Financial Costs of Surgical Training - Ed Fitzgerald - JASGBI News

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AssociationofSurgeonsofGreatBritainandIreland

NEWSLETTER

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25,March2009

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THE FINANCIAL COSTS OFSURGICAL TRAINING

Ed Fitzgerald, Vice-President, Association ofSurgeons in Training.

Money is the barometer of a society's virtue.

Ayn Rand

(Russian born American Writer and Novelist,

1905-1982)

The economics of healthcare regularly feature inmainstream media these days, with increasingnumbers of pejorative articles focussing ondoctors (largely GPs) salaries. Little mediaattention is given to the costs incurred in thecourse of professional training to reach this

position. Indeed, outside of medicine, manycomparable professions will cover these coststhrough commercial sponsorship or competitivefunding bursaries. For current medical traineesthese costs have risen rapidly in recent years, withno such sponsorship or means of offsetting them.

With the advent of tuition fees, training fees, lossof free hospital accommodation, reduced pay

banding, reduced study leave budgets andincreasingly expensive courses and exams, theaverage trainee currently feels like their pocket isgetting very tightly squeezed.

As a post-graduate, craft-based profession with atraditionally longer period of training, surgicaltrainees have been particularly affected. Thecontroversial new ISCP training fee, stronglyopposed by ASiT, was introduced in 2008 tosecure funding for the Joint Committee onSurgical Training (JCST) and in doing so re-

focussed attention on this area. ASiT concernsnonetheless pre-date this, with our 2007 positionstatement on the costs of surgical training seekingto raise awareness of these spiralling expenses[1].

There is little data, and even less debate, in thisarea, and whilst some may dismiss such costs asthe price to pay for a professional career, there arealso other broader issues raised. With medicinealready criticised for being a predominatelymiddle-class profession, it is hard to see how such

post-graduate costs will encourage lessadvantaged trainees to embark on a surgicalcareer. Discouraging good trainees disadvantages

the surgical profession as a whole, and severalinternational medical workforce studies alreadylink indebtedness, or anticipation of this, withchoice of speciality[2, 3].

What Influences the Costs of Training?Numerous factors have sought to rapidly inflate thecosts of surgical training. Not only have costs risen,

but income in terms of study-leave budgets and

salaries have also fallen for all junior doctors, notjust in surgery. EWTD has impacted on salariesthrough reduction of hours worked and thesubsequent reduction in pay-banding. Well-

publicised pressures on NHS budgets havegradually eroded the study-leave budget, which is,in any case, highly variable between Deaneries.Marked increases in the Intercollegiate Exam andPMETB fees in recent years have also beenhighlighted as contributing to the rising expenditure.

The reduction in working hours has served toincrease the onus on alternative modes ofeducation, through courses, conferences andexternal lectures. Speciality skills courses runthrough the Royal Colleges now typically cost theequivalent of two-years worth of study leave

budget per two-day course. Many of these arevoluntary for the individual trainee, however thehighly competitive nature of surgery is such thatmany feel there is little option but to undertakesuch courses in order to remain a viable applicantfor future posts.

The thorniest funding issue of all in recent timeshas been the introduction of the ISCP training fee

by the JCST, which has created divisions at alllevels of the surgical profession. ASiT has firmlyopposed this on the basis that the ISCP is still notfully functional and that, until such a time as thesystem has proven utility, its development costsshould not be passed on to trainees. Whilst it isaccepted that these fees only cover a proportion ofthe costs incurred, the JCST is a body that has

been commissioned by the Royal Colleges, andASiT feels that funding should, therefore, becovered by its commissioners. There has been, andstill is, a huge strength of bad feeling amongsttrainees regarding this issue. ASiT continues toactively raise this matter and still seeks a means ofdiscarding this fee or, at the very least, absorbingit into College or specialist society subscriptions.

How Much Does Training Cost?What is a cynic? A man who knows the price ofeverything and the value of nothingOscar Wilde (1854-1900)

Estimating the cost of surgical training is complex.Direct costs incurred by the individual throughtangible expenses are easy to quantify, howevercosts in terms of lost or reduced income from

periods of higher research or training fellowshipsare more difficult to estimate. Both of these must

be balanced against the costs incurred by societyas a whole through postgraduate deanery expensesand subsidised University tuition fees.

Taking into account costs to the individual first,any consideration of post-graduate training must

be placed in the context of expenses already

Figure 1: Proportions of public versus trainee funding in surgical training. (Adapted from The Costof Surgical Training Position Statement by the Association of Surgeons in Training, May 2007)


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incurred for undergraduate education. As anyparent reading this will know, with theintroduction of University tuition fees in 1998these costs are considerable and are rising year-on-year. The annual BMA Survey of StudentFinance shows that the average debt forgraduating medical students in 2006-2007 was21,057. For students starting medical school inthe current academic year this is projected toreach 37,000 at qualification[4].

Previous work by ASiT in 2007 calculated thecumulative costs to the individual trainee asapproximately 130,000, with a further cost tosociety of 282,000 for a typical surgical training

pathway (five-year university medical course, one-year pre-registration year, two years of basicsurgical training, two years of dedicated research,and five years of higher surgical training with anadditional fellowship year). The relative proportionsof public versus trainee funding will also varythroughout these different stages of training.

Figure 1provides an estimate of this variation.

In the space of two years, considerable changes

have occurred in both the typical surgical trainingpathway and the costs incurred as trainees progressalong this. Most recently, a small study investigatedthe average financial costs borne by surgicaltrainees in the early stages of speciality trainingwithin the Trent Deanery[5]. Trainees contributed amean 5,975 from their own income by the end ofthe third year of surgical training, with the greatest

proportion spent on recommended or mandatorysurgical training courses. A breakdown of thesefigures is given inFigure 2. This compares to2,755 as estimated by ASiT for the same time

period in 2007, and both pre-date the new JCSTtraining fee. Of note, these figures all omit fixedcosts such as GMC Registration, Royal College andindemnity fees, etc. that would be similarlyincurred within other medical specialities.

Figure 2: Breakdown of the mean costs ofsurgical training

Internationally, many would consider these coststo be a tiny fraction of what trainees might incurin the course of surgical training. Comparabletraining programmes in both Australia and NorthAmerica result in debts several orders ofmagnitude greater than this. However, this must

be taken in the context of higher starting salariesand considerably greater earning potential fromlargely private healthcare systems.

Who Should Pay For Surgical Training?The principle of beneficiary pays is often adoptedin discussing relative funding contributions whereseveral groups benefit from the end product, withthe contribution in proportion to the benefit gained.In the case of qualified surgeons a wide range ofgroups can lay claim to receiving benefits inaddition to patients, and surgeons own bank

balances in later life (Figure 3).

Some argue that it would be unacceptable forprivate healthcare providers to make considerablefinancial profit from surgeons withoutcontributing something towards their training. Inthe fully commercialised world of UK healthcare,surgeons would sell their services to such

providers at a rate freely determined by marketforces, and in combination with this should takefull responsibility for their own costs of training.Unfortunately, that situation cannot exist in theUK due to the NHS monopoly on training. Wheresociety contributes towards the costs of thistraining, the private sector should not be allowedto profiteer without some form of contribution.

In this commercialised situation, where theelective or outpatient health care delivered is fullycosted, calculating the contribution of the surgeonto a private health companys profits is feasible. Inthe NHS, costing other areas of care ormanagement input is more difficult, althoughappropriately addressed in North America.Costing the benefit derived by individual patientsrequiring surgery is virtually impossible.

What Does the Future Hold?Professional surgical organisations must realise thatthe introduction of fees also introducesconsumerism, similar to that experienced by

Universities since the advent of tuition fees.Expectations of the service provided rise in parallelwith complaints when these are not met. The ISCPfee has been a case in point, with many traineesobjecting to an educational service that is not fullyfunctional, does not meet their needs, and thatmany trainers have been slow to engage with.However, unlike Universities, surgical organisationsand the NHS have a monopoly on surgical trainingmeaning that the competition introduced by feecharging cannot exist. Globalisation has led to awell-publicised increase in top UK school leavers

pursuing expensive Ivy League University

educations overseas in order to advance theirprospects and future earnings. It will be interestingto see in coming years whether the UK experiencesa similar brain-drain of surgical trainees seeking

better surgical training and financial prospectsabroad. Anecdotally, surgeons who left the UK inthe wake of MTAS in 2007 are now feeding backstories of training experiences that leave our UKsystem looking increasingly antiquated.

With this in mind, one way surgical Colleges andspeciality associations can head off criticism will

be to increase the transparency of funding andfees before demands for this start to rise. Withoutthe element of competition, there is no incentivefor such organisations to keep fees as low as

possible for trainees. Goodwill could be gainedfrom clearly indicating why such charges are

justified and how that money is being spent. Thislack of accountability is otherwise deeplytroubling to trainees.


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Consumerism will also be felt in other ways. Theintroduction of NHS Payment by Results (PbR)funding has established unit costs for all inpatientand outpatient treatment episodes. With this hascome a gradual realisation amongst trainees thattheir work directly contributes to their hospitalsfinancial balance sheet. Basic pay for juniordoctors in training is provided by Deaneries,hence trainees are potentially valuable income-generators relative to their NHS salaries. Althoughthis is yet to be publicly quantified by the NHS

(perhaps deliberately), trainees and theirrepresentatives will justifiably demand that thisfinancial contribution is repaid with qualitytraining opportunities.

As far as the study leave budget is concerned, ahiatus has ended with the establishment ofMedical Education England (MEE), following inthe footsteps of the other devolved administrationsfor whom such an establishment has met withsome success. It can only be hoped that thecoming months will bring positive steps and aclear focus to improving postgraduate training.Trainees should not be penalised for the

mismanagement of NHS budgets, and it is hopedthat with MEE taking charge of this area somestability will be returned. Indeed, modernisationand innovation in this area would be welcome,with suggestions of a personal, portable training

budget that follows a trainee from post to postregardless of hospital or Deanery. Surgicaltrainees are professionals progressing through aformal training system, and many see it as oddthat such a system does not already exist.

ConclusionsIf you want to feel rich, just count the things youhave that money can't buy Proverb

Those wishing to pursue a career in surgeryshould ideally be driven by a deep interest in thespeciality and a desire to learn the craft. Anoverriding motivation driven by income is notsomething anyone would wish to promote as their

primary reason for this career choice.

While penury is not often encountered amongstsurgeons, many other careers within and outsideof medicine have become more attractive as the

balance of costs and income continue to tip awayfrom surgical trainees. Although many otherfactors including competition and work-life

balance come into play, relative income hasundoubtedly contributed to the marked rise in GP-training applicants over recent years.

As the economic downturn continues, it is likelythat the politics of envy will come back into play, as

many see the medical profession as a comparativelysafe haven of reasonably remunerated stability.When such media articles next report this we shouldhope that some balanced consideration is given todebilitating student loans piled up by moderntrainees, the high proportions of income reinvestedin training and career development, and themandatory fees and subscriptions for the privilegeof doing so. But as the old journalists saying goes,you shouldnt let the facts stand in the way of agood story and for the sake of tomorrows patientsand the surgical profession as a whole we shouldhope these facts dont stand in the way of future

trainees career choices.References

[1] Harrison E, Shalhoub J.The Cost of Surgical Training: Position Statement by theAssociation of Surgeons in Training. London: TheAssociation of Surgeons in Training May 2007.

[2] Moore J, Gale J, Dew K, Simmers D.Student debt amongst junior doctors in New Zealand; part2: effects on intentions and workforce. The New Zealandmedical journal. 2006;119: U1854.

[3] Geertsma R H, Romano J.Relationship between expected indebtedness and careerchoice of medical students. Journal of medical education.1986;61: 555-9.

[4] BMA Medical Student Committee.Survey of Medical Student Finances 2006/07. London:Health Policy and Economic Research Unit, BritishMedical Association September 2007.

[5] Fitzgerald J E F, Armstrong A, Carter A, Smith J.The Costs of Surgical Training [Trainee Presentations].Annals of the Royal College of Surgeons. 2009;91.

Figure 3: Groups gaining benefit from surgical training. (Adapted from The Cost of SurgicalTraining Position Statement by the Association of Surgeons in Training, May 2007)

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Financial Costs of Surgical Training - Ed Fitzgerald - JASGBI News