Letters

Rewarding performance vs. longevity

To the Editor:
I commend Judy Capko for stating the need to establish staff-salary structures on a more thoughtful basis than gut feelings ("How to Keep Salaries on Track and Under Control," April 1998). I would like to point out, however, that there are other models to choose from.

The model Capko discusses, let's call it model A, is clearly designed to serve as a cost-control tool. It gives you a rational way to examine whether you are paying higher than market salaries, based on the model's factors for establishing each job's internal worth.

Model A uses factors such as educational level, years of work experience and number of direct reports to determine salary grade assignment; therefore, model A rewards credentials, quantity of experience and hierarchy. But I regularly see employees with lesser credentials outperform co-workers with more credentials, and an employee's years of experience are often less relevant than his or her quality of experience. Furthermore, rewarding hierarchy encourages empire building while also working as a subtle but powerful force against intragroup teamwork and intergroup collaboration.

Model A also puts pressure on you to continue moving marginally performing staff up through each level on the basis of their years of experience. This type of salary structure is hard to defend to a staff member who is paid less because of fewer years of experience but is making a superior level of contribution to the practice than a higher-paid co-worker. Consequently, model A often results in higher turnover, with the best-performing staff being the first to leave.

Dale W. Shimko, MA
Nashville, Tenn.

Author's response:
The salary structure in "model A" does indeed reward excellent performance, but with financial prudence rather than emotion. In my experience, management and staff like model A because it offers individuals a clear understanding of what each position is worth and it does so in a fair and consistent manner, placing high performers at the top of the scale. Marginal employees should not advance in pay rate but should be placed on performance-improvement plans.

As for motivating employees and maintaining high morale, the real solution is leadership and management skills, not pay rates (as long as pay rates are fair).

Judy Capko
Newbury Park, Calif.

A pound of prevention

To the Editor:
I was surprised and somewhat dismayed to read that "annual prostate cancer screening tests," which "may include ... a prostate-specific antigen blood test," will soon be covered by Medicare for men over age 50 ("An Ounce of Prevention," April 1998). I hope this does not lead readers to believe that PSA is a recommended routine test. It is not. Neither the AAFP nor the American College of Physicians has recommended PSA testing as routine because 1) there are no studies to support the benefits of early detection outweighing the risks of complications from treatment, especially in males over 70 years old; 2) routine PSA testing without thorough discussion of the potential outcomes of testing is inappropriate; 3) PSA is an organ-specific test, not a disease-specific test, and as such is not a reliable screening test for prostate cancer; and 4) PSA is more effective when used to follow prostate cancer patients post-treatment to determine cure versus return/metastases.

The U.S. Preventive Services Task Force Report recommends against routine testing,¹ for the reasons cited above.

I hope that by January 2000 we will have a safe, efficacious screening test for prostate cancer. If we don't, I feel it is ethically wrong (and potentially illegal) to order this test as a routine screening test, or even to refer to it as a "screening test."

While an ounce of prevention is worth a pound of cure, a pound of prevention is not necessarily better.

D. Michael Jervis, DO
Jacksonville, Fla.

1. Frame P, Berg A, Woolfe S. US preventive services task force: highlights of the 1996 report. Am Fam Phys. 1997; 55(2):567-576.

Copyright © 1998 by the American Academy of Family Physicians.
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