However, to become world class is expensive, and it is always worthwhile to wonder whether you are getting value for money. So, are we getting value for money from the education of our health professionals? First, is the education of health professionals effective, and second, is it as cost-effective as it could be? The short answer to both these questions is that no one really knows. The first question on the effectiveness of medical education is perhaps the easier to answer. Medical educational research is still in its early years, but it has made progress, and we now know much more than we did about what constitutes effective medical education. For example, we know that the active participation of learners in small groups is likely to be better than passive attendance at a lecture along with 200 other learners.¹ We know that assessment and exams should be practical, reliable and valid tests of applied knowledge, problem-solving skills and simulated behaviours rather than assessment of academic and seldom-applied knowledge.² We know that learning works best when it is practical and tied as closely as possible to the learner’s everyday working life, and that learners are much more likely to change and improve their actual practice when they are educated in this way.³ As our knowledge of the evidence base for effective learning has built up, many medical schools and postgraduate deaneries and providers of continuing professional education have stepped up to the mark and created new outcomes-based curricula, renovated their assessment methods and, in some cases, created workplace learning programmes. There is still a long way to go and we don’t frankly know if medical education is as effective as it should be, but we do know that it is more effective than it was.

Many would say that the current state of medical education is healthy or at least that it is taking a penetrating look at its weaknesses, is seeing how best to address these and is developing a coherent vision of what medical education should be like. For example, most health professionals are now signed up to the need for medical education to be explicitly focussed on improving the knowledge, skills and behaviours of such professionals with the clear and ultimate outcome of improving patient care.⁴ Most are signed up to the principle that, as health professionals work together in teams, they should learn together in teams and that the medical education community should pay more attention to integrated care and care pathways than it has in the past.⁵ Finally, most agree that medical education provision should be based on the needs of individual clinicians and the needs of patients and communities for whom they are responsible.⁶

However, one big issue for medical education that has not really been addressed until now is cost effectiveness. That is where our real lack of knowledge comes to the fore. There have been very few systematic studies of the cost effectiveness of medical education, and so we don’t really know the most cost-effective way to provide undergraduate, postgraduate or continuing medical education. Stated simply, we don’t know the most cost-effective way of designing a curriculum, rolling it out or doing a final evaluation of it a few years later. Considering the cost of medical education, there is remarkably little known about its cost effectiveness. There is little known about how to calculate costs, about what constitutes costs or how to get maximal value for money. Up to now, there have been no books on this subject and precious few articles. Most of the articles that do exist are reviews that bemoan the lack of original research in this area. So, this is exciting territory. In the current international economic climate, cost effectiveness in medicine and in medical education is likely to come to the fore in the coming months and years. If providers and commissioners of medical education have limited budgets or budgets that have been cut back, then they are likely to want to know how best to spend their money. For these reasons, the problems and potential solutions outlined in the following chapters are likely to be timely and important.

The costs of not providing high-quality medical education should also be considered. The most important one is the human cost—medical error accounts for a massive amount of morbidity and mortality, and error is very common. Approximately 2% to 14% of medication orders contain an error, and this is just prescribing error.⁷ Then, there is the financial cost to the health service in rehabilitating and caring for patients who have survived medical error as well as the costs to the economy in terms of lost productivity due to short- or long-term disability.⁸ To close the circle, there are the costs of rehabilitating those health professionals whose standards are no longer up to scratch or may never have been up to scratch in the first place—possibly because of inadequate undergraduate or postgraduate education or inadequate continuing professional development. Remediating health professionals who need to improve their clinical or non-clinical skills can be a long and expensive process.

There will be those, like Drummond Rennie in the opening quote, who are sceptical of the value of cost-effectiveness analysis. His quote will find echoes in a health-professional audience who have slowly come to terms with the concept of analysis of the cost effectiveness of healthcare and know the difficulties of changing long-held opinions even with new and compelling evidence that these opinions are wrong. But, this is a policy of despair: like evidence-based medicine, evidence-based medical education must become the only show in town—regardless of how uncomfortable we may feel with the outcomes of new research or analyses into medical education and its cost effectiveness.

There will be still more critics who will bemoan the emergence of a new cadre of medical education cost-effectiveness analysts poring over direct and indirect costs of medical education resources. A famous and favourite quote for educationalists is that of Yeats–‘education is not the filling of a pail but the lighting of a fire’, which is a sentiment that will always sit uncomfortably with closely managed education that is held to strict fiscal account. However, the worldwide recession and economic winter facing many healthcare and health education budgets will mean that the cost of medical education will need to be measured and economies made when possible.

The questions that remain are how best to make such measurements and how and where to make economies—the following chapters will hopefully shed some light on how best to come up with answers to these questions. One question, though, can be answered at the start: high-quality and effective medical education is essential—we must never sacrifice this at the altar of cost.