Jones R F, Korn D
Section for Institutional and Faculty Policy Studies, Association of American Medical Colleges, Washington, D.C. (AAMC) 20037, USA.
Acad Med. 1997 Mar;72(3):200-10. doi: 10.1097/00001888-199703000-00015.
The cost of educating a medical student has been an issue of intermittent public concern for most of the twentieth century, beginning in 1910 with the Flexner Report. The issue is now reemerging as a topic of high public and political interest, for several reasons, including concern about medical schools and their financing. Estimates of medical student education costs appear to vary widely; but such variations derive from the different ways the question has been framed. Costs can be categorized as instructional costs and total educational resource costs. Instructional costs, which can be distinguished further as marginal costs or proportionate-share costs, are those costs that can be related directly to the teaching program and its support. Total educational resource costs are those costs supporting all faculty deemed necessary to conduct undergraduate medical education in all their activities of teaching, research, scholarship, and patient care. The authors review studies spanning a period of more than 20 years and find that instructional cost estimates of medical student education, when adjusted to a standard base year (1996 dollars), fall within a fairly narrow range: most are between $40,000 and $50,000 per student per year. Estimates of total educational resource costs show greater variation, but four of six estimates fall between approximately $72,000 and $93,000 per student per year. The authors note that present directions of curricular innovation-small-group learning, investment in information technology, and clinical education in ambulatory sites-offer little solace to those concerned with mitigating the costs of medical student education. Several proposals have been advanced to restructure medical student education in the name of efficiency and cost-effectiveness, but many are simply maneuvers to transfer responsibility for costs to other entities. Only by a net reduction of the medical school curriculum might costs truly be reduced. Yet the medical knowledge base continues to increase, as does the range of information and skills required of medical students. Unless society is prepared to change dramatically its concept of the well-educated physician, opportunities for significant reductions in the costs of medical student education are difficult to visualize.
自1910年《弗莱克斯纳报告》问世以来，医学生教育成本问题在20世纪的大部分时间里一直间歇性地引发公众关注。如今，由于包括对医学院及其资金状况的担忧在内的多种原因，这个问题再度成为公众和政治高度关注的话题。医学生教育成本的估算似乎差异很大；但这种差异源于问题的不同表述方式。成本可分为教学成本和教育资源总成本。教学成本可进一步区分为边际成本或比例份额成本，是那些可直接与教学计划及其支持相关的成本。教育资源总成本是指支持所有被视为开展本科医学教育所需的教职员工进行教学、研究、学术和患者护理等所有活动的成本。作者回顾了跨度超过20年的研究，发现当将医学生教育的教学成本估算调整到标准基年（1996年美元）时，其范围相当狭窄：大多数为每年每名学生40,000美元至50,000美元之间。教育资源总成本的估算差异更大，但六项估算中有四项落在每年每名学生约72,000美元至93,000美元之间。作者指出，当前课程创新的方向——小组学习、信息技术投资以及门诊场所的临床教育——对于那些关注降低医学生教育成本的人来说，并没有带来多少慰藉。为了提高效率和成本效益，已经提出了几项重组医学生教育的提议，但许多提议不过是将成本责任转嫁给其他实体的手段。只有通过净减少医学院课程，成本才可能真正降低。然而，医学知识库在不断扩大，医学生所需的信息和技能范围也在不断增加。除非社会准备大幅改变其对受过良好教育的医生的观念，否则很难想象有大幅降低医学生教育成本的机会。
