To apply a simplified time-driven activity-based costing (TDABC) model in an outpatient neurology fellow clinic and explore its utility in clarifying the cost of fellowship training.

The cost of clinical care and education has been difficult to calculate accurately. Clinical fellowships offer multiple benefits to neurology trainees, preceptors and departments. Fellow salaries may be drawn from a variety of sources and may appear, using traditional costing, to be “losing money” to a department, as an expense without added clinical revenue compared to an attending-only outpatient model.

TDABC calculates care cycle costs by multiplying resource’s costs with the time they are utilized. The capacity cost rate of a neurology attending and fellow was calculated from the median academic salary (AAN Report 2025) and salary information online. Benefits and overhead costs were excluded in this exploratory application. A high-level outpatient visit map was designed, eliminating overhead and stable costs. Time equations were built and costs were compared.

The median attending and fellow cost rate was $3.14/min and $1.01/min respectively. The visit map included chart review, history and examination, staffing and teaching, returning to examine with the attending and counseling, orders and documentation. The physician cost per new visit was $266.8 for an attending-only model and $268.13 for a precepted fellow model. For each return visit, the cost was $125.6 and $134.3 respectively. The calculated physician cost was similar between three models of a 4-hour clinic session: one attending precepting two fellows completing two new visits each, one attending seeing two new patients while precepting a fellow seeing another two new patients, or one attending seeing 4 new patients independently ($1072.5, $1070, $1067.5 respectively).

TDABC-calculated costs were comparable between teaching and non-teaching clinic models. This model can be individualized and explored further to justify the value of clinical fellowships for academic neurology departments.