In the nineteenth century there were few standards in medical education. Students would often do an apprenticeship with a general practitioner and gradually gain experience in the trade. They had to pay for their education—which barred all but those from the privileged classes from becoming a doctor. For those who did persevere with their education there was the constant thought—am I getting value for money for my fees?
For the modern student, medical education is much more structured and standardised—but questions about value still remain. Education comes from the Latin educo (to draw out) and medical education should be just that—a drawing out of the student’s abilities rather than an attempted transfer of knowledge from lecturer to student. But even this light touch educational theory meets with short shrift from some students. One London student who I met recently had particular cause for complaint about small groups. He said students were left to themselves; they had little supervision; that it was teach yourself medicine. My arguments about the benefits of small group work (such as learning to work in teams, or learning from your peers) fell on deaf ears. His concerns were more practical. He said—am I going to rely on my friend Jon to lead the small group work and teach me about coeliac disease? Jon is a great guy, he’s smart and fun, but I know he spent all last night at a party and is hung over, and doesn’t do any reading until the last minute, and likes practical jokes so is just as likely to tell us all that people with coeliac disease shouldn’t eat beetroot—just to see who will believe him. I want a gastroenterology registrar or consultant to tell me all I need to know about coeliac disease and who will be reliable and approachable and someone I can put my questions to without feeling an idiot. What he didn’t say, but what I thought was an underlying current to our conversation was—“and I pay thousands of pounds per year in tuition fees and so I expect some value for money.”

Medical education has undergone many evolutions over the past hundred years. It has changed from passive to active, from hit and miss to curriculum driven, from uniprofessional to interprofessional—to mention just a few. All these changes have probably been right and have probably delivered better education, but they have all been driven from above—ultimately from curriculum designers who think that these new ways of doing things is better. What will be the impact of changes brought about by learners who see themselves as customer-purchasers? Will they choose schools and curricula that deliver education and ultimately doctors that the population needs over the next thirty years? Or will they choose schools that will help them pass their exams and start them off on a highly lucrative specialty with high potential for earnings from private practice? Their debts might drive them towards the latter.

Competing interests

Kieran Walsh works for BMJ Learning—the medical education division of the BMJ Group. He has written a book on cost and value in medical education published by Radcliffe.

Kieran Walsh is clinical director of BMJ Learning—the education service of the BMJ Group. He is responsible for the editorial direction of BMJ Online Learning, BMJ Masterclasses, and BMJ onExamination. He has written two books—the first on cost and value in medical education and the second a dictionary of medical education quotations. He has worked in the past as a hospital doctor – specialising in care of the elderly medicine and neurology.