Physician‐faculty perceptions towards teaching incentives: A case study at a children’s hospital

Abstract Purpose This exploratory study examines affiliate physician‐faculty perceptions and attitudes regarding a teaching incentive programme at a free‐standing children's hospital in the United States. We describe the compensation model and present faculty interpretations of its influence on the institutional culture. Methods A case study methodology was applied to understand the sociological aspects of academic productivity interventions. In‐depth interviews, direct observation of leadership meetings, teaching activity logs, organisational theoretical lens and survey results were used for methodological triangulation. Data from these multiple sources were coded and discussed between investigators iteratively to identify core themes. Results Of the faculty eligible for the incentive, 32 engaged in in‐depth interviews (N = 32/107; 30%) and 88 (interviewees included) in the survey (N = 88/107; 82%). Findings suggest that while the implementation made some strides in mitigating barriers for some, for others gaps were identified that suggest further exploration within this domain of study is warranted. The incentive implementation was perceived as strategic, intending to encourage the academic culture of the hospital, though participants commonly expressed confusion about the rationale behind the omission of teaching allocations in formal contracts. However, high satisfaction levels for the programme as a conduit to change were evident. There was a perception of a shift in the collective faculty morale that reflected an evolving institutional culture that increased enthusiasm for teaching. Finally, faculty noted their perception that institutions that employ teaching incentives could positively influence faculty recruitment. Conclusion We found a modest incentive‐based reward for teaching activity was successful in informing the perceptions of faculty regarding their institution's academic prestige goals and teaching recognition. Such programmes, while requiring a small investment of time and resources by institutional leadership, can convey that the educational mission remains a priority in this era of increasing clinical and administrative pressure and an institutional culture that may positively influence faculty morale and dedication to teaching.


| INTRODUC TI ON
In recent decades, free-standing teaching hospitals in the United States (US) that train medical students, residents and fellows continue to receive limited financial support for the educational mission from affiliate medical schools, yet are still expected to meet intense clinical productivity targets. The Relative Value Unit (RVU) system, which is utilised by the vast majority of US hospitals to measure clinical effort and procedural productivity for physician reimbursement and compensation, is heavily emphasised by administrative leaders, and tends to overshadow academic productivity. As a result, time and compensation for required teaching are challenging to balance with clinical expectations given the financial realities of the current health care system. 1 Some clinical departments within academic medical centres (AMCs) measure and reward engagement in teaching activities with bonus pay incentives or a buy down (subsidised release time) of clinical schedules as an academic relative value unit (aRVU)' 2 to recognise physician-faculty contributions to the educational mission. [1][2][3][4][5][6][7] Free-standing teaching hospitals are similar to AMCs where accreditation standards apply and the four missions (research, teaching, patient care, administrative service) must be met to keep clinical productivity afloat while adequately training learners. As executive leadership at these hospitals frequently look to national trends and regulatory entities to navigate the organisational course, institutions are increasingly adopting monetary teaching incentives for physician-faculty (from this point forward referred to as faculty) as a response. 8 Teaching incentive programmes in medicine are an example of organisational behaviour that sociological theorists like DiMaggio & Powell 8 define in their seminal work as institutional isomorphism. In the sociological context, isomorphism is the morphing of structure or process such that they become similar to other institutions. The motivation to become more similar can be due to the desire to imitate or respond to a set of shared constraints or conditions. Two isomorphic pressures that hospitals respond to via implementation are normative and mimetic. First, normative pressure is defined as pressure to adopt, remove or modify an office because of requirements from the profession. In this instance, normative pressure is observed in the expectation to keep pace with the basic requirements of national medical education accreditation councils that set curricular standards (eg Liaison Committee Medical Education). It is expected that faculty obtain academic appointments in order to lecture, mentor and engage in scholarship with medical students, residents and fellows. The profession demands that even affiliate faculty, who often carry heavy clinical loads, make time for uncompensated and underrecognised academic pursuits with learners.
Second, mimetic pressure is defined as stress experienced by the organisation through uncertainty or transitions in institutional priorities that result in mimicking peer institutions to remain competitive.

Thus, hospitals behave similarly to individual clinical departments in
AMCs who also implement teaching incentives as a way to increase instructional engagement and reward faculty for their contribution to the educational mission. Institutional morphism frames how and why institutions, like hospitals, respond to external forces. This can, therefore, play an influential role in how the organisational culture, common values and beliefs around the value of education are developed and sustained. The organisational culture, then, will signal teaching expectations. 9 Organisational motivation (as influenced by leadership's own motivations) and how it interacts and complements faculty motivations to value and participate in the teaching mission and engage in incentive models is a bilateral and complex dynamic that warrants greater attention.
There is a paucity of documented, effective academic productivity compensation models. In addition, after over two decades of publication on academic incentives in medical education, there is no clear standard for models of compensation for academic activity, much less direct teaching activity. 3 Existing publications are predominantly quantitative descriptive reports on compensation algorithms and productivity metrics to establish that teaching productivity can be measured. [1][2][3][4][5][6][7] Previous survey studies on teaching incentives focus on the general sentiments of faculty about monetary gain, reasons for getting involved with teaching or satisfaction with the navigation of electronic platforms for clinical teaching. [1][2][3][4][5][6][7] Demonstrative of isomorphism, these studies are informative in that they do capture the trend of incentive implementation to appeal to faculty extrinsically to increase participation and meet medical education training programme needs. Moreover, we know from prior studies the multiple intrinsic and extrinsic motivators faculty have for teaching as well as the commonly associated barriers. In a critical synthesis, seven barriers to teaching were identified that incentives are intended to mitigate: competing priorities that make balancing of workload difficult; lack of recognition; lack of faculty instructional development; unmotivated students; low interest in teaching; overly bureaucratic academic culture; and poor environmental factors, such as inadequate space and facilities for engaging learners. 10 Previous literature suggests that there is a complex interplay between individual motivation to teach and the organisation's motivation to increase participation, as well as reward and cultivate a particular culture. 1,2,10-13 However, we find that a nuanced contextual understanding about the perceived teaching culture at institutions, as it relates to teaching incentives, is an overlooked dimension.
We wanted to examine what lessons can be learned from teaching incentive programmes, and, specifically how they inform faculty attitudes towards teaching recognition, recruitment, retention and morale. In addition, how do such programmes affect the perception of institutional culture by faculty? After all, faculty motivation to teach does not occur in a vacuum. It is informed by multiple environmental, intrinsic and systematic elements. 10 A clear understanding of what faculty think and feel about the direction of the hospital as it relates to teaching and recognition has yet to be explored in-depth, especially with regard to the influence of teaching incentives in medical education. To address this gap, we prospectively conducted an exploratory qualitative study to examine faculty perspectives about the value of education, coincident with the introduction of a new incentive programme at our hospital.
Of particular interest is understanding the influence of teaching incentives on affiliate faculty (those employed by the hospital) associated with local US medical schools as they tend to have a significant footprint in the training continuum. 14,15 Depending on the institution, faculty at such clinical affiliates are sometimes also termed 'volunteer' faculty. Engagement of such faculty across all specialties is a continual challenge, especially for free-standing hospitals partnering with medical schools. Further, for this study, the teaching incentive includes a broad range of academic activities that intersect with student, resident, fellow and faculty learning and service commitments related to the educational mission (Table 1).
In all, the influence of academic incentives on job satisfaction, morale and perception of institutional culture from an affiliate faculty member's perspective has been minimally addressed. Previous studies describe their various models be they bonus (which is com-

| ME THODS
Phoenix Children's Hospital (PCH) has served for nearly 40 years as a clinical teaching site. What led to the implementation of an incentive programme at PCH was the same isomorphic pressure faced by other institutions. As the institution evolved from an independent, community hospital (ie non-to-minimal academic provider) in 1983 to a free-standing, specialised paediatric hospital in 2002, the physician group at PCH grew from a small paediatric subdivision to a total of 34 clinical divisions, and now serves as an essential paediatric teaching hub for the Phoenix metropolitan area. There are three core ACGME residencies, nine ACGME accredited fellowships, and ten non-ACGME accredited fellowships comprising approximately 200 GME learners each year; in addition, 500 medical students, residents, fellows and graduate students from multiple local academic partner institutions rotate through annually.

| Study design and data collection
A case study methodology was applied in this cross-sectional study to understand the sociological aspects of academic productivity incentives. Such an approach optimally informs us on faculty perceptions about organisational culture, around the educational mission and attitudes towards the teaching incentive. 16,17 The PCH Institutional Review Board approved our human subjects study.
Traditional to case study design, we utilised six sources along with a primary source to systematically conduct an in-depth exploration of a group of physician-faculty who voluntarily participated in the first year of the incentive programme utilising methodological triangulation as defined in Denzin's (1978) seminal work. First, a primary source serves as the data closest to the origin of thematic results. Consistent with Between-method triangulation, the remaining sources buoy and assist with interpretation, synthesis and understanding of the issue from different dimensions to counter design weakness in and across sources. 18  were taken by the co-lead author (GFM), a non-hospital employee, as part of observation to memorialise and understand the hospital's culture first hand as a 'participant-observer'. 17 Additionally, meeting minutes served as documentation data for artefact analysis that were mapped back to the corresponding field notes. Fourth, monthly e-log trends, by division specialty, were tracked to confirm participation and note total hours allocated to teaching activities. Organisational culture theory (OCT) uses individual perceptions, opinions, norms and attitudes to define organisational culture, climate and trends. 9 We turn to OCT to further frame the teaching culture that is unfolding as perceived by participating faculty in our study.

| Data analysis
Interviews were recorded and sent for transcription to a third-party vendor, TranscribeMe ® ! E-log reports, observation field notes, meeting minute documentation and interview transcripts were

| Motivation to 'pay it forward' amid perceptions of a teaching expectation conundrum
In interviews, all faculty reflected on their academic identity and Despite discord regarding the optimal means of monetary translation of the value-perceived in teaching, and clarity that the hospital places on teaching expectations in contracts, the motivation of participants to teach and to give back is evident. OCT concludes that the omission of teaching expectations from the contract with the implementation of an incentive in a teaching hospital setting presents a misaligned message to faculty. It is also worth noting that leadership meeting minutes and observation notes omit discussion about contract boilerplate language or section revision to match expected academic participation. I think there's momentum that is moving in the direction that PCH needs to go in…I think that we're eventually going to get there, but it's going to take a while because, I think, [pause] PCH still has a lot of community hospital genes in it… We're making improvements. We're in US News and World Report. We're getting more recognition, but it's a process, you know? And I think that we are never going to get more recognized if we don't move more towards emphasizing the importance of teaching and research…it's not going to happen if we continue to rely on clinical RVUs to define ourselves only.

| Perceptions about collective morale
The same sentiment resurfaced in almost half of survey responders open comments. One survey participant wrote, 'I think it is a good start! A huge disparity remains between reimbursement and cultural recognition within the organization of clinical vs teaching effort'.
Expressions from faculty such as these capture an optimistic orientation that appears to take note of progress over perfection. By and large, the introduction of the incentive shaped participating faculty's perceptions about the academic direction of the hospital that furthered enthusiasm for the teaching mission.
When considering interview and survey responses, we infer that differences in perceptions among faculty in one hospital and specialty could be grounded in their individual need for detailed information, appropriate promotion of the programme, and support for teaching engagement at divisional levels. In this case, we find that the immediate teaching environment and subculture may not be signalling recognition from leadership or could be indicative of inefficient flow of information downstream. I think we're moving in that direction slowly. Because I think that is going to be the only way that they are going to be able to recruit the people that they want to recruit…. Because we've been hiring more people who are highly interested in academics and we're trying to get that up and running, but it's a process.

| Perception on implications regarding national recruitment, promotion and retention
But I will tell you that we've been trying to incentivize teaching… It is a big leap of faith that administration In all, findings suggest that recognition for teaching by incentive could be a vital component in faculty recruitment, retention and satisfaction, if such initiatives were prioritised in hospitals with a similar context to that of PCH. Survey questions did not include a specific prompt on the topic of recruitment, promotion or retention. As such, related trends in the survey comments were absent. In line with OCT, findings highlight a culture where faculty perceive that the incentive could improve faculty recruitment, assist with much-needed teaching and academic service portfolio documentation for promotion dossiers and annual performance reviews, and faculty retention rates.

| D ISCUSS I ON
The results from our study both illustrate and underscore the im- Based on overall participant responses, the incentive was well-received. In answering our research questions, we found that the incentive was mostly perceived as a strategy to encourage the academic culture of the hospital. From previous literature, we know organisational leadership groups often introduce incentives to modify faculty behaviour and tend to default to a bonus model. 1,2,6,11 It generally seems that the type of incentive, in bonus form or otherwise, has little impact on the medical education mission, but often leads to increased job satisfaction. There is a similar assumption about teaching participation drivers and forms of recognition made by organisational leadership in our study. However, we find that this may not be the case for some. A minority of respondents reported a general lack of transparency to the faculty about distribution details, which led to dissatisfaction with the incentive.
The design of the incentive as a bonus distributed from a pre-determined total allocation pool assumed that most faculty would interpret the implementation as recognition for their teaching con- The misalignment suggests that the organisational culture is not explicit in relating clear teaching expectations in support of teaching participation. This can be interpreted as an example of an incomplete or memetic response still progressing to match peer institutions.
Despite these issues, high satisfaction levels and a general appreciation for the programme as a conduit for change were evident.
In addition, the very attempt at the creation of an incentive con-

| Limitations
The size of our primary data source pool is similar to previous quantitative academic incentive literature 1-4 and common to case study design. 16,17 However, our study could have been strengthened with an additional breakdown of demographics that included ethnicity and race to be able to further investigate differences in the reception of the incentive. Additionally, interview and survey data collection tools in the area examining recruitment, retention and promotion needed to have aligned better. There is a survey design omission in this area. A significant bias is the lack of data from those eligible for the programme who chose not to participate. Had we somehow been able to include such data, a potentially different and deeper understanding of motivation and perceptions about the organisational culture could have surfaced.

| CON CLUS ION
Institutional priorities reflect organisational culture and manifest in resource allocation as distributed by executive leadership. 21 Allocations not only reflect responses to external pressures, but reflect the collective values of the leadership. When leadership changes are frequent, organisational values, direction, timelines and ultimately allocations typically alter; sometimes causing confusion, frustration and uncertainty of the institutional fit for some individuals. It is important to remain cognisant that many physicians in free-standing hospitals consider themselves academicians-hence, their professorial appointments. These appointments are not only because of normative isomorphic pressures from national medical education accreditation agencies, but for some, their identity remains grounded in being a clinical educator. This particular identity is meaningful to their happiness, sense of respect, job satisfaction and motivation to pay it forward, as we noted frequently in our study. 1,4,7 We can infer that there is potential for institutional leaders to reap the socio-psychological benefits of retaining faculty and increasing teaching participation if they invest in teaching incentive models. Our study further solidifies that that hospitals are strengthened by deliberate and coordinated institutional philosophy and organisational goals that consider the significance of faculty perceptions and morale around teaching, since faculty are the backbone of any teaching institution. 22 Our study is applicable to an array of specialties. It is particularly relevant to any community hospital or clinical training site that has moved from hosting the occasional learner to becoming a bona fide stand-alone teaching hospital. Such institutions, that

E TH I C A L A PPROVA L
Approved by Phoenix Children's Hospital IRB.

PR E V I O US PR E S ENTATI O N S
Podium presentation of findings presented 9 November 2019 AAMC Learn Serve Lead National Conference in Phoenix, Az.