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Korean J Fam Med > Volume 36(2); 2015 > Article
Walsh: The Cost of Postgraduate Medical Education and Continuing Medical Education: Re-Examining the Status Fifty Years Back

Abstract

The subject of the cost and value of medical education is becoming increasingly important. However, this subject is not a new one. Fifty years ago, Mr. DH Patey, Dr. OF Davies, and Dr. John Ellis published a report on the state of postgraduate medical education in the UK. The report was wide-ranging, but it made a considerable mention of cost. In this short article, I have presented the documentary research that I conducted on their report. I have analyzed it from a positivist perspective and have concentrated on the subject of cost, as it appears in their report. The authors describe reforms within postgraduate medical education; however, they are clear from the start that the issue of cost can often be a barrier to such reforms. They state the need for basic facilities for medical education, but then outline the financial barriers to their development. The authors then discuss the costs of library services for education. They state that the "annual spending on libraries varies considerably throughout the country." The authors also describe the educational experiences of newly graduated doctors. According to them, the main problem is that these doctors do not have time to attend formal educational events, and that this will not be possible until there is "a more graduated approach to responsible clinical work," something which is not possible without financial investment. While concluding their report, the authors state that the limited money invested in postgraduate medical education and continuing medical education has been well spent, and that this has had a dual effect on improving medical education as well as the standards of medical care.

Recently, the subject of the cost and value of medical education is increasingly being discussed,1,2) however, this subject is not a new one. In fact, it has been cited in papers that are over 100 years old.3) Similarly, the subject of the cost of postgraduate medical education and continuing medical education has also received considerable attention. However, this subject is not particularly new either. Fifty years ago, Patey et al.4) published a report on the state of postgraduate medical education in the UK. The report was wide-ranging, but it made a considerable mention of cost. In this short article, I have presented the documentary research that I conducted on their report. I have analyzed it from a positivist perspective and have concentrated on the subject of cost, as it appears in their report. In keeping with the positivist perspective, I have adhered closely to what can be objectively viewed and quantified. The document reviewed is undoubtedly genuine-it was retrieved from the archives of "The BMJ." The document has been written from the perspective of the above listed authors. It was based on discussions with a special committee of the Nuffield Trust. It covers a variety of topics within postgraduate medical education, and cost is a common theme in many of these topics.
The authors describe reforms within postgraduate medical education; however, they are clear from the start that the issue of cost can often be a barrier to such reforms.
They state the need for basic facilities for medical education, but then outline the financial barriers to their development. They quote a government circular that advises that capital expenditure on improved physical facilities for education should come from existing allocations, in other words, there is no new dedicated money for medical education. The circular also asserts that the use of non-exchequer funds would be an appropriate alternative to meet these costs. However, it does not say what these non-exchequer funds might be. The result was that the development of physical facilities for medical education became 'sporadic.' The authors decry this development, explaining that "postgraduate medical education is an essential prerequisite to better service to the patient, and the consequent giving of some priority to educational facilities, however low, is of fundamental importance in any intermediate or long-term plans affecting the hospital." They continue by explaining the difficulty in finding capital for centers. They say that the cost might not be very high as compared to the proportion of the total hospital spending; however, they acknowledge that even low costs are unachievable without ring fenced funding. They emphasize that centers need not be "filled with expensive audiovisual equipment, large auditoria, and over spacious offices," but that their primary purpose should be educational, and that keeping this in mind should help to control costs.
The authors then discuss the costs of library services for education. They state that the "annual spending on libraries varies considerably throughout the country." However they also make it clear that the starting point for any expenditure should be the salary of the librarian-to be borne by the hospital management committee-as well as the costs of books and journal subscriptions. In contrast, they praise the "permitted separate allocation for recurrent expenditure on postgraduate schemes" for training. As well as being inherently of value, they state that these schemes are "an excellent means of bridging the gap between hospitals, general practice, and local health authority services." They emphasize the importance of ensuring that funding for educational schemes should not have to compete with other interests in hospital budgets.
The authors also describe the educational experiences of newly graduated doctors. According to them, the main problem is that these doctors do not have time to attend formal educational events, and that this will not be possible until there is "a more graduated approach to responsible clinical work," something which is not possible without financial investment. In this context, they also mention continuing medical education for general practitioners (GPs). They describe a number of barriers to engagement in continuing medical education amongst this group; however, cost is a common theme amongst these barriers. The terms and conditions of the GPs mean that there is only an incentive for them to attend continuing medical education when they will be able to increase their earning as a result of their learning. Therefore, for example, GPs will attend obstetrics education when it enables them to qualify for the obstetrics list and increase their income as a result. According to the authors, clinical assistantships in hospitals are popular educational activities amongst GPs, but, once again, the method of remuneration for these activities inhibits the full engagement of GPs in these activities. The authors also reflect on the relationships between universities and hospitals, what both of these entities should be responsible for, and where the costs of certain activities should lie.
While concluding their report, the authors state that the limited money invested in postgraduate medical education and continuing medical education has been well spent, and that this has had a dual effect on improving medical education as well as the standards of medical care.
As with any documentary research, certain inferences for the present day may be drawn from this report. Interestingly, some of the inferences from this paper are still uncomfortably familiar. These include the need to ring fence funding for medical education, the variations in how education is delivered and costs allocated, the balance between service and education for trainees, the financial incentives for education, the importance of establishing where costs lie, and lastly and perhaps most importantly, the link between investment in medical education and improving medical education and standards of medical care. In 1965, these themes manifested in the need to construct new buildings for medical education, while in 2015, they manifest in the need to construct new curricula. However, the need for investment, especially evidence-based investment, and for evaluating the outcomes of investment remains the same.

CONFLICTS OF INTEREST

No potential conflict of interest relevant to this article was reported.

References

1. Walsh K, Jaye P. Cost and value in medical education. Educ Prim Care 2013;24:391–393. PMID: 24196592.
crossref pmid
2. Sandars J, Walsh K. A consumer guide to the world of e-learning. BMJ Career Focus 2005;330:96–97.
crossref
3. Cost of medical education. Br Med J 1893;2:536.

4. Patey DH, Davies OF, Ellis J. Assessment of postgraduate medical education: a report to the Nuffield Provincial Hospitals Trust. Br Med J 1965;2:557–564. PMID: 5826901.
crossref pmid pmc


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