“Protected Time” in the New Financial Reality

The COVID-19 pandemic is causing massive changes in the United States healthcare system. Some of these changes are issues that Emergency Medicine has been advocating and promoting for years, such as increased access and reimbursement for telemedicine. Other changes, beyond the most immediate and emergent clinical issues, are going to cause massive disruption to the status quo in ways that we have not yet predicted nor have developed contingency plans for. In particular, the new financial reality will significantly affect the pipeline for developing and supporting researchers, and if not addressed could lead to a lost generation or more of physician-investigators in Emergency Medicine.

Hospitals, health systems, and universities nationally have already shut down the majority – even the vast majority – of non-COVID related research activities. While the shut-downs are described as temporary, the end-date of the current shut-down remains unclear. Also, anticipating future revenue shortfalls due to the concurrent budgetary crisis, many institutions have frozen non-essential hiring, construction, and expenditures. Health systems, seeing real-time losses from the lack of elective procedures and a decrease in outpatient volume, are only now starting to understand the effect of COVID-19 on future budget goals and projections, but no one is predicting anywhere near the prior status quo.

A 2018 report in Nature looked back at the 10-year effects of the 2008 global economic recession (1). Good news first: the article reported that in the decade after 2008, global R+D funding had more than rebounded, mostly due to firm structural policies in the European Union and the United States. However, more worryingly, it also reported that the larger the economic depression that occurred in each country, the larger the decrease in research funding in the next few years. While not a true analytic study, it makes sense that the substantially larger impact of the current COVID-19 pandemic will also have a substantial impact on funding for the next few years.

So, what impact will this have on individual emergency departments and investigators? Already we are seeing the effects of revenue shortfalls in community medicine, with well-publicized salary cuts, even among frontline COVID-19 providers. Academic medicine has not received as much attention thus far, but we can easily imagine that department chairs and school budget officers are taking a wary look at spreadsheets to decide what funding can be reduced without affecting the core functions of the clinical mission. In Emergency Medicine we tend to follow a salary model where we pay ourselves. In departments where salary has an efficiency component that relationship is much more explicit, but even those without plan on each full clinical load physician generating more revenue than is paid out in salary. Something likely to be on the table for reductions is internally funded salary support for non-clinical work, usually called “protected time.”  Later career physicians will be more insulated from these changes, as they have external support, but those funded from private foundations may be affected as well. As for early career and new hire physician-investigators, they often rely on the departments themselves, with the departments regarding this “investment” in the investigator’s future as paying out over the long-term, both financially and to satisfy the non-clinical goals of the department.

It takes significant non-clinical time to develop the skills, preliminary data, grant-writing ability, and infrastructure to successfully compete for external research funding. If time is not available to develop these requirements, then it is very likely we will not have the next generation of Emergency Medicine investigators available to compete with better funded, more research-oriented specialties for external research funding. Outside of basic research, Emergency Medicine leads the way in research into the social determinants of health and healthcare inequities. The researchers engaged in this effort are more diverse, by gender, race/ethnicity, and socioeconomic status than the demographics of most other research areas. They are exactly the types of investigators most at risk to not even begin a research career if the required institutional support is not there to do so.

Furthermore, mentorship is a crucial component of developing a successful investigator. Mentors also need time away from their externally funded projects and clinical responsibilities to be able to engage and mature junior faculty and trainees. Some mentors compensate for this by having mentees work on their existing funded work, but this limits the ability of mentors to only advise mentees who are interested in working on the mentors immediately available and funded research. The National Institutes of Health recognizes this need by funding K24 grants, but often this is funded internally by “administrative” time, another potential victim of COVID-19 induced budget cuts.

Overall, the entire Emergency Medicine physician-investigator infrastructure is based on having a foundation of passionate and supported trainees and junior faculty willing to take risks in the pursuit of answers to important questions. The passion and breadth of questions will always be there, but now, more than ever, our specialty and leaders will need to support the ability of physician-investigators to answer them.

References

1. Rehm J. Ten years after the economic crash, R&D funding is better than ever. Learn more here. Accessed 4/25/20.

Dan Buckland