To teach or not to teach? A cost–benefit analysis of teaching in private general practice

As in many countries, Australia has increasing numbers of medical students,1 prevocational junior doctors and postgraduate vocational trainees who will place increasing demands on existing training posts in hospitals and general practice. For general practice, the increasing demand is likely to have a significant impact. Unlike public hospital settings, teaching in general practice uses private businesses within a fee-for-service arrangement, which affects the care provided, as well as space, staff resources and general practitioners’ time and income.2-4 This makes it different to other teaching environments, such as public hospitals, where supervisors are salaried.

In Australia, about 1305 of 9600 general practices are involved in teaching medical students, and 1933 are involved in general practice vocational training.5 With an estimated 3000 medical students, 900 interns and over 600 registrars requiring placement in general practice each year by 2012, training positions will fall well short of requirements unless more teaching sites are recruited or larger numbers of trainees are placed at each site.5

Some financial compensation for the impact of teaching on general practices and general practice supervisors is provided through various government schemes, but some of these subsidies have been documented as being inadequate.6,7 Many subsidies have been based on historic costing that may not reflect all aspects of teaching.

Some research has been undertaken on the financial costs of teaching in general practice, but mainly with a focus on the impact that medical students have on a supervisor’s productivity.3,8-11 None of these studies have placed a dollar value on this impact. Some studies have investigated the costs associated with an entire training program, but not at a practice level.12-15 To our knowledge, no studies have looked at the financial benefits associated with teaching in general practice, nor investigated the costs and benefits of teaching in private general practice across the whole medical training continuum. We aimed to identify the financial costs and benefits associated with teaching medical students, junior doctors (postgraduate year 1 and postgraduate year 2 or 3) and general practice registrars in private general practice.

Data on the time associated with teaching were obtained from a 2007 questionnaire-based survey of GPs who taught medical students, junior doctors and general practice registrars within their private general practices. Details of the survey method are provided elsewhere.6 Briefly, the Adelaide to Outback GP Training Program (AOGP)16 surveyed 325 GPs in 102 urban, outer metropolitan, rural and remote practices located in its training region. A response rate of 60% was achieved from general practice supervisors and 75% from general practices. A general practice supervisor is a GP who undertakes the primary teaching role in a practice (hereafter referred to as a “supervisor”). Also evaluated was the traditional model of teaching, involving one-on-one teaching by a supervisor within a practice — for example, a supervisor teaching a fourth-year medical student, junior doctor at postgraduate year 1 level (intern), or general practice registrar at basic level.

A cost–benefit analysis was performed on all levels of training in private general practice within the AOGP training region in South Australia and in association with the Discipline of General Practice at the University of Adelaide. Applying a practice perspective, costs were calculated by quantifying the resources used to teach and assigning a specific unit cost to these resources. The benefits associated with teaching were calculated using data collected on the income generated by trainees and the teaching subsidies received. For the medical student level, the analysis only applied to students placed in general practice through the undergraduate medical course provided by the University of Adelaide. The length of these placements varied with the year of study.

The study was overseen by a steering group, consisting of supervisors with experience in teaching at all levels investigated, who validated the methods and results. The study was approved by the University of Adelaide Human Research Ethics Committee.

The weekly financial costs and benefits associated with teaching medical students, junior doctors and general practice registrars in general practice (by stage within each of these training levels) are shown in Box 2.

For teaching medical students, there was a net financial cost for practices that was statistically significantly different from zero. For teaching junior doctors and general practice registrars, there were small net financial benefits to a practice, although the mean estimates were not statistically significantly different from zero. Within each of the three training levels, the net cost or net benefit varied according to the stage of training. For example, at the medical student level, the greatest significant net financial cost to practices for teaching was for fourth-year medical students (− $1385 per week; 95% CI, − $1746 to − $1100) and the least was for sixth-year medical students (− $630 per week; 95% CI, − $907 to − $400). The largest net financial benefit came from teaching interns ($484 per week; 95% CI, − $536 to $1026), although this estimate was not statistically significantly differently from zero.

The means and 95% CIs generated by the probabilistic sensitivity analysis for the net costs and benefits of teaching at different training levels are shown in Box 3. For all medical student stages, we can be certain that the net financial outcomes are negative. For general practice registrars, there is a high probability that the net financial outcomes are positive. The most uncertainty lies around the net financial outcome of teaching postgraduate year 1 and postgraduate year 2 or 3 trainees, where the net financial outcomes are more evenly distributed between positive and negative values.

The one-way sensitivity analysis indicated that for all stages of medical students, interns and general practice registrars, the net financial outcomes were most sensitive to the estimates of additional time per session. However, the effects on the net financial outcomes of applying the estimated 95% confidence limits for the additional time parameters were not large, indicating that the mean results are robust. For postgraduate year 2 or 3, the estimated net financial outcomes were highly sensitive to additional time per session.

These results show that the net financial outcome in a general practice of one supervisor teaching one type of trainee varies between training levels (medical student, junior doctor or general practice registrar). There was a significant net financial cost for teaching medical students, but there were net financial benefits for teaching junior doctors and general practice registrars.

Not surprisingly, the greatest cost driver at all levels was direct teaching activities. This finding complements those of other studies,3,9,11,19,20 which have found that teaching added time to patient consultations and total time spent at work, and reduced the number of patients seen by the supervisor. How a practice organises its teaching may reduce the impact that teaching has on consultation length. It has been reported that the use of a parallel consulting model for students does not significantly increase a rural GP’s consultation length.21 However, only a few studies have determined a monetary value for teaching time, included other activities related to teaching (such as teacher upskilling and administrative time) or looked beyond medical student training.3,10,11 Two studies found few differences in practice income if students were present or not,10,20 while another found that third-year medical students, in terms of supervisor time, cost $73.80 per day.11 To our knowledge, our study is the first to determine the financial costs and benefits associated with teaching in private general practice across the whole training continuum. Our costing analysis shows that interns were the most costly to teach when compared against all the training stages and levels investigated. However, these high costs were offset by commensurate benefits (subsidies and income generated by interns) for the practice. In contrast, at the medical student level, the benefits received by practices (subsidies) did not offset the costs.

These results have implications for the recruitment and retention of general practices as teaching environments, particularly for medical student teaching. Our results provide evidence for a review of these arrangements and an exploration of methods for recognising the accurate teaching costs for GPs, most specifically undergraduate medical teaching. One possible option for this level of teaching is to introduce a graduated subsidy rate, reflecting the varied costs of teaching within the stages of medical student training, as occurs at the prevocational and vocational training levels. Our results may also have implications for the involvement of other private health providers in teaching — for example, similar issues may arise in private hospitals and private allied health practices, particularly in light of the Health Workforce Australia funding for clinical training placements.22

Our study has a number of limitations. The data relate only to teaching in practices based in the AOGP region of SA. However, the profile of the practices that participated in the study suggests they are representative of practices across Australia. Additionally, the rates and subsidies were based on those used by the AOGP, and these may vary between training regions. The costing analysis was based on data self-reported by supervisors, so estimated time spent on teaching activities may be overestimated or underestimated, and this is a key limitation of our study. The scope of our study did not allow for formal triangulation of the results using a time-and-motion method, where these times are documented by observation. However, the results were reviewed by the study’s steering group and, based on their experience, assessed as valid. Data on numbers of patients seen by registrars were checked through a review of practice records for a number of registrars. We also reviewed the data to identify outlier results and, where possible, confirmed these with the respondent. Finally, coefficients of variation for the individual items assessing time were calculated and there were no major discrepancies regarding differences in variability across training levels.

This study only investigated the costs associated with medical undergraduate training and did not include graduate-entry medical students, therefore direct comparisons between universities may not be possible. Also, no distinction was made for subgroups within medical undergraduate training, such as rural cohorts where placement length differs and additional subsidies are available to practices. Even so, the financial model developed for this analysis could be adjusted to take these variations into account. Similarly, the number of practices involved in prevocational doctor training is limited at a national level, and linked to funding available for this training. However, SA has the largest number of intern positions in this program, with all the Prevocational General Practice Placements Program practices in the AOGP region involved in such training since at least 2005. Finally, other intangible benefits or costs of teaching for the supervisor were not included in the analysis. While these were identified in the survey,6 it was not possible to place a monetary value on these for this study, but this is worthy of consideration in the future.

Our study has shown there is a marginal net financial gain to general practices involved in prevocational and vocational training but not for those involved in undergraduate medical student training. A major contributor to these results appears to be the low level of teaching subsidies paid to practices for teaching medical students. It may be time to review the subsidies paid to teach medical students to ensure that, at the very least, a cost-neutral financial outcome is achieved. It may also be worthwhile exploring the net financial outcome of different models of teaching within general practice.

3 Mean weekly financial costs and net financial outcomes (NFOs), with 95% confidence intervals, of teaching in private general practice, by training level and stage