We have also made several specific recommendations for alleviating the current situation, including innovative ways to fund child neurology as well as ways to enhance job satisfaction. RELATED ARTICLE Editorial Putting value back into the “V” of wRVU Page 57 Introduction Child neurologists evaluate children with complex medical issues, whose care cannot be managed in a typical 15- to 20-minute pediatric visit. In addition, they must counsel parents who are under stress and have a multitude of questions. These patients typically require multidisciplinary team care and ongoing case management to attain optimum outcomes and quality of life. The time required for this intensive, diagnostic approach and multidisciplinary care plan not only results in better direct outcomes for the child and family, but also in decreased emergency room visits, fewer unscheduled hospitalizations, and less burden on the primary care provider. A developing critical shortage of child neurologists is making patient access difficult and increasing the burden on the remaining and strained workforce. Increasing the number of child neurologists is therefore essential for the future of children with neurologic disorders. To help increase this number, child neurologists spend many hours training the future generation of child neurologists and other health care providers. However, this educational mission is only possible with the proper support structure and with the recognition that these efforts will affect clinical productivity. All physicians have a practice ideal of how to manage their patients clinically, viewing care as a mission. Failing to consistently meet patient needs has a profound effect. As stated in one article,1 physicians are not burning out, they are experiencing “moral injury”—where there is direct conflict between the increasingly business-oriented and profit-driven health care environment and the physician’s desire to provide optimal care. On a personal level, this conflict can mean physical and emotional exhaustion, resulting in difficult choices such as restricting From the Department of Pediatrics and Neurology (M.L.Z.), Division of Pediatric Neurology, Children’s Hospital of Orange County, Orange, CA; Neurodevelopmental Science Center (B.H.C.), Akron Children’s Hospital, OH; Department of Pediatrics, Neurology, and Molecular Genetics and Microbiology (P.B.K.), University of Florida, Gainesville; Department of Pediatrics and Neurology (D.E.M.), Alpert Medical School of Brown University, Providence, RI; Department of Neurology (J.M.), University of Rochester Medical Center (J.M.), NY; The Center for Neurological and Neurodevelopmental Health and the Clinical Research Center (M.M.), Voorhees Township, NJ; Department of Neurology and Pediatrics (A.T.), Louisiana State University, Baton Rouge; and Department of Pediatrics and Neurology (W.T.), Penn State University, Milton S. Hershey Medical Center. Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article. Copyright © 2019 American Academy of Neurology 75 Copyright © 2019 American Academy of Neurology. Unauthorized reproduction of this article is prohibited. one’s practice, curtailing all commitments except direct patient care, leaving the academic setting, setting up a cashonly practice, or early retirement. On a societal level, it can result in the unwillingness of physicians-in-training to take on the burdens involved in this subspecialty and the premature loss of practicing child neurologists. At most medical centers, a well-defined, uniform patientschedule template for all neurologists, regardless of subspecialty, removes variability and for many practices, establishes an agreement between the physician and employer about how much clinical work a physician will be expected to perform. The work relative value unit (wRVU), as a system of work value, has been developed and verified as a measure of work. Although the fairness of work value between a cognitive service such as an office visit and a procedure such as an appendectomy can be disputed, the work, as estimated by the annual wRVUs when comparing neurologists who perform only evaluation/management services, should be valid. In September 2017, the Child Neurology Society (CNS) convened a special task force to review the practice of child neurology in the United States. The CNS relative value unit (RVU) Task Force designed and distributed a survey that queried child neurologists from both academic and private practices. The survey covered the use of RVU requirements, salary and compensation, time allotted for new and established patients, administrative and teaching mandates, clinical and administrative support, weekly face-to-face patient time, protected time, and educational opportunities. The aim was to define the challenges faced by child neurologists in providing optimum patient care and fulfilling the academic mission of research and education in today’s health care marketplace. We surveyed 25 academic child neurology programs of diverse sizes as well as independent private organizations and practices (IPOP). In our initial analysis of the data, we identified common themes in each division or practice surveyed. We summarize our data below and offer specific recommendations. CNS RVU task force data summary gathered specifically from child neurology divisions Of the 25 academic programs surveyed, 20 provided enough detail for a complete data analysis. The programs were divided into small, medium, and large programs. The small programs2 were composed of less than 5 faculty. The medium programs (12) contained 7–18 faculty with the majority of programs aggregating between 12 and 14 (median 13). The large programs6 were composed of over 20 faculty, varying between 22 and 64. There were no substantial geographic differences between salaries among the various programs, with the exception being a smaller salary scale (junior vs senior) in the larger programs. 1. Salaries for 1.0 full-time employees (FTE) ranged from $175,000 to $350,000 (table e-1, http://links.lww.com/ WNL/B41). Small programs: Median and mean salary of $210,000 Medium programs: Junior faculty—median salary $191,500; mean salary $191, 917 Senior faculty—median salary $273,500; mean salary $285,455 Large programs: Junior faculty—median salary $165,000; mean salary $164,400 Senior faculty—median salary $290,000; mean salary $271,000 2. In 100% of programs surveyed, salary increases were based on years of experience or academic rank, but bonus structures varied considerably, as described in no. 4. 3. Minimum wRVU requirements for 1.0 FTE positions were variable(table e-2, http://links.lww.com/WNL/B41): Small programs: Mixed: 4,891 wRVUs (range 4,800–4,981) Medium programs: General neurology: 3,060 wRVUs (range 2,200–3,800) Mixed: 4,365 wRVUs (range 4,000–4,980) Epilepsy/proceduralist: 4,490 wRVUs (range 3,200–6,000) Large programs: General neurology: 3,309 wRVUs (range 3,023–3,500) Mixed: 4,200 wRVUs (1 program only) Epilepsy/proceduralist: 4,361 wRVUs (range 3,900–7,177) 4. A financial bonus was available in most divisions and was generally rewarded for exceeding wRVU targets. Clinical neurophysiologists (procedure-based pediatric neurologists) could have bonuses exceeding $150,000. Most bonuses were generated by exceeding wRVU targets: ◦ One program used a pooled bonus divided equally among the faculty. Glossary CNS = Child Neurology Society; FTE = full-time employees; IPOP = independent private organizations and practices; NP = nurse practitioners; RVU = relative value unit; wRVU = work relative value unit. 76 Neurology | Volume 94, Number 2 | January 14, 2020 Neurology.org/N Copyright © 2019 American Academy of Neurology. Unauthorized reproduction of this article is prohibited. ◦ Many programs had a fixed base with incentive, incentive primarily wRVU based, with a small amount for educational effort and teaching, as well as research.