Recently, there have been dramatic changes in the health care system. The growing trend to implement relative value unit (RVU) metrics model into academic medicine has created a challenging environment for the learners. Faculty members are under pressure to produce more RVUs versus spending time on teaching or research. Although there have been several attempts to measure academic productivity, no standardized metrics are available to assess the academic activities. Resources should be devoted to maintain balance between clinical productivity and the mission of academic medicine. The graduate medical education office and the leadership of training programs need to collaborate with local regulatory officials and hospital administration regarding the importance of medical education and research in preparing the future health care providers. In conclusion, it is crucial to understand that residents and fellows are an integral part of any successful academic institution, and a strong emphasis on their training in patient care as well as scholarly activities should be encouraged.

On January 1, 1992, the centers for Medicare and Medicaid Services introduced the RVU system to guide reimbursements for physicians. This was the first time objective quantitative criteria were used to measure the work performed by physicians. The RVU metrics model is a quantification of the 3 components of patient care: physician work, practice expenses, and malpractice expenses. It assigns a calculated number of RVUs for each clinical activity and by adding these RVUs, the total activity of physician, department, or institution can be measured and analyzed. Initially, the RVU reimbursement system was designed mainly for group practice or in other settings where productivity could be compared among physicians. The Medicare formula does not reimburse academic pursuits. In fact, it discourages nonreimbursed or less reimbursed activities, such as teaching and research, by overemphasis on clinical RVU-based metrics of performance. Although academic centers have made attempts at creating metrics to quantify nonclinical work such as teaching and research, these have not been universally adopted.

As trainees, we have been protected for several decades by the salary-based model. Our faculty members at academic institutions in the past were not under pressure to generate more clinical RVUs. They were paid a negotiated salary to perform a specific amount of clinical work, teaching and were provided protected time for research and other scholarly activities. In general, academic physicians choose to stay in training institutions, with a significantly less competitive income compared with their peers in the private sector because they enjoy teaching, interacting with trainees, and conducting research. Moreover, the Accreditation Council for Graduate Medical Education requires that faculty must devote sufficient time to the educational program to fulfill their supervisory and teaching responsibilities. From a resident and fellow’s perspective, this creates an optimal environment for learning, acquiring new procedural skills, and participating in research projects.

Because of financial pressures caused by funding cuts, decreased reimbursement, and increasing market competition, many academic institutions have moved away from a fixed salary-based model toward an RVU reimbursement system. Nowadays, faculty members are being asked to increase their clinical activities to meet RVU benchmarks. This leaves less time for teaching and research. The real challenge is how modern academic medicine adapts to health care evolution and at the same time maintains its tripartite mission of clinical care, research, and education along with administrative responsibilities. Unlike clinical productivity, there is no realistic measure of academic productivity. Several attempts to evaluate academic productivity, using “teaching RVUs” or “research RVUs,” have yielded few significant results. A recent survey performed by the American College of Cardiology estimated that 46% of academic cardiologists did not receive RVU-like credit for academic activities. Most physicians (71%) reported that the reduction in pay required to pursue academic activities as a significant disincentive. This reduction in pay can reach $75,000 per year. Faculty members have to decide how to allot their time, and many find difficulty in trading clinical RVUs to spend more time in teaching or research. From a trainee’s perspective, this means less time with the attending, fewer didactics and a decline in scholarly activities.

In the current era of the pure RVU metrics model, residency and fellowship training programs, faced with fewer resources, are stuck between a rock and a hard place. On one side, the Accreditation Council for Graduate Medical Education requires training programs to provide high-quality education, research, and clinical care to maintain accreditation. On the other side, hospital administration keeps adding more RVU-based tasks to faculty members. Ironically, these 2 governing bodies have minimal cooperation. Residents and fellows in training have little say in this debate.

There are a number of possible strategies, however, to minimize the potential negative impact of the RVU system on training programs. They include a novel partnership between a university that supports a portion of salary dedicated to academic activities and the hospital that provides support for patient care–related activities. Incentives for performing educational activities must be implemented into the reimbursement packages. Some training institutions have educational RVUs to help pay faculty for training medical students, residents, and fellows. Other institutions have adopted a corrective model in which RVUs are weighted to amount of time a faculty member is expected to provide clinical care (i.e., 50% clinical time for a program director would be given a twofold weight in RVU calculation). The graduate medical education office and the leadership of training programs should encourage and reward excellence in teaching, research, and patient care. They also need to partner with local regulatory officials and hospital administrators in the process of appropriately valuing medical education and research. Ultimately, the mission of any academic institution is not to achieve target RVU benchmarks, although it is a factor, but to advance professional careers of their faculty, provide excellent training for the next generation of physicians, and promote research. Residents and fellows are an integral part of any successful academic institution, and a strong emphasis on their training in patient care as well as scholarly activities should be encouraged.