Letters to the Editor
To the Editor:
Dr. Whitcomb1 eloquently captures a dilemma facing graduate medical education programs in the United States. The core problem is a financial one. Dr. Whitcomb is correct that the current U.S. political climate makes increased funding for medical education seem unlikely, and that more will have to be done with the funding that is currently available. In such a context it is tempting to believe that shortening graduate medical education could help ease the financial burden. To achieve better educational and workforce outcomes with current funding requires increasing value in medical education, but there is a lack of evidence base about how to achieve this. The choice facing medical education is stark: Develop an evidence base for creating value and act upon it, or face the possibility of market failure in medical education.
Shorter training programs might be one way to achieve greater value. Others might include interprofessional education, modular training resulting in a more flexible workforce, e-learning, low-technology simulation programs, ambulatory care training, importing doctors, skill shifting so that other staff can do the work traditionally done by doctors, decreasing dropout rates, and perhaps even more large-group teaching. The possibilities are myriad—what they have in common is a strong prima facie case that they could save money and achieve reasonable educational and workforce outcomes, and yet no economic evidence base that they would increase value in medical education.
In many industries, market failure results when stakeholders follow their own exclusive self-interest at the expense of and to the detriment of others’ interests. The result is inefficiency and ultimately unaffordability. Could providers of medical education be such stakeholders? Certainly it is tempting for individual specialties to make a series of small decisions that are in their own interest and to continually defer big decisions—like how to establish low-cost workforce development that will give the population the health care workforce that it needs. Developing a strong evidence base for how to achieve value in medical education can better inform the use of limited resources for maximum benefit and avoid market failure.
Kieran Walsh, FRCPI, FHEA
Clinical director of BMJ Learning, the medical education service of the BMJ Group, London, United Kingdom; firstname.lastname@example.org.
1. Whitcomb ME. Decreasing the length of residency training: A public policy perspective. Acad Med. 2013;88:1802–1803