Embracing a dialogue about cost in physiotherapy education

Article accepted

This article has been accepted for publication. Peer reviews and author responses are available at the end of the article.


Physiotherapy education cannot occur without resources. A pragmatic approach to education design is required, with explicit consideration for the cost of our teaching and learning practices. In this editorial, we explore the concept of cost-conscious educational design in the context of physiotherapy education.


Author: Ben Ellis
Review date: 15 June 2018
DOI: 10.14426/opj/20180615
Permalink: Review - Embracing a dialogue about cost in physiotherapy education

Thank you for submitting this editorial on a relevant contemporary issue for physiotherapy educators and higher education institutions. Overall I think you have achieved your aim of stimulating a discussion around cost, using a clear framework and well considered examples. Below are some minor comments and questions which were stimulated by my reading of your article for you to consider.


The title is clear and concise. I particularly like that it is framed as a call for physiotherapy educators to engage in a dialogue that we may often avoid.


As this is an editorial your abstract is essentially your opening paragraph. It is therefore not required to set out a precis of the entire article but should draw a reader in to the article and highlight the main theme. To that end I would suggest that your opening paragraph has an explicit link to cost as currently I read it as having a broader focus on value and sustainability.


Paragraph 1. As above, I wonder if a more explicit focus on cost would help to frame the article. Could the distinction that you draw between the cost and outcome components of value in paragraph 4 be introduced here?

Paragraph 2. You make a good case that this is a neglected area of inquiry in physiotherapy. It may be outside the scope of this editorial, but I would be interested in whether there were themes from the more plentiful nursing and medical literature which are relevant to physiotherapy education, or whether there are sufficient disciplinary differences that make application across disciplines impossible.

Paragraph 3. Is there an established link between countries training to independent autonomous  practitioner and increased cost of education?

Paragraph 4. Establishes your focus on cost over outcomes clearly (although as above I wonder if this would be better placed earlier). The opening statement did make me wonder if there would be any institutions happy to accept slightly worse outcomes for a significant reduction in cost? Is there any data supporting the growing demand for physiotherapists? (For example in the UK the CSP has used workforce modelling to demonstrate the need for 500 additional graduate physiotherapists a year)

Body of editorial

The types of costs are clearly explained for the reader who may not be familiar with economic terminology. 

Personnel costs. To maintain your argument that better cost management would result in greater numbers of equal outputs or improved outputs rather than risking worse outcomes, is there evidence to demonstrate that a move to online learning would not risk a decrease in output quality? For example, George et al 2014 reported equivalent knowledge gains following online learning compared to classroom-based in a systematic review of studies in healthcare students.

Box 1. You make a number of good suggestions. I would possibly challenge the argument that a 2:1 model of clinical education reduces the clinical educator workload by half. But this model creates other peer learning opportunities and there may even be evidence to support 3:1 models.

Facility costs. The argument is well made that flipped classroom models may not necessarily decrease cost, but may change the nature of space requirements. I wondered whether there was a link to be made between changes in the dominant pedagogy might impact on facility costs. For example, moving from more didactic teaching methods to active learning/inquiry-based approaches may require more investment in social learning space and wifi capacity over traditional lecture theatres and audiovisual equipment.

Equipment costs. Your arguments in relation to economies of scope and the need to carefully consider the additional benefits of more costly equipment are clear.

Client-input costs. I found the two examples used to illustrate your points here really thought-provoking. Again this may be outside the scope of this editorial, but I wondered what the differences are in terms of who carries the cost burden between the different stakeholders in different countries?


I think your conclusion is clear and thought-provoking, achieving the aims of your editorial. I like the use of Box 2 to summarise your key points.


Thank you again for the opportunity to review this editorial.

Kind regards

Ben Ellis, Senior lecturer/MSc (Pre-registration) Physiotherapy Subject Coordinator, Oxford Brookes University

Author: Nina Rydland Olsen
Review date: 7 May 2018
DOI: 10.14426/opj/20180507
Permalink: Review - Embracing a dialogue about cost in physiotherapy education

I would like start with saying thank you to the authors for inviting readers to a dialogue about costs in physiotherapy education. In summary, I find this editorial relevant and useful as it points to our responsibility as educators for considering costs when designing physiotherapy education. Your suggestions and tips are useful for both educators and managers of educational programs. Below I have some minor suggestions for changes and some questions you might want to consider.


I find the title short, catchy and to the point.


Do you need an abstract at all? I would say that you do not. However, if you do want to keep these lines, could you consider adding the word “cost” to the text, as this is the focus of the editorial? To me, it is not clear what you mean by “sustainability in achieving these outcomes” – just from reading the abstract.


Paragraph 1: Repeating myself, regarding “sustainability in achieving these outcomes” –  I see that sustainability is linked to issues that are linked to costs (directly or indirectly), for example re-using and sharing resources – however, will readers automatically see this link? Could you consider using the word “cost” in this introductory paragraph?

Paragraph 2: what does “this” refer back to when you write “despite this”? Consider rephrasing.

Paragraph 3: I believe you make an important point when you link the issue of cost in education to the expectations from WCPT regarding clinical education, as this is likely the most costly part of physiotherapy education.

Paragraph 4: I agree, and I think that you are right, regarding the importance of improved management for generating better learning outcomes for the same costs. To strengthen your argument, could you consider adding a reference to research evidence on this issue? Again, I am not sure what “this” refers back to; I am not sure if I can see the link between growing demand of physiotherapy services and the need for improved management. The purpose is clear.

“Body” of the editorial

Personnel costs: when you state that “Curriculum designers may optimise personnel usage by considering economies of scale” – could you also refer to “basic economic literacy”, as in your earlier paper, the Prato Statement” (Maloney et al. 2017)?

Equipment and material costs: I noticed that there is a new systematic review on the impact of flipped classroom (https://www.ncbi.nlm.nih.gov/pubmed/29544495), with a more convincing conclusion than the review by Chen, Lui & Martinelli (2017). However, it could be that this review is less relevant for your argument.

Box 1:

  • The list of suggestions are important and informative, but could you organise it similar to Box 2, or alternatively highlight with bold the text that works as heading, e.g. “Look beyond physiotherapy”.
  • In the second point that you make in the box – you refer to the fact that “By using a 2:1 ratio, clinical educator time per learner is effectively halved”. This means that we need less clinical educators; an important point to make – as finding clinical educators is a big challenge. However, do we have evidence to support that this ratio means less time used on supervision (and thereby less costs)? I wonder if the argument that you make later in the second paragraph about facility costs – could also be applied for this point – somehow (“However, such approaches are highly heterogeneous (Liu et al., 2016), and depending on implementation, facility costs may not necessarily be different compared to traditional approaches (Maloney et al., 2015).”).
  • You also refer to an example of an international collaboration from medical school. Do we have something similar within physiotherapy education?

Client input costs: When you refer to the importance of keeping relevant stakeholder groups in mind; consider again referring to the Prato Statement and the points made there about considering multiple perspectives.


I find that the conclusion has a punch to it; in particular, in the last paragraph.  If possible, could you also add a few words on the importance of academics using economic reasoning to advocate for change – similar to the point made in the Prato Statement? Often educators need good arguments for making changes – and costs could be a good one.

Thank you for the opportunity to review this editorial!

Kind regards,

Nina Rydland Olsen, Associate Professor/Program director of Master in Clinical Physiotherapy, Faculty of Health and Social Sciences, Department of Health and Functioning, Western Norway University of Applied Sciences

Amendments made to this article following review

These amendments were made post reviewer feedback. There were two main changes.
1. Clarifying that this editorial is about cost from the very start.
2. Increased number of references to other literature to support claims, and provide examples specific to physiotherapy education.

Conflict of interest statement

Author SM declares that he is on the Advisory Board for OpenPhysio. Both authors declare an interest in the Society for Cost and Value in Health Professions Education, of which author SM is the current Chair, and JF is the Secretary.

Leave a Reply

This site uses Akismet to reduce spam. Learn how your comment data is processed.