Issue 22 / 17 June 2013

WHAT does it cost a university to educate a medical student? Medical Deans Australia and New Zealand in 2011 estimated the cost was $50 000–$51 000 per student per year across a selection of medical schools.

With help from PricewaterhouseCoopers, we have estimated the cost in 2010 to the University of Sydney was $53 093 per student per year. This is in line with similar costing in the UK and the US.

While this was the actual cost to the university, we also examined a hidden cost — teaching not paid by the university. This is usually teaching carried out by government employees (mainly in hospitals) and in some cases by clinicians in private practice.

This teaching occurs throughout most medical courses, particularly in teaching hospitals. It includes teaching by paid medical, allied health and nursing staff in lectures, evidence-based learning sessions, small group tutorials at the bedside, in clinics, in skills laboratories and in community settings as well as opportunistic teaching.

Ward rounds, operating sessions, clinician, specialist and GP consulting room sessions take longer when medical students are present. This is effectively “teaching time”.

We found that the value of teaching provided to students at the Sydney Medical School in 2010 for which the university did not pay was $34 326 per student per year.

Taking both university and non-university components into account, the cost of face-to-face teaching in the final 2 years of the 4-year postgraduate course represented 79% of the total cost of face-to-face teaching.

This reflects the fact that while much teaching is given in lectures and in large practical group demonstrations, the majority of teaching in the final 2 years is in small group tutorials as well as one-to-one teaching.

So the true overall cost of teaching a medical student at the Sydney Medical School is the cost to the university of $53 093 plus the value of the time committed to face-to-face teaching by non-university paid teachers of $34 326 — a total of $87 419 per student per year.

International students (24% of the 2012 intake) pay the University of Sydney $62 880 per year.

It is interesting that health is one of the few professions where practitioners teach students on behalf of the university for no financial reward — simply altruism.

Professor Kerry Goulston and Professor Kim Oates are emeritus professors at the Sydney Medical School, University of Sydney.

10 thoughts on “Kerry Goulston

  1. kryan says:

    This is a splendid contribution to a long-overdue debate.

    Altruism is great stuff, but when those manifesting it are pressed, it tends to be pushed aside. Billionaires can afford to be altruistic and benefactorial: lesser-endowed mortals cannot.

    I find it exceedingly odd that a health services such as ours that has three principal activities – clinical care, research and education – struggles to support the latter two. I am not saying it provides no support – that would be wildly incorrect – but the contributions are not often as explicit as for clinical care and practitioners wonder about the seriousness of the commitment. Dedicated, paid time for research and teaching are under pressure from clinical duties all the time. Two things come to mind as ways forward.

    First, the ‘story’ of health care should more frequently rehearse why we do what we do, and the values that inform it. I have yet to hear a coherent story told about all the recent reforms (and I believe many have been valuable) and the values underlying them. Our leaders need to spell out the human concern that informs health care, education and research for the encouragement of us all.

    Second, budgeting needs to take account more formally of the costs of education and research support. It happens, but not perhaps as explicitly as it might. More explicitness might encourage young practitioners to see the value in research and education – and infuse their altruism with enthusiasm, not least because it is clearly economically viable.

  2. CKN Queensland Health says:

    Thank you for the great work on improving our understanding of the true investment in undergraduate medical education. It is worth also noting that, unlike some other health professions, there is little or no contribution of medical students to actual work in most hospitals and healthcare settings, as they are generally unable to perform many tasks autonomously  or even under supervision. Hence our return on this investment (ROI) is almost all in the future. The ROI is missing completely for IFFP students for whom your research suggests Australian doctors, health services and taxpayers are subsidisng $25,000 per year for each student, above their direct payment to the university.

    I am also not sure that practitioners are teaching students for ‘simple altruism’. Their contribution to teaching is admirable and hugely appreciated. However this cost is to some extent borne by health services who provide practitioners with time to teach in many cases, or whose efficient delivery of service is compromised by time senior practitioners spend teaching. Obviously health services and health professionals believe this is a good investment toward the future contrbution of those students. Many of these employers also recognise contrbutions to teaching in promotions and in selection criteria for senior positons. Involvement in teaching also provides a balanced professional life for many senior doctors, which is protective against burnout or departure from the profession. So – while admirable – I’m not sure its ‘simply altruism’.

    Thanks again for the great work in shining a light on the cost of medical education



  3. Chris Andrews says:

    This article highlights an issue I have met recently as far as examining medical students is concerned. I have been asked often to participate as examiner in final exams, and earlier year exams.

    Examining is a fundamental part of teaching. It is a highly predictable cost, able to be budgetted, and just so far from an optional extra to teaching that the two cannot be separated.

    I was asked again recently to assist examining final year graduating students. I was informed right up front that this activity was much appreciated – and I’m sure that is true, but it was expected to be an unpaid activity. The time involved for the full commitment was about 17 hours over a full weekend, although one could undertake part of that commitment.

    I have no fundamental necessity to be paid, and would be willing to donate this time. But the issue here is that this reflects the value placed on the activity by faculty. We all know we live in times of constraint, but for a fully precictable fundamental activity, this is real cost, and cannot be a part of on-the-cheap student training. Many of my colleagues are aware of this expression of low priority, and my feeling is that until we stand up and decline on behalf of faculty, then there will be ongoing expectation that training can be done on the cheap.

    I’ve often felt that one can tell the strength of a profession (having been part of three professions now) by the way it treats its young. The attitude of teaching/examining being a low priority activity does not express proper care for the future of our colleagues – nor of their patients when we are long gone.



  4. Dr F T Scheelings says:

    It has intrigued me for the last 5 years or so that I am asked to teach Medical student in my practice, which I never refuse if it is convenient as I feel it is an ethical duty, but have never been paid as my practice is not accredited.  Evidently I am not a good enough doctor when it comes to PIP payments but good enough to influence the future doctors of this nation, because I can’t be bothered with the beaurocracy of accreditation. Am I altruistic or just stupid?

  5. Dr Chris Mckenzie says:

    I have thought for sometime now that teaching in the country GP setting is far too important to do “on the run” as an aside, piecemeal, etc.  As Stephen Leeder says above “Altrusim is great but gets pushed aside in those who are pressed”.  The margins in GP land do not allow proper consideration to be given to teaching. If governments expect teaching from doctors it needs to be properly resourced & funded. Our future doctors deserve no less .

  6. Dr Alexander Bennie says:

    I greatly respect my Professor colleagues. I think medical education costing has a rightful place in the scheme of things. I could estimate that the opportunity cost of my teaching activities is about $25,000 per annum…so what ! I have always believed that I am one of the privileged. I have had a wonderful work life experience, doing what I have perceive was for the good of our community, but a material reward is as a consequence, not as an objective.  I do admit however, that in one of my roles I had to justify the indirect costs of medical education to demonstrate the value of teaching in a non-major teaching hospital setting….” it a core activity where there are clinical activity pressures…? ”.   What I find disconcerting is that we have to have these issues tabulated and defined. Yes, teaching is time consuming, but hey, the last tutorial I gave I had to do research. How good was that for me to dig deep into what I needed to brush up on..students come back at you with the most interesting challenges. Yes, let’s make sure that the fund holders know that medical education in Australia is different and there is opportunity cost involved. But let’s not overstate this to our newer generation of graduates who may not see altruism as an attribute. We must however, continue to challenge the fund holders. Medical practitioners have been sidelined at the “seat of distribution”. Other professions would not agree to provide teaching resource unless funds were directly provided. I for one, believe this would not be a good way to go as it may tend towards more of a funded faculty model and less reliance on experiential teaching.

  7. University of Tasmania says:

    I have worked around the world and since returning to Australia I have been saddened by the focus on money. This is just another example.  Is it not in the hipporcratic oath you take upon graduating To hold him who has taught me this art as equal to my parents and to live my life in partnership with him, and if he is in need of money to give him a share of mine, and to regard his offspring as equal to my brothers in male lineage and to teach them this art — if they desire to learn it — without fee and covenant

    Alturistic? I could go on but…The benefits you get in and the life long career you have, I think you should think of other trades and professions that work equally hard and train those that keep this country going.

  8. Christine Qian says:

    Universities these days sell medical degrees like commercial products, then expect over-worked doctors to do the teaching for them – for free.

  9. Dr David De Leacy says:

    This is a long overdue discussion that the medical profession, the wider community and, the politcal classes need to have. I believe that what evolved over the final decades of the last century, the first of this one and indeed is continuing to evolve is an accelerated loss of belief in or understanding of the importance of “Descarte’s Social Contract” which is the philosophical basis of our modern democratic nation state. The assault on ‘Descarte’ has been from both unfettered capitalism and progressive socialism (democratic or otherwise). The demise of the power and influence guilds (eg, the Specialist Colleges) that has inevitably occurred due to the concurrent rise of centralised government power (eg,  Medicare, AHPRA, etc) when combined with a general sense in the wider Australian community that the sole function of government is to nurture and foster a belief of entitlement rather than that of altruism, individualism and personal endeavour leads inevitably to an understandable sense of cynicism within our profession. It is a sad truth that only the lawyers of our country now control their fate and income by controlling the laws of the land. Not withstanding the above very pertinent reminder by “Caroline” of our Hippocratic Oath, the really hard-nosed question to answer now is: Are we really an independent profession or in truth just a relatively well paid regimented government employee group one step removed. If the latter pertains then surely the internal ‘hiding or cross-subsidising’ of the true costs of medical education is totally unjustified and indeed is unsustainable in the longer term.

  10. University of Sydney says:

    As a final year medical student, I have found the above article and replies rather interesting. Certainly I agree that “clincial work, research and education” (Prof. Leeder) are the foundations of a medical career. However, I’m interested that teaching during working hours (for example, small group tutorials, or even the attendance of medical students at ward rounds) is perceived as somehow separate from the other job requirements. I have always perceived teaching to be implicit in the job description of a doctor; whether that teaching be incidental discussions with juniour medical staff, presentations at grand rounds, discussions during mutidisciplinary meetings, or activites involving medical students. The environment is one of collaboration and sharing, as a part of clinical practice rather than seperate from it. Of course, there are examples of true altruism (such as that miraculous tutor who goes above and beyond), and certain activites that do require recompense, but essentially teaching is not an additional cost to the hospital, but an integrated activity.

    As an aside, I am obliged to point that medical students do contribute to the workforce, possibly in the most altruistic way of all (having incurred a heavy debt for their work, as opposed to financial recompense). The hours of unpaid labour medical students contribute to data analysis in research is probably the most significant, plus the clerking of patients, minor procedural skills etc. I’m sure the financial contribution of this is virtually insignificant. However, perhaps this discussion would be better focussed on acknowledgement of contribution rather than cost..?

    Thank you.

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