Costs in medical education: How should we report them?

Dear Sir

Medical education is expensive (Walsh 2010). Its expense has led a growing number of researchers to look at the cost of different medical education interventions and consider what value they offer in light of their costs, and perhaps how more value might be gleaned from a given expenditure (Brown et al. 2001; Walsh et al. 2010). A small but growing number reports has started to emerge in the literature (Cookson et al. 2011; Pell et al. 2013). This is a good thing as it gives recognition to those who are conducting cost analyses and also enables others to learn from their experiences or even reproduce the analysis in their own setting and perhaps reproduce some cost savings. This is important as it is the ultimate purpose of research and publication. However readers will only be able to decide whether to try to reproduce cost-saving or value-enhancing interventions in their own setting if they understand the intervention and the outcome. A researcher may report cost savings with a medical education intervention, but how should they express cost savings in such a way that readers will understand?

The obvious answer is in dollars, dinars or dirhams but this approach also has weaknesses. Although cost expressed in monetary terms is instantly understandable, it has a number of inherent flaws. First of all, the currency of the reader will often be different to that of the researcher, however this is easily solvable with a currency converter. Secondly inflation may often render monetary statements of cost rapidly out of date. Most people will have a sense of the rate of inflation in their own country, but only a few will have an idea of the rate of inflation in other countries. Thirdly and most seriously the monetary cost for a medical education service in one country may be completely different in another. For example, in some countries standardized patients are paid a fixed honorarium per day plus expenses, in others they offer free services free. In some countries problem-based learning facilitators might be highly paid specialists, in others they might be doctors in training or allied healthcare professionals. A cost analytic study that reports savings of a certain sum as a result of having larger groups and thus using fewer problem-based learning facilitators will mean a lot within the country where the research was done and in a country with similar system of medical education, but will mean little outside it. Currency and/or inflation adjustors will not help here.

So if hard currency as a means of expressing cost has its downsides, then what would be better? The short answer is that there may be no single best alternative and that it is probably best to cite both currency and some other denomination. In our search for alternatives, it is worth returning to what typically makes up costs in medication education. Different costs will need to be allocated in different circumstances but largely it is true that for most interventions costs will need to be allocated to faculty and staff, facilities, equipment and consumables (Walsh & Jaye 2013; Zendejas et al. 2013). It is an old adage that “costs walk in on two feet”, and it is likely that much of the cost of medical education is related to faculty and staff, and so it is worth starting with these. Faculty and staff can be described in terms of pounds and pence, and also in terms of tutors, tasks and time. A cost analysis paper that found a cost saving with a new assessment intervention might therefore report a saving of £10 000 and also express this as a saving of 30 hours of ten senior lecturers’ time in marking papers. This would be instantly understandable in all territories and contexts. In the case of facilities, a cost analysis might report a saving in terms of £20 000 of facilities no longer needed; it might also report it in terms of 40 hours in a 100-seat lecture hall saved. Finally in the case of equipment and consumables, a cost analysis might report £2000 of consumables saved and also state exactly what consumables were saved.

The purpose of cost analyses is to show readers how they might maximize value or save costs, readers will only be able to do this if outcomes data are accessible and in terms that they understand. For this reason it is likely to be best for cost analyses to describe outcomes in monetary terms and also in terms of the exact outcomes observed.

Declaration of interest: The author reports no conflicts of interest.