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Letters to the Editor

Cost Must Be a Theme in Our Measurement of Accountability

Walsh, Kieran, FRCPI

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doi: 10.1097/ACM.0000000000000208
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To the Editor:

Baron has presented a fascinating account of the current state of public accountability for graduate medical education (GME) outcomes.1 He is wisely reluctant to recommend too many extra measures and thereby to risk unnecessarily adding to an already heavy measurement burden. Instead he concentrates on themes such as competence, the learning environment, and workforce outcomes. However, there is one theme that I feel he has missed out on—that of cost.

It is difficult to think of a context other than GME where authorities discuss accountability without explicit mention of cost. Shouldn’t we have better public accountability because public money is being spent to fund GME programs? Doesn’t the public have the right to ask whether it gets value for the money spent on these programs? Could institutions run lower-cost programs and achieve the same outcomes? Or could a higher quantity and/or quality of trained specialists be produced with the same expenditure? The short answer to all of these questions is that we don’t know because the research has not yet been done.2

Fortunately, there is a growing interest in cost and value in medical education. Measuring the cost of programs, however, is not completely straightforward, as it is often difficult to delineate and separate out the cost of the provision of medical education and the cost of provision of health care. This is particularly true of GME where trainees learn and work at the same time.3 However, some components of education (and therefore their costs) can be separated from health care. These include curriculum design, direct provision of medical education (e.g., through lectures, small-group sessions, or simulation), assessment of trainees, and evaluation of training programs. Even more difficult is the development of measures that touch on cost as well as outcomes. These might include outcomes of good comparative cost-effectiveness, or favorable cost-benefit or cost-utility ratios, or even simple cost feasibility studies.4(p10) Baron touches on these concepts when discussing workforce outcomes, but only tangentially.

When discussing workforce outcomes, we are considering our return on investment. In a country that needs more rural physicians, the 26.1% of sponsoring institutions that are producing no rural physicians are providing a low return on investment.1 Themes of accountability within medical education have been around a long time, but we seem to have made fitful progress. Could the overt measurement of cost and value make us realize that we now need to make more rapid progress?

Kieran Walsh, FRCPI

Clinical director of BMJ Learning, BMJ Publishing

Group, London, UK;


1. Baron RB. Can we achieve public accountability for graduate medical education outcomes? Acad Med. 2013;88:1199–1201
2. Walsh K Cost Effectiveness in Medical Education. 2010 Abingdon, UK Radcliffe
3. Williams C. Understanding the essential elements of work-based learning and its relevance to everyday clinical practice. J Nurs Manag. 2010;18:624–632
4. Levin HM, McEwan PJ Cost Effectiveness Analysis: Methods and Applications. 20012nd ed Thousand Oaks, Calif Sage Publications
© 2014 by the Association of American Medical Colleges