The full costs of patient educators

Dear Sir

Allen et al. present a fascinating account of the educational and financial impact of using patient educators to teach physical exam skills (Allen et al. 2011). The educational outcomes of using patient and physician educators are similar, but the costs savings reported are statistically and financially significant. The authors are explicitly clear on how they reached their educational and financial conclusions; however, it is questionable whether they included all costs associated with patient educators. They state that the “costs of training, space, exam supplies, and faculty time spent other than in direct teaching were not included, as these costs were either unrelated to the teaching model or were costs that could be amortized over multiple future years.”

First, it is questionable whether all these costs are unrelated to the teaching model. The time to train a patient educator is likely to be significantly longer that the time to train a physician educator and the cost is thus likely to be higher. Grading written histories is also likely to be different in the context of patient and physician educators. On the other hand, use of space and exam supplies may be lower when patient educators are used alone.

Second, the issue of amortization or spreading the cost of a curricular innovation over multiple future years is uncertain on two counts. Amortization will surely spread out the costs – but there will still be a cost in year one which must be accounted for. Whether amortization will be equivalent with patient and physician educators is also an open question. Patient educators may be less likely than physician educators to stay in the course as teachers over many years: they may get tired or ill or move to another hospital. New patient educators will thus need to be recruited and trained, and so amortization will not work in a similar way for patient and physician educators – the costs with patient educators are more likely to be recurrent.

Third, the travel and subsistence costs of patient educators were not accounted for. It may be that the patient educators paid for these themselves out of their honoraria, but in many countries it is common practice to pay travel and subsistence costs as well as an hourly rate.

The issue of cost and value in medical education is not new. Many years ago, Vincent Norman wrote: “The lot of our own medical students is, from a financial standpoint, not a bed of roses, and I have personal recollections of existence for over three years on a diet of cocoa and dry bread, with an occasional kipper for variety, in order to save enough money to pay my hospital fees.” (Norman 1938). Allen et al. are to be congratulated for bringing to the fore an intervention that may reduce financial burdens on both students and tax-payers, but we must be sure that all costs are accounted for.