A pilot study of the cost of educating undergraduate medical students at Virginia Commonwealth University

Never again? Challenges in transforming the health workforce landscape in post-Ebola West Africa

BACKGROUND

The 2013-2014 West African Ebola outbreak highlighted how the world's weakest health systems threaten global health security and heralded huge support for their recovery. All three Ebola-affected countries had large shortfalls and maldistribution in their health workforce before the crisis, which were made worse by the epidemic. This paper analyzes the investment plans in Liberia, Sierra Leone, and Guinea to strengthen their health workforces and assesses their potential contribution to the re-establishment and strengthening of their health systems. The analysis calculates the plans' costs and compares those to likely fiscal space, to assess feasibility.

METHODS

Public sector payroll data from 2015 from each country was used for the workforce analysis and does not include the private sector. Data were coded into the major cadres defined by the International Standard Classification of Occupations (ISCO-88). We estimated health worker training numbers and costs to meet international health worker density targets in the future and used sensitivity analysis to model hypothetical alternate estimates of attrition, drop-outs, and employment rates.

RESULTS

Health worker-to-population density targets per 1000 population for doctors, nurses, and midwives are only specified in Liberia (1.12) and Guinea's (0.78) investment plans and fall far short of the regional average for Africa (1.33) or international benchmarks of 2.5 per 1000 population and 4.45 for universal health coverage. Even these modest targets translate into substantial scaling-up requirements with Liberia having to almost double, Guinea quadruple, and Sierra Leone having to increase its workforce by seven to tenfold to achieve Liberia and Guinea's targets. Costs per capita to meet the 2.5 per 1000 population density targets with 5% attrition, 10% drop-out, and 75% employment rate range from US$4.2 in Guinea to US$7.9 in Liberia in 2029, with projected fiscal space being adequate to accommodate the proposed scaling-up targets in both countries.

CONCLUSIONS

Achieving even a modest scale-up of health workforce will require a steady growth in health budgets, a long-term horizon and substantial scale-up of current training institution capacity. Increasing value-for-money in health workforce investments will require more efficient geographical distribution of the health workforce and more consideration to the mix of cadres to be scaled-up.

Cost-effectiveness of peer role play and standardized patients in undergraduate communication training

BACKGROUND

The few studies directly comparing the methodological approach of peer role play (RP) and standardized patients (SP) for the delivery of communication skills all suggest that both methods are effective. In this study we calculated the costs of both methods (given comparable outcomes) and are the first to generate a differential cost-effectiveness analysis of both methods.

METHODS

Medical students in their prefinal year were randomly assigned to one of two groups receiving communication training in Pediatrics either with RP (N = 34) or 19 individually trained SP (N = 35). In an OSCE with standardized patients using the Calgary-Cambridge Referenced Observation Guide both groups achieved comparable high scores (results published). In this study, corresponding costs were assessed as man-hours resulting from hours of work of SP and tutors. A cost-effectiveness analysis was performed.

RESULTS

Cost-effectiveness analysis revealed a major advantage for RP as compared to SP (112 vs. 172 man hours; cost effectiveness ratio .74 vs. .45) at comparable performance levels after training with both methods.

CONCLUSIONS

While both peer role play and training with standardized patients have their value in medical curricula, RP has a major advantage in terms of cost-effectiveness. This could be taken into account in future decisions.

Medical student education: what it costs and how it is funded

The cost to Sydney University to educate a medical student in 2010 was obtained by dividing the total teaching costs by the number of students. This showed the annual cost to educate one medical student was $53,093. Sixty-one per cent comprised salaries. Fifty-three per cent is met by Commonwealth funding and the Higher Education Loan Programme. Fees from international medical students contributed a margin of only 2% towards total education costs. The shortfall of 45% is provided from other sources within the university. This cross-subsidisation may not be sustainable.

Burnout and serious thoughts of dropping out of medical school: a multi-institutional study

PURPOSE

Little is known about students who seriously consider dropping out of medical school. The authors assessed the severity of thoughts of dropping out and explored the relationship of such thoughts with burnout and other indicators of distress.

METHOD

The authors surveyed medical students attending five medical schools in 2006 and 2007 (prospective cohort) and included two additional medical schools in 2007 (cross-sectional cohort). The survey included questions about thoughts of dropping out, life events in the previous 12 months, and validated instruments evaluating burnout, depression symptoms, and quality of life (QOL).

RESULTS

Data were provided by 858 (65%) students in the prospective cohort and 2,248 (52%) in the cross-sectional cohort. Of 2,222 respondents, 243 (11%) indicated having serious thoughts of dropping out within the last year. Burnout (P < .0001), QOL (P < .003 each domain), and depressive symptoms (P < .0001) at baseline predicted serious thoughts of dropping out during the following year. Each one-point increase in emotional exhaustion and depersonalization score and one-point decrease in personal accomplishment score at baseline was associated with a 7% increase in the odds of serious thoughts of dropping out during the following year. On subsequent confirmatory multivariable analysis, low scores for personal accomplishment, lower mental and physical QOL, and having children were independent predictors of students having serious thoughts of dropping out during the following year.

CONCLUSIONS

Approximately 11% of students have serious thoughts of dropping out of medical school each year. Burnout seems to be associated with increased likelihood of serious thoughts of dropping out.

No debt for medical students in Greece

BACKGROUND

Medical education in Greece is government-funded by constitution. Tuition fees are therefore not payable by students. This investigation aims to identify the sources of income of medical students in Greece.

METHODS

This is a questionnaire-based analysis of a sample of 488 students who were asked to state their sources of income.

RESULTS

Mean contributions to total student income are parental financial support (93.2%), part-time employment (2.4%), scholarships (2.5%) and other sources including loans (1.9%).

CONCLUSION

The income of medical students in Greece is mostly dependent on parental contributions. Other sources do not represent popular options. This situation differs to that in other countries, where loans make significant contributions to the total income of medical students.

Assessing the cost of a cardiology residency program with a cost construction model

BACKGROUND

Although the total costs of graduate medical education are difficult to quantify, this information is of great importance in planning over the next decade.

METHODS AND RESULTS

A cost construction model was used to quantify the costs of teaching faculty, cardiology fellows' salaries and benefits, overhead (physical plant, equipment, and support staff), and other costs associated with the cardiology residency program at the University of Texas-Houston during the 1996 to 1997 academic year. Surveys of cardiology faculty and fellows, checked by the program director, were conducted to determine the time spent in teaching activities; access to institutional and departmental financial records was obtained to quantify associated costs. The model was then developed and examined for a range of assumptions concerning cardiology fellows' productivity, replacement costs, and the cost allocation of activities jointly producing clinical care and education. The instructional cost of training (cost of didactic, direct clinical supervision, preparation for teaching, and teaching-related administration, plus the support of the teaching program) was estimated at $73,939 per cardiology fellow per year. This cost was less than the estimated replacement value of the teaching and clinical services provided by cardiology fellows, $100,937 per cardiology fellow per year. Sensitivity analysis, with different assumptions on cardiology fellows' productivity and replacement costs, varied the cost estimates but generally represented the cardiology residency program as an asset.

CONCLUSIONS

Cost construction models can be used as a tool to estimate variations in resource requirements resulting from changes in curriculum or educators' costs. In this residency, the value of the teaching and clinical services provided by cardiology fellows exceeded the cost of the resources used in the educational program.

Rewarding teaching faculty with a reimbursement plan

OBJECTIVE

To develop a system for measuring the teaching effort of medical school faculty and to implement a payment system that is based on it.

DESIGN

An interventional study with outcomes measured before and after the intervention.

SETTING

A department of internal medicine with a university hospital and an affiliated Veterans Administration hospital.

INTERVENTION

We assigned a value in teaching units to each teaching activity in proportion to the time expended by the faculty and the intensity of their effort. We then calculated total teaching units for each faculty member in the Division of General Internal Medicine and for combined faculty effort in each subspecialty division in the Department of Medicine. After determining the dollar value for a teaching unit, we distributed discretionary teaching dollars to each faculty member in the Division of General Internal Medicine and to each subspecialty division according to total teaching units.

MEASUREMENTS AND MAIN RESULTS

The distribution of discretionary teaching dollars was determined. In the year after the intervention, there was a substantial redistribution of discretionary teaching dollars among divisions. Compared with an increase in total discretionary dollars of 11.4%, the change in allocation for individual divisions ranged from an increase of 78.2% to a decrease of -28.5%. Further changes in the second year after the intervention were modest. The distribution of teaching units among divisions was similar to the distribution of questions across subspecialties on the American College of Physicians In-Training Examination (r =.67) and the American Board of Internal Medicine Certifying Examination (r =.88).

CONCLUSIONS

It is possible to measure the value of teaching effort by medical school faculty and to distribute discretionary teaching funds among divisions according to the value of teaching effort. When this intervention was used at our institution, there were substantial changes in the amounts received by some divisions. We believe that the new distribution more closely approximates the desired distribution because it reflects the desired emphasis on knowledge as measured by two of the most experienced professional groups in internal medicine. We also believe that our method is flexible and adaptable to the needs of most clinical teaching