Adv in Health Sci Educ DOI 10.1007/s10459-014-9544-2 REFLEXIONS

Cost in medical education: one hundred and twenty years ago Kieran Walsh

Received: 8 June 2014 / Accepted: 6 August 2014 Ó Springer Science+Business Media Dordrecht 2014

Abstract The first full paper that is dedicated to cost in medical education appears in the BMJ in 1893. This paper ‘‘The cost of a medical education’’ outlines the likely costs associated with undergraduate education at the end of the nineteenth century, and offers guidance to the student on how to make financial planning. Many lessons can be gleaned from the paper about the cost and other aspects of nineteenth century medical education. Cost is viewed almost exclusively from the domain of the male gender. Cost is viewed not just from the perspective of a young man but of a young gentleman. There is a strong implication that medicine is a club and that you have to have money to join the club and then to take part in the club’s activities. Cost affects choice of medical school and selection into schools. The paper places great emphasis on the importance of passing exams at their first sitting and progressing through each year in a timely manner—mainly to save costs. The subject of cost is viewed from the perspective of the payer—at this time students and their families. The paper encourages the reader to reflect on what has and has not changed in this field since 1893. Modern medical education is still expensive; its expense deters students; and we have only started to think about how to control costs or how to ensure value. Too much of the cost of medical education continues to burden students and their families. Keywords

Medical education  Cost  History

There is a growing interest in the subject of cost and value in medical education. (Walsh 2010) Over the past 10 years an increasing number of orginal articles, systematic reviews and opinion pieces have appeared on the subject. (Cookson et al. 2011, Walsh et al. 2013) And yet the subject is not a new one - there have been references to cost and value in medical education from the eighteenth century literature. (Smith 1776) However the first

K. Walsh (&) BMJ Learning, BMA House, Tavistock Square, London WC1H 9JR, UK e-mail: [email protected]

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full paper that is dedicated to the subject that I can find appears in the BMJ in 1893. This paper ‘‘The cost of a medical education’’ outlines the likely costs associated with undergraduate education at the end of the nineteenth century, and offers guidance to the current or prospective student on how to make financial planning for their medical education. (Cost of Medical Education 1893) In this short From the Archives piece I review the article with a view to sharing lessons from the past. How much can you learn from a single paper? In this case, I think that you can learn quite a lot. Even though the paper concentrates on the UK, much of the content is relevant in all countries. One thing that you learn from the paper is that the subject of cost is viewed almost exclusively from the domain of the male gender. Even though medical education was available for women at the end of the nineteenth century, the paper makes only a single reference to female medical students (a tangential reference to the London School of Medicine for Women). By contrast there are constant references to the male gender—to ‘‘any man’’, to ‘‘men’’, to ‘‘his future’’. Whether the cost of medical education for women might be more or less is not referred to. Another thing that you learn is that cost was viewed not just from the perspective of a young man but of a young gentleman. So the text refers to giving ‘‘an idea of what a gentleman willing to live carefully can keep himself upon’’. It is assumed that medical school is a place for gentlemen and where gentlemanly activities are undertaken. The paper discusses what style of life a medical student should aspire to and mentions what holders of various occupations would expect to live on. So there are the expenses of an artisan, a ‘‘blackcoated clerk’’ and a curate—but most importantly those of a gentleman. The paper must have been actively off off-putting to anyone not from the upper classes. Diversification of medical school attendees would have been a foreign concept at the time. And what would a medical student of the time be spending their budget on? Here again there are surprises. Apart from the expected expenses on accommodation, subsistence, books and equipment, there are constant references to the expense of sporting activities. So there is mention of ‘‘cricket, football, or rowing clubs’’. According to the author ‘‘the athletic side of education is really more necessary for the medical than for any other class of student.’’ Although not explicitly mentioned, there is the implication that the medical student should be a Renaissance man—athletic but also learned in the classics, and indeed the text is littered with Latinisms. There is also a strong implication that medicine is a club and that you have to have money to buy into the club and then to take part in the club’s activities. One hall of residence is referred to as having ‘‘the character of a club so far as admission is concerned, applications being voted on by the residents’’. A financial cushion should enable the student to avoid having ‘‘to study economy and even parsimony at the expense of sociability’’. Students ‘‘chum together’’ and become part of a ‘‘set’’. Living too frugally results in the student losing ‘‘a great part of those wider educational advantages which a more intimate association with his fellows ought to give.’’ Do cost factors affect choice of medical school? Of course they do: ‘‘richer men tend to flock to the more expensive schools, where it is difficult to prevent them from setting the fashion in many ways’’. Once again the implication is clear: poor men will tend not to go to expensive schools and, even if they do, will probably feel out of place. Costs and expenses in medical education are not viewed in isolation—the effect that excess spending may have on the moral character of students is also considered. The ultimate aim of supervision of a student’s finances is to prevent ‘‘loafing or dissipation’’. After emphasising the importance of cost to enable the student to buy into the club of medicine, the author does eventually touch on what you might have thought would be the

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core purpose of the article—to outline the costs of ‘‘the fees for medical schools and hospital attendance’’, the ‘‘fees for examinations’’, and the fees for books and materials. Undergraduate examinations loom large in the discussion of cost. The main reason is that failure in an exam will delay graduation and increase cost. This point is made repeatedly. The author emphasises the importance of passing exams at their first sitting—mainly to save costs. The students and their families are clearly the payers of the fees and so the paper views the subject of cost solely from their perspective. On reading the paper one could be forgiven for thinking that the core purpose of medical education is to pass exams and then to earn a living. So anything that would delay passing an exam (be it lack of study or ill-health) will have an adverse effect on costs and thus achievement of the student’s goal. The author is also explicit that undergraduate medical education ‘‘leads to little else but medicine’’; so study that does not lead to qualification as a doctor is simply time and finances gone to waste. The paper looks only at the cost of medical education in both the cities and the provinces. The big cities dominate much of the content. The author repeatedly emphasises the high costs of the metropolitan schools and the high costs of city living in comparison with the lower costs of the provincial schools and provincial living. The paper does suggest some means by which costs could be controlled or diminished. Scholarships and prizes are one means although the author is realistic enough to admit that this will only help a few people. It also suggests that ‘‘in the fifth year it might be possible to act as assistant to a practitioner and so diminish the expense of living’’. However once again it broadly advises against this strategy as acting as an assistant might take time away from studies and hospital attendance. The paper touches on the subject of selection for medical school towards the end. The paper recommends that ‘‘intellectual fitness should certainly be borne in mind not only in the choice of one’s profession, but in the arrangement of one’s studies.’’ Once again the main reason why bright young people should apply is that they will be able to complete their course in the allotted time and thus save costs. Indeed the paper suggests that the prospective student should try to pass exams in ‘‘chemistry and physics, practical chemistry, and elementary biology’’ before becoming a student—once again to reduce the risk of financial mishap that comes with failing exams. As is often the case with reading historical documents, it is easy to see what is mentioned but more difficult to notice what is absent. However some omissions are worth noting. There is no mention of international medical education, interprofessional education, student choice, learning environments, postgraduate training, the humanities, study skills, supervision, mentoring, remediation, transitions, feedback, evaluation, or quality improvement. This is no mention of patients. Surprisingly for a paper on cost, there is no mention of value. There is no author, and so no declaration that competing interests are present or absent. Could this be because the author mentions individual schools and their advantages and disadvantages, and fears repercussions as a result? It is impossible to tell. However there are at least two lessons that can be drawn from the paper. The first lesson is that we have made progress in many areas. Medical education is no longer just a manly or gentlemanly reserve. In the twenty-first century in most countries, very many students are female, and many are of middle class origin. Medical education is no longer just about passing exams as quickly as possible to save money and then to start earning money—the modern era has brought reforms in medical education in all the fields mentioned in the last paragraph. So there is good news—we have made some progress. However there is still more progress to be made. In the twenty-first century we continue to be preoccupied with the concept of the graduate doctor as a Renaissance person. So we

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encourage the pursuit of various subjects such as art or literature during the course of medical education. Is this so very different to the practice of our nineteenth century forebears with their penchant for classical scholarship? The subjects might have changes but the underlying theme is probably continuing. Although in the modern era we try to engender in our students notions of service and social contract, medicine as a career still commands considerable income and prestige. It is worth considering how much progress we have really made here from the graduate of the past who was transparent about the need to pass medical exams in order to start to generate an income. The Victorian doctor might not be all that out of place in the twenty-first century. But the second lesson is not so good at all. In the area of cost in medical education we have made little or no progress. Twenty-first century medical education is still expensive; its expense deters students; and we have only started to think about how to control costs or how to ensure value for a given cost. Too much of the cost of medical education continues to burden individual students and their families. It is still difficult to become a doctor if you are poor.

References Cookson, J., Crossley, J., Fagan, G., McKendree, J., & Mohsen, A. (2011). A final clinical examination using a sequential design to improve cost-effectiveness. Medical Education, 45(7), 741–747. Cost of Medical Education (1893) British Medical Journal Sep 2; 2(1705): 536. Smith A. (1776) The Wealth of Nations. Bk I:X. Walsh, K. (Ed.). (2010). Cost effectiveness in medical education. Abingdon: Radcliffe. Walsh, K., Levin, H., Jaye, P., & Gazzard, J. (2013). Cost analyses approaches in medical education: there are no simple solutions. Medical Education, 47(10), 962–968.

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Cost in medical education: one hundred and twenty years ago.

The first full paper that is dedicated to cost in medical education appears in the BMJ in 1893. This paper "The cost of a medical education" outlines ...
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