCA educational activities that are not related to direct patient care (such as teaching residents, or delivering lectures off the PCA)
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From page 184... ...
WARD 1: GENERALMED Beds 30, ADC 28 WARD 2: GENERAL MED Beds 30, ADC 28 WARD 3: RENAL/ENDOCRINE Beds 31, ADC 27 ADC 28 x 16* min = 448 min ADC 28 x 16 min = 448 min ADC27 x 16min = 432 min Staff physician time/patient/day (Mon-Fri)
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From page 185... ...
] Staff = 1 fellow, 1 resident Endoscopy Lab: 13 procedures per weekday Staff = 1 fellow, 1 resident, 1 tech Bronchoscopy Lab: 2 branches per weekday Staff = 1 fellow, 1 resident, 1 tech ADC 27 x 16 mitt = 432 mitt AD C 26 x 16 min = 416 men ADC 14 x 16 min = 224 mitt ADC25 x 16min = 400 min ADC16 x 16min = 256 min ADCS x 20min' = 100min ADC9 x 20min = 180 mitt ADCll x3min=33min New Admissions: l S/day x 38 min/paiient = 5~70 min 0.9 caths/day x 50 mitt = 45 mitt 0.4 PTCAs/day x 70 win = 28 mitt 13 procedures/day x 30 min = 390 mitt 2 bronchos/day x 45 mitt = 90 min TaI.AL MEDICINE PHYSICIAN HOURS REQUIRED FOR PCA 1: 4,492 min/60 min/hr = 74.87 hr Staff physician time/critical patient/day (Mon-Fri)
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From page 186... ...
86 PHYSICIAN STAFFING FOR THE VA QUESTION: PCA 1 We are interested in exactly how you used the available information to derive interrust requirements for this PCA. Please explain in this workspace any rule of thumb you used or any assumptions that will help us to understand your reasoning.
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From page 187... ...
Admissions are taken on a Daily Admissions:20 rotating basis, according to specialty. Total Intermediate SurgeryResident Specialties: Beds that Float Among Surgical Wards: 15 General Surgery 13 Plastic Surgery 1 Average Daily Census: 6 Neurosurgery 2 Thoracic Surgery 2 Occupancy Rate: 40% Ophthalmology 5 Vascular Surgery 1 Length of Stay: 27 Orthopedics 5 Urology 4 Daily Admissions: 0.2 Otolaryngology 5 UNIT DESCRIPTIONS PHYSICIAN HOURS REQUIRED (Worksheet)
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From page 188... ...
Total min = 13.6 x 30 = 408 mitt TOTAL MEDICINE PHYSICIAN WEEKDAY HOURS REQUIRED FOR PCA 2: 408 min/60 = 6.8 hr
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From page 189... ...
0.4/day Consults/Day 1.0 0.2 o o Assume 30 min/consuk Total ntin = 1.2 x 30 = 36 min TOTAL MEDICINE PHYSICIAN AVERAGE WEEKDAY HOURS REQUIRED FOR PCA 3: 36min/60 = 0.60 hr
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From page 190... ...
UNIT DESCRIPTIONS PHYSICL4~N HOURS REQUIRED (Worksheet) Consults/DaY WARD 1: CLOSED; PSYCHOTIC, SCHIZ, BIPOLAR, ORGANIC Beds 42, ADC 31, plus 2-Bed Psych Evaluation and Admission Unit, ADC 2 WARD 2: CLOSED; This ward is identical to Ward 1.
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From page 191... ...
Consults/Day WARD 5: DETOXIFICATION No residents Beds 26, ADC 23 WARD 6: OPEN; ALCOHOL REHAB 1 resident, half-time Beds 34, ADC 30 WARD 7: OPEN; DRUG REHAB 1 resident, half-time Beds41,ADC34 SPECIAL PROCEDURES: ECI PROCEDURES: 33 done in 1989 in the OR. 0.8 0.1 0.2 Assume 30 min/consult Total mitt = 6.1 x 30 = 183 min TOTAL MEDICINE PHYSICIAN AVERAGE WEEKDAY HOURS REQUIRED FOR PCA 4: 183 min/60 = 3.05 hr
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From page 192... ...
Consults/Day WARD 1: GENERAL REHAB; AMPUTEE, MUSCULAR DYSTROPHY, HEAD INJURY Beds 26, ADC 23 SPECL\L PROCEDURES: EMG SERVICE: 5/weekday l 0.4 Assume 30 min/consult Totalmin =0.4x30=12 TOTAL MEDICINE PHYSICIAN AVERAGE WEEKDAY HOURS REQUIRED FOR PCA 5: 12 min/60 = 0.20 hr
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From page 193... ...
Consults/Dav WARD 1: GENERAL SCI Beds 26, ADC 19 0.6 Assume 30 min/consuk Totalmin =0.6x30=18min TOTAL MEDICINE PHYSICIAN AVERAGE WEEKDAY HOURS REQUIRED FOR PCA 6: 18 min/60 = 0.30 hr
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From page 194... ...
= 20 min ADC 74 x 8 min = 592 min ADC 22 x 12 min = 264 min TOTAL MEDICINE PHYSICIAN AVERAGE WEEKDAY HOURS REQUIRED FOR PCA 7: .
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From page 195... ...
CLINIC DESCRIPTIONS PHYSICIAN HOURS REQUIRED (Worst) Individual Physicians Required at Clinics x Clinic Hr/Wk GENERAL MEDICINE: 1,079 per weel; 5 days per week, all day 7 residents PULMONARY: 53 per week 1 half-day per week 1 fellow, 1 resident ENDOCRINE: 23 per week 1 half-day per week 1 fellow, 1 resident METABOLISM: 27 per week 1 half-day per week 1 fellow, 1 resident CARDIOLOGY: 96 per week 1 day per week 10 residents GASTROENTEROLOGY: 48 per week 1 half-day per week 3 residents 4 sta~phys x 40 hr/wk = 160 hr 2 staf)
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From page 196... ...
Individual Physicians Required at Clinics x Clinic Hr/Wk HEMATOLOGY: 18 per week 1 half-day per week 1 fellow, 1 resident HYPERTENSION: 56 per week 5 half-days per week 1 nurse practitioner RENAL: 22 per week 1 half-day per week 2 residents DIALYSIS: 16 per week 5 days per week 1 resident RHEUMATOLOGY: 1 14 per week 1 day per week 2 residents ONCOLOGY: 70 per week 1 day per week 1 resident NEUROLOGY: 126 per week 3 half-days per week 5 residents GEN SURGERY: 103 per week 1 day per week 10 residents ORTHOPEDIC: 169 per week 5 half-days per week 3 residents 1 stafJ~phys x 4 hr/wk = 4 hr 1 staf~phys x 20hr/wk = 20hr 1 staff phys x 4 hr/wk = 4 hr 0.1 staffphys x 40hr/wk = 4hr 2 stagphys x 8 hr/wk = 16hr 2 staf~phys x 8 hr/wk = 16 hr
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From page 197... ...
1 resident I staff phys x 8 hr/wk = 8 hr 0.2staffphys x 10hr/wk = 2 hr
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From page 198... ...
15 visits are psychiatric No specialty clinics are held No residents EMPLOYEE HEALTH: 29 per day Daily, all day No residents TOTAL MEDICINE PHYSICIAN AVERAGE WEEKDAY HOURS REQUIRED FOR PCA 8: 298 hr per week . 5 days = 59.60 hr
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From page 199... ...
180 hr 2. In many facilities, this night and weekend coverage is provided without actually hiring extra FTEE because of the use of residents and backup staff physicians.
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From page 200... ...
Purchased Coverage Hours (question #2) PCA 1: Medicine PCA 2: Surgery PCA 3: Neurology PCA 4: Psychiatry PCA 5: Rehab Med PCA 6: SCI PCA 7: Long-Term Care PCA 8: Ambulatory Care TOTAL MEDICINE HOURS 4.
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From page 201... ...
How many hours of physician time would be required at this facility in an average month to fi~lf~ll these functions? Education of residents (didactic, classroom, 980 hr (l hr/day x 20 days = 20 not on the PCA)
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From page 202... ...
Subtotal Non-Patient-CareRelated FTEE: 10. Now create your Grand Total Medicine FTEE.
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From page 203... ...
For the latter cases, we seek your estimates of how physician requirements vary with respect to such variables as the volume of patients and the availability of residents and nonphysician practitioners. By systematically varying the levels of workload and nonphysician personnel, we hope to infer from your numerical responses the implicit formulas you used to relate physician time to these variables as well as the nature of the relationship between workload and staffing, e.g., linear or nonlinear.
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From page 204... ...
level below, please fill in the average number of physician hours required from the Medicine Service. Keep in mind that the daily rounds do not include new admission work-ups, since they are covered in Chart 1.
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From page 205... ...
205 Medicine Ward ADC ADC ADC ADC ADC ADC Average LOS = 71 5 10 15 20 25 Charting,High 0.33 1.25 2.50 3.75 5.00 6.25 Phone, andLow 0.10 0.50 0.50 0.75 1.00 1.00 PaperworkMean 0.23 0.80 1.50 2.00 2.75 3.25 Median 0.25 1.00 1.50 2.00 3.00 3.00 Patient andHigh 0.25 1.25 2.50 3.75 5.00 6.25 Family Contacts, Low 0.00 0.17 0.67 0.25 0.33 0.33 plus Teaching Mean 0.13 0.82 0.92 1.42 1.75 2.18 Median 0.08 0.25 0.67 0.75 1.00 1.50 Supervision High 0.10 1.00 1.50 1.50 2.00 2.00 and Teaching Low 0.00 0.00 0.00 0.00 0.00 0.00 (Residents/Staff) Mean 0.02 0.27 0.67 0.70 0.60 0.60 Median 0.00 0.05 0.25 0.25 0.30 0.50 Overall Mean Time 0.61 2.25 4.51 6.59 8.16 9.71 Overall Median Time 0.65 2.35 4.35 7.00 7.00 8.00
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From page 206... ...
Mean 0.52 0.67 0.75 0.80 1.00 1.00 Median 0.50 0.75 1.00 1.00 1.00 1.00 Overall Mean Time 0.85 1.78 2.66 3.45 4.41 4.92 Overall Median Time 0.54 1.50 2.75 3.38 4.44 4.89
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From page 207... ...
Mean 0.50 0.45 0.58 0.75 0.83 0.92 Median 0.50 0.50 0.83 0.75 0.75 1.00 Overall Mean Time 0.94 1.82 2.70 3.54 4.29 4.95 Overall Median Time 0.99 1.75 2.63 3.50 4.50 5.00
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From page 208... ...
(When the resident is present, assume that he/she is performing the consult under the supervision of an attending physician.) Chart 5 Time per Consult Without Resident Consultation off your PCA Time per Consult With Resident High Low Mean Median High Low Mean Median Neurology 1.00 0.50 0.73 0.75 0.75 0.25 0.47 0.50 Surgery 1.00 0.75 0.83 0.75 0.75 0.50 0.53 0.50 Nursing Home 1.00 0.50 0.73 0.75 0.75 0.25 0.47 0.50 Intermediate 1.00 0.50 0.63 0.50 0.75 0.25 0.37 0.25 Rehab Medicine 1.00 0.50 0.70 0.67 0.75 0.25 0.40 0.37 Psychiatry 1.00 0.50 0.73 0.50 0.75 0.25 0.47 0.50 _ TIME PER FOLLOW-UP CONSULTATION OFF YOUR PCA Fill in the average time in hours required by a staff physician in your service for each follow-up consultation visit on another service, noting the presence or absence of a resident from your service.
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From page 209... ...
1.00 0.25 0.53 0.42 1.00 0.33 0.53 0.42 AMBULATORY CARE Please fill in the average time in hours required by a staff physician in your service for the average ambulatory care clinic visit by a typical patient to one of your specialty program clinics, noting the presence or absence of residents and nonphysician practitioners (e.g., a physician assistant [PA] or a nurse practitioner [NP]
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From page 210... ...
Physician Time per Visit Type of Visit High Low Mean Median New Patient Visit with NP or PA Follow-Up Visit No Resident Follow-Up Visit with Resident Follow-Up Visit with NP or PA 1.00 0.33 0.67 0.70 0.33 0.25 0.30 0.33 0.33 0.08 0.22 0.25 0.33 0.08 0.25 0.25 .
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From page 211... ...
211 cd o ;> - ~ ed a ~ mu of ·~ o .O o u)
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From page 214... ...
Ward 1: ADC = 26: 5.08 hr3 Ward2: ADC=31: 5.10hr3 Ward 3: MICU w/ADC = 6: 3.07 hr4 Ward 4: CCU w/ADC = 6: 3.07 hr4 Ward 5: Bone Marrow Transplant Unit (BMTU) w/ADC = 5: 2.63 hr5 Since VAMC I is a highly affiliated, research-intensive facility, all physician time estimates assume resident availability.
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From page 215... ...
The former is supplied by the VAMC; the latter is from Chart 7 of Figure 5.2. Cardiac Caths: 1.5 Caths/day x 1.50 hr/cath = 2.25 hr Endoscopies: 6 Endos/day x 0.70 hr/endo = 4.20 hr Bronchoscopies: 3.5 Bronchos/day x 0.87 hr/broncho = 3.03 hr Subtotal for Special Procedures = Subtotal for Medicate I'lpatie~lt PCA: 9.48 hr 40.04 hr/day Consultations Physician hours is the product of consults per day and the panel's median estimate of physician time per consult, given resident availability.
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From page 216... ...
9Based on median consult times to surgery service, since SCI not included in current medicine SADI.
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From page 217... ...
Initial: Follow-up 3.6 visits x 0.70 hr/visit 14.4 visit x 0.25 hr/visit Subtotal Cardiology: 13.6 visit/day7 Initial: Follow-up: 2.72 visits x 0.50 hr/visit 10.88 visit x 0.25 hr/visit Subtotal Dermatology: 17 visit/day7 Initial: Follow-up: 3 .40 visits x O.50 hr/visit 13.60 visit x 0.25 hr/visit Subtotal Endocrine: 6.4 visit/day7 Initial: Follow-up: 1.28 visits x 0.50 hr/visit 5.12 visit x 0.25 hr/visit Subtotal 217 = 10.00 hr = 20.00 hr 30.00 hr/day = = = = 2.52 hr 3.60 hr 6.12 hr/day 1.36 hr 2.72 hr 4.08 hr/day 1.70 hr 3.40 hr S.lOhr/day 0.64 hr 1.28 hr 1.92 hr/day reassume 20 percent of ambulatory care visits involve new patients and 80 percent are for follow-up. Physician times per ambulatory visit are in Chart 8 of Figure 5.2.
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From page 218... ...
218 PHYSICLlN STAFFIN'G FOR THE VA Gastrointestinal: 8.4 visit/day7 Initial: 1.68 visit'° x 0.50 hr/visit Follow-up: 6.72 visit x 0.25 hr/visit Subtotal Hypertension: 8.4 visit/day7 NPs available. Initial: 1.68 visit~° x 0.70 hr/visit Follow-up: 6.72 visit x 0.25 hr/visit Subtotal Pulmonary: 12.6 visit/day, Initial: 2.52 visiti° x 0.50 hr/visit Follow-up: 10.08 visit x 0.25 hr/visit Subtotal Renal: 4.8 visitlday7 Initial: 0.91 visit'° x 0.50 hr/visit Follow-up: 3.84 visit x 0.25 hr/visit Subtotal Dialysis: 10.6 visitlday7 Initial: 2.12 visit~° x 0.50 hrlvisit Follow-up: 8.48 visit x 0.25 hr/visit Subtotal Rheumatology: 7.6 visit/day7 Initial: 1.52 visit'° x 0.50 hr/visit Follow-up: 6.08 visit x 0.25 hr/visit Subtotal 0.84 hr 1.68 hr 2.52 hr/day 1.18 hr 1.68 hr 2.86 hr/day 1.26 hr 2.52 hr 3.78 hr/day 0.48 hr 0.96 hr 1.44 hr/day 1.06 hr 2.12 hr 3.18 hr/day 0.76 hr 1.52 hr 2.28 hr/day
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From page 219... ...
that VAMC I, Compensation and Pension Examinations are not performed by VA staff physicians, but externally through contract arrangements.
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From page 220... ...
lead to an overall median estimate of 54% for the percentage of total medicine service time allocated to these activities.'4 Hence, total THEE for the medicine service at VANIC I = 17.6/(1 - 0.54) = 38.3 This implies that about 38.3 x 0.34 = 13.0 FTEE would be devoted to research, and 38.3 x 0.08 = 3.1 FTEE to continuing education.
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