Physician Staffing for the VA Volume II, Supplementary Papers (1992) / Chapter Skim
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Other Physician Specialities Panel Report
Other Physician Specialities Panel Report
Pages 269-310
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From page 269... ...
tThe initial draft of this "port was prepared by Bobbie J Alexander,-ff Locate to the Other Physician Specialties Panel during the conduct of the study.
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From page 270... ...
Approach The first Ding of the over physician specialties panel was convened in APIA of 1990. The primary purpose was to determine whether the expert judgment panelprocess, as the study committee first conceivedit, represented a viable means for determining physician staffing for these four physician specialties at individual VAMCs.
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From page 271... ...
.~; acknowledge more clearly the potential role of residents and fellows in working with staff physicians to provide Hands on. patient care in nuclear medicine; provide greater specificity regarding the adequacy of nonphysician staffing, focusing on purses, technicianste.g., occupationalpathologist assistant, cytology technician, etc.)
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From page 272... ...
Ibis DSE is nearly identical structurally to those constricted for the four physician specialties analyzed by this panel. In Section A of each DSE, the basic question is the same for each patient care area: In hours, how much time must be contributed by physicians in the relevant specialty (laboratory medicine, nuclear medicine, diagnostic radiology, or radiation oncology, as the case may bet to meet a specified workload level during an average weekday, under certain assumptions about patient my and the availability of residents and support staff.
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From page 273... ...
From these discussions, the panel worded toward a consensus about the appropriate data, assumptions, and methodology required for expert judgment assessments of physician requirements. Strategies were discussed for reconciling He three major alternative approaches to deriving physician requirements: expert judgment, statistical modeling, and external (to the VA)
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From page 274... ...
the respondent must d~mine the total amount of physician time in that specialty Hat should be allocate to research, classroom instruction, continuing education, Ambition, and leaves of absence. To derive physician requirements in that Specialty for a given VAMC, the estimate physician hours for patient care and non-patient~e activities are summed, then converted to t-1EE under the 44)
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From page 275... ...
Under He IPF approach, the physician -ME in a given specially required for direct patient care and resident education at a VAMC is modeled as a function of the inpatient, outpatient, and long-term care workload Here, plus possibly other factors. Thus, IPFs can be estin~l expressly for laboratory medicine, diagnostic radiology, nuclear medicine, and radiation oncology.
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From page 276... ...
The principal purpose of analyzing physician requirements at these sites was model development-specifically, to test the feasibility and appropriateness of alternative staffing methodologies. It would be premature to conclude from these analyses, focusing on only three facilities, whether the VA as a whole is over- or understaffed in laboratory medicine, nuclear medicine, diagnostic radiology, or radiation oncology.
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From page 277... ...
In general, the panel found that comparing current VA staffing with that suggested by the application of such external norms was difficult because of differences in how workload and FTEE are measured, and also differences in the type of patient populations being served. CONCLUSIONS As a framework for determining physician requirements in the specialties of laboratory medicine, diagnostic radiology, nuclear medicine, and radiation oncology, the panel endorses the Disaggregate weighted-average approach to the Reconciliation Strategy (see Equation 6.1 of Volume I)
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From page 278... ...
relies heavily on staffing data from the VA's cost distribution report (CDR) , whose reliability the panel regards as variable at best, and specifically unreliable in these hospital-based specialties.2 Though the panel did not feel the need to adopt such an approach, it does see the merits of a version of the Reconciliation Strategy in which F1EE requirements are computed as a weighted average of expert judgment and statistical modeling results especially for establishing reasonable initial increments, or decrements, in physician staffing relative to the status quo.
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From page 279... ...
~9 , ~ ~ am_ ~ ~ Id _ ~ ~ far am.
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From page 280... ...
in diagnostic radiology, nuclear medicine, and radiation oncology; laboratory medicine appeal neither significantly overstaffed nor understaffed in these facilities. However, the panel is unwilling at present to extend these conclusions to the VA system ~ whole.
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From page 281... ...
As the VA pus to refine the laboratory medicine SADI, it should investigate the development of time estimates at the level of task specificity found in the pathology service survey instruments. Fmal Remarks For determining physician requirements in laboratory medicine, diagnostic radiology, nuclear medicine, and radiation oncology, the panel endorses the variant of the Reconciliation Strategy described above.
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From page 282... ...
across all PCAs, plus total contract laboratory medicine t-lt;E at the VAMC, plus total VA laboratory medicine [-lisle allocated to resident education, plus 1; LABWWU = total inpatient WWUs at He VAMC (divided by 10,000) ; LABCAPWWIJ = total CAPWWUs at the VAMC (divided by 10,000)
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From page 283... ...
across all PCAs, plus total diagnostic radiology contract physician t-1EE at the VAMC, plus total VA diagnostic radiology physician P-liiE allocated to resident education, plus 1; RADWWU = the sum of all MED1NWU, SURWWU, and NEUWWU at the VAMC (divided by 10,000~; RADCAPWWU = the sum of all MEDCAPW~U, SURCAPWWU, NEUCAPWWU, and OTHERCAP1NWUs (dividedby 10,000) , where He latter is tile total CAPWWUs generated in the ambulatory other physician services PCA; RADRUGWWU = total MEDRUGWWU at He VAMC (divided by 10,000)
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From page 284... ...
across all PCAs, plus total nuclear medicine contract physician Floe at the VAMC, plus total VA nuclear medicine physician [-lisle allocated to resident education, plus 1; the sum of all MEDWWU, SURWWU, and NEUWWIJ at the VAMC (divided by 10,000) ; NMRUGWWU = total MEDRUGWWU at Me VAMC (divided by 10,000)
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From page 285... ...
across PCAs, plus total radiation oncology contract physician -ME at the VAMC, plus total VA radiation oncology physician valise allocated to resident Gaining, plus 1; ROWWU = the sum of MEDWWU, SURWWU, and NEUWWU at the VAMC (divided by 10,0003; ROCAPWWU = the sum of MEDCAPWWU, SURCAPWWU, NEUCAPWWU, and OlrHERCAPWWU (divided by 10,000~; and RORUGWWU = total MEDRUGWWU at He VAMC (divided by 10,000~.
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From page 286... ...
~ LABORATORY MEDICINE CDR 3.4 9.2 2.0 IPF 5.9 9.8 3.5 DSE 3.7 5.8 1.8 SADI 2.9 5.2 1.8 SADI-Modified' 1.6 3.1 1.5 Survey2 3.9 8.0 2.0 NUCLEAR MEDICINE CDR 2.0 2.0 0.0 IPF 2.2 2.0 0.6 DSE 4.4 3.5 0.9 SADI 6.7 3.1 1.8 SADI-Modifiedl 5.1 2.9 1.3 Survey2 5.0 3.5 1.5 "Derived by replacing the SADIbased estimates for nompatient-care activities with estimates based on the DSE; all FTEE for patient care and resident training in the PCAs continue to be derived from die SADI. 2Panel median response to the question, poses by mail survey in September 1990, of what is the overall preferred physician "EB level at each VAMC.
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From page 287... ...
2Pasel median r~onsc to the question, poses by mail Lucy in September 1990, of what ~ the overall preferred physician WEE lend at each VAMC. To pronto a context for the remorse, each pall member was presented a summary of the physician ~= Ievd cmerg~, altenuti~rely, from the CDR, from the IPF, and from both expert judgment approacbes.
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From page 288... ...
288 P~IYSICUN STAFFING FOR TO VA-VOLUI.IE 11 TABLE 3 Application of External Norm to Compute Other Physician Specialties Physics Requirements l Computed V! uE Requirements at: Workload/ Specialty/Source Flied VAMC I VAMC II VAMC m Nuclear Medicine American College of Nuclear Physicians 2000 procs 1-2.0' 1-2.0' 1.0 GMENAC Delphi Survey 177.5 beds 2.1 5.5 6.1 Diagnostic Rad~obgy American College of Radiologists 10,500 proce 4.1 9.8 3.9 GMENAC Delphi Panel 11,240 procs 3.9 9.3 3.7 American Healthcare Radiology Administration 16,266 procs 2.7 6.4 2.6 Radiation Oncology Inter~ociety Council 226 patients o2 4.3 o.o2 for Radiation Oncology Laboratory GMENAC Delphi Panel Based on 5.25 6 6 bed size ranges Plus 1 optional FTEE for ultrasound and CI.
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From page 289... ...
It is a question well worth examining if the VA elects to use expert judgment models as one basis for detennining physician staffing requirements in laboratory medicine.
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From page 290... ...
Number of Residents Assisting by Performing Gross/ Screening AP Surgical Pathology Routine 45.0 20.0 18.0 25.0 Special 60.0 30.0 2.0 0.0 DNA Probes 0.0 0.0 0.0 0.0 AP Cytology 40.0 10.0 8.0 0.5 Cytology Scoping 30.0 0.0 0.0 0.0 AP Hematopathology 0.0 0.0 0.0 0.0 AP ~nunop~ology 0.0 0.0 0.0 0.0 AP Neuropathology 0.0 0.0 0.0 0.0 AP Electron Microscopy 0.0 0.0 0.0 0.0 AP Other 0.0 0.0 0.0 0.0 CP Clinical Chemistry 0.0 0.0 0.0 0.0 CP Hematology 0.0 0.0 0.0 0.0 CP Inununology 0.0 0.0 0.0 0.0 CP Microbiology 0.0 0.0 0.0 0.0 Computed as total weekly hours reposed by a panicipat=,g fit ime pathologist at VAMC II.
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From page 291... ...
O1~ER P~C~N SPECULTIES P~NEL REPO~T 291 Number of Residents ~sis~g I. Diagnosis and Averagc Average Total by Perfonning b~te~p~ion Min/Compl Min/Uncompl Hours/ Gross/ (continued)
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From page 292... ...
292 PHYSICUN SIFTING FOR THE Via-VOLUME Usually Performed by: II. ConsulLation Average Hours/ Staff (continued)
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From page 293... ...
Research TOTAL* Medical Students, Path + A/O Residents, Path, + A/O Nurses Clinical Physicians QA Coordinators Commi~ees/Meetings-Medical School Other Clinical Pathology Anatomic Pathology Other _ 293 Hours/Wesk 3 2 o o o o o o o o o HourelWeelc 3 o 2 o o o Hours/Weelc o 4 o SS hours/wedlc Computed as total weekly hours reported by a participating 5lll time pathologist at VAMP it.
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From page 294... ...
, p~esun~bly duplicating the results Specialty panelists themselves would have derived. Your responses to the SADI will allow us not only to develop these algorithms but also to compare the relative efficacy of estimating physician requirements by disaggregated job activity versus estimating them more globally, e.g., by ward or Patient Care Area, as used in the original Detailed Staffing Exercises.
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From page 295... ...
Times indicated below should incorporate the following activities, as appropriate: Chart 1 Conferring with referring physicians Conferring with support services Charting, phone, paperwork Counseling patients and families Teaching and supervising residents Rounds _ i-t ~ procedure, of the type indicated Worldoad Element With Resident Without Resident Autopsy 1.00 2.50 Cytology Accession 0.17 0.17 Electron Microscopy Accession 1.00 1.00 Surgical Accession 0.25 0.33
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From page 296... ...
296 dirt 2 P~YSICUN SI~FFI~G FOR TTIE Vat-VOLUME Average time required (in hours) for these numbers of procedures (in thousands)
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From page 297... ...
in FY 1988: Low: High: e.g.; VAMC I with S8.8 million in total funding; Median: e.g.; VAMC II with S2.75 million in total funding; e.g.; VAMC m with about S176,000 in total funding.
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From page 298... ...
Overall Median 0.5 0.5 0.5 For (:hief2 2.0 2.0 2.0 For Non~hief Physician 2.0 2.0 1.2 [Examples of research level as defied by total amount of research finding (VA plus no~VA) in PY 1988: High: e.g.; VAMC I with S8.8 million in total fimting; Medinn: e.g.; VAMC II with S2.7S million in total fundu~g; Low: e.g.; VAMC m with about S176,000 in total funding.
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From page 299... ...
staff member of your service Would devote to each of the following categories of non-patient~related activities? ~t4 Assume the Hunt of research accomplished at this VAMC is: Hight Medium' Low' l Continuing Education 12.5 12.5 8.0 Research (off the PCA)
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From page 300... ...
Times indicated below should incorporate the following activities, as appropriate: Conferring with referring physicians Confemag with support services · Charting, phone, paperwork · Counseling patients and families Teaching and supervising residents Rounds Cbalt 1 Average time required (in hours) for one procedure of the type indicated Workload Element With Resident Without Resident Scan 1.00 1.13 Others: Vitro 0.25 0.25 Cardiology 1.50 1.25 Therapy 2.50 2.00
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From page 301... ...
List the time in hours that you would add to each physician's average weekday to allow for the types of non-patientcare~related activities listed below: ~t2 Assume the amount of research accomplished at this VAMC is: High' Medium' Low' Hi Lo Med Hi Lo Med Hi Lo Med Education of residents (didactic, classroom, not on the PCA) Administration - by Chief (time required to manage your whole service by a Chief and/or Assistant Chief)
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From page 302... ...
Overall Median For Chief 2 For Non-Chief Physician 6.0 0.4 1.5 5.0 1.0 0.4 4.0 0.4 1.0 10.0 2.4 3.5 8.0 2.0 3.0 5.0 2.0 3.0 16.0 3.0 3.4 14.0 3.0 1.5 5.0 1.1 2.6 "Examples of research level as defined by total amount of research fudge MA plw Do+VA) in FY 1988: High: c.g.; VAMC I with S8.8 million in total funding; Median: e.g.; VAMC II with S2.7S million in tote Fuji - ; Low: e.g.; VAMC m with about S176,000 in total Ending.
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From page 303... ...
Vacation, Administrative Leave, Sick Time, Over Total Percentage of Time 8.3 6.0 8.3 6.0 3.0 32.0 15.0 25.0 15.0 10.0 16.0 0.0 0.0 0.0 8.0 10.0 14.0 14.0 1.0 8.0 10.0 8.0 14.0 46.0 33.3 44.0 32.0 28.3 30.0 18.3 14.0 17.0 IBxamples of research Ic~el as defined by totat amount of rcacarch fundu~g (VA plw no~VA) E7Y 1988: High: c.g.; VAMC I with S8.8 million in total funding; Mediun: c.g.; VAMC II with S2.7S million in total finding; Low: c.g.; VAMC m with about S176~000 in total funding.
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From page 304... ...
Times indicated below should incorporate the following activities, as appropriate: Ch rt 1 · Confemag with referring physicians Confemng with support services Cling, phone, paperwork Counseling patients and families Teaching and supervising residents Rounds Average time required (in hours) for one procedure, of the We indicated Workload Element With Resident Without Resident New Patient Examination 2.00 2.00 Treatment visit 0.13 0.13 Other: Treatment Planning and Simulation 2.50 2.50
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From page 305... ...
List the time in hours that you would add to each phyac~n's average weekday to allow for the types of non-patient~related activities listed below: Chart 2 Ash the amount of research accomplished at this VAMC is: High1 Mediuml Low Education of residents 1.00 1.00 0.00 (didactic, classroom, not on the PCA) Administration by Chief 2.00 2.00 0.50 (time required to manage your whole service by a - Chief andlor Assistant Chief)
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From page 306... ...
10.00 Vacation, Administrative 9.60 Leave, Sick Time, Other Total Percentage of Time 24.60 5.00 0.00 9.60 9.60 19.60 14.60 "Examples of research level as deSned by total amount of research fit g (VA plus no~VA) in FY 1988: High: e.g.; VAMC I with S8.8 million in total Finding; Medium: e.g.; VAMC II with $2.75 million in total funding; Low: e.g.; VAMC m with about S176,000 in total funding.
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From page 307... ...
Times indicated below should incorporate me following activities, as appropriate: Cb5~t 1 Confemng win refemag physicians Confemng with support services Charting, phone, paperwork Counseling patients and family Teaching and supervising residents Rounds 307 Average time reqliired (in hours) for one procedure, of the type indicated Workload Element With Resident Without Resident Diagnostic x-ray 0.17 0.13 (chest film, skeletal, etc.)
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From page 308... ...
List the time in hours mat you would add to each physician's average weekday to allow for the types of non-patient~e-related activities listed below: C}~t 2 Assume the amount of research accomplished at this VAMC is: High' Medium' Lowt Education of residents (didactic, classroom, not on the PCA) Administration by Chief (time required to manage your whole service by a Chief and/or Assitant Chief Administration by Others (time required for individual non-Chief physicians)
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From page 309... ...
lYSICUN SPECUl-'llES PA REPORT 309 Part 2. In order to determine tibe actual Staffing in this hospital, the number of [-lL;E must be adjusted to allow for CME, research, and any off-time required.
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From page 310... ...
310 ~ ~ ~-~ __~u~m -_of~^ ~^ _ ACME at. ~ (mat ~_o am am aims St.
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