*Corresponding Author:

Dr. Walsh K
BMA House, Tavistock Square, London WC1H 9JR, United Kingdom.
E-mail: kmwalsh@bmj.com

Abstract

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“Of 191 new Indian schools in the past three decades, 147 are private.” So stated the Lancet Commission into healthcare professional education in 2010.[1] A similar situation is occurring in Brazil - where the growth of private medical schools far exceeds the growth of public schools.[1] Not all of these schools are for profit - however a significant number of them are. Whilst the world is undoubtedly short of healthcare professionals and so any new investments in medical education are welcome, opening new schools for profit raise questions about the purpose of medical education, about the quality of education provision, and about the social accountability of institutions.[2] Should the profit and the profit motive be part of our considerations in medical education provision and planning? This paper outlines the advantages and disadvantages of the profit motive in undergraduate medical education.

The concept of the profit motive means that the goal of business is to deliver profit. So firstly the main advantage of the profit motive is that it means that institutions should act efficiently. They should ensure that spending is controlled and that funding is only spent on that will deliver more or better medical education. So staffing and other resources will be kept to the minimum required to deliver a high?quality service. Secondly as in other walks of life, the profit motive should be a driver of innovation, and this should also be the case in medical education. The profit motive should drive innovators to develop radical new forms of medical education and should also enable these innovations to be scaled up at pace. Certainly the profit motive has been one of the drivers behind a thriving medical education simulation industry. This industry has grown on a model that depends on firms providing the highest quality simulation at low costs.[3] The same could be said of E?learning in medical education.[4,5] Thirdly allowing profits within medical education should attract more investment. Investors could sink funds into medical education, and learners would benefit as a result; inevitably investors would like to see a return on investment - however, successful and wise investors would likely be patient and so make long term strategic investments that result in healthy long lasting businesses. Such investors would also reduce the cost to the public purse. Fourthly and lastly the profit motive should drive investigations into low?cost methods of education. Medical education is expensive, and so anything that drives down the cost whilst maintaining value is likely to be worth pursuing.[6]

However, there are a number of disadvantages to the admixture of profit and undergraduate medical education. First of all there will be questions as to the core purpose of medical education: Is it to produce healthcare professionals that a population needs, or to deliver a profit or both? If it is both, which purpose should take precedence in the event of the conflict between the two - profit or education? Most would argue that it is education and, therefore, wonder why we should muddy the waters by considering profit in the first place. There will also be questions as the quality of education provision at profit making schools. Will they be able to provide high?quality medical education if they also have to deliver a profit? Even if they can deliver a profit and provide high?quality education, surely they would be able to provide even more and better education if the profits were reinvested into education rather than passed on to investors or shareholders? This last point is almost unassailable - it begs difficult questions of supporters of the profit motive. Thirdly questions will inevitably arise as to the social accountability of medical education institutions. Most would say that they should be socially accountable and that this accountability should be to only a single master - the population that they serve. Certainly having only one master offers the benefit of simplicity of purpose. Fifthly involving the profit motive in undergraduate medical education may add another element to the hidden curriculum of schools. The stated curriculum of a school may state that its core purpose is to produce competent doctors who will want to stay in the vicinity of the school to provide primary care. However, it may be an open secret at the school that its real purpose is to deliver a profit - no matter what the economic, educational or healthcare costs. It is certainly well known that the hidden curriculum can have a powerful effect on undergraduates at medical school.[7] Sixthly some would argue that giving consideration to the profit motive in medical education is unfair to all involved - from investors to providers to learners. The duty of a profit making organization is to deliver value to shareholders - it is unfair to expect the organization to deliver education at the expense of profit. Seventhly and finally the profit motive may result in some unwanted incentives in the system. It may encourage schools to provide education that will help students to pass their exams and not necessarily education that is based on students’ needs, and in the final analysis patients’ needs.[8] This last set of needs must always be paramount.

In conclusion, whilst there are undoubtedly some benefits to the provision of undergraduate medical education by profit making organizations, on balance it is likely that the disadvantages outweigh the advantages. Some medical education institutions might be private, but profit?making private institutions should ideally not provide undergraduate medical education. There is one final point to be made. It is easy to criticize those whose motives are influenced by profit- mainly because their conflicts of interest are so obvious. However, other stakeholders in medical education can often have conflicts - these might be medical trade unions or medical education associations or even government bodies. Their conflicts might be less obvious - yet are no less real for all of that.[9] All stakeholders in medical education should act in the best interests of learners and ultimately patients - regardless of whatever conflicts they might have.

References

1. Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T, et al. Health professionals for a new century: Transforming education to strengthen health systems in an interdependent world. Lancet 2010;376:1923?58.
2. Cruess RL, Cruess SR. Expectations and obligations: Professionalism and medicine’s social contract with society. Perspect Biol Med 2008;51:579?98.
3. Ker J, Hogg G, Maran N. Cost effective simulation. In: Walsh K, editor. Cost Effectiveness in Medical Education. Abingdon: Radcliffe; 2010. p. 61?71.
4. Sandars J. Cost?effective E?learning in medical education. In: Walsh K, editor. Cost Effectiveness in Medical Education. Abingdon: Radcliffe; 2010.
5. Sandars J, Walsh K. A consumer guide to the world of e?learning. BMJ Career Focus 2005;330:96?7.
6. Maloney S, Haas R, Keating JL, Molloy E, Jolly B, Sims J, et al. Breakeven, cost benefit, cost effectiveness, and willingness to pay for web?based versus face?to?face education delivery for health professionals. J Med Internet Res 2012;14:e47.
7. D’Eon M, Lear N, Turner M, Jones C, Canadian Association of Medical Education. Perils of the hidden curriculum revisited. Med Teach 2007;29:295?6.
8. Walsh K. How to assess your learning needs. J R Soc Med 2006;99:29?31.
9. Bion J. Financial and intellectual conflicts of interest: Confusion and clarity. Curr Opin Crit Care 2009;15:583?90.