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.

Authors: Jon Foo1, Stephen Maloney1
Institutions: 1Department of Physiotherapy, Monash University, Australia
DOI: 10.14426/art/474
Date submitted: 20/03/2018
Date accepted: 15/06/2018

Abstract

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.

Embracing a dialogue about cost in physiotherapy education

Introduction

Resources for education are limited. Choices must – and will – be made about their allocation. As educators, it is our responsibility to not only consider optimal learner outcomes, but also the cost of achieving these outcomes. Consideration of cost is necessary to ensuring efficiency and sustainability of physiotherapy education practices (Maloney, 2017).

Despite the importance of resource allocation, physiotherapy education appears to be occurring with little systematic thought on the economic costs involved. A quick PubMed search (conducted January 3, 2018) combining MeSH terms for physiotherapy education and cost analyses returns a paltry 9 articles, compared with 208 and 1199 for nursing and medicine respectively.

Issues of cost are ubiquitous – affecting the viability of existing programs, the introduction of new programs, and the uptake of educational innovations. The cost of education will play a key role in the future development of the global physiotherapy profession, particularly if we are to attain the educational standards outlined by the World Confederation for Physical Therapy (World Confederation for Physical Therapy, 2015b). For example, building capacity for independent autonomous practice, which is currently met by only 63% of countries (World Confederation for Physical Therapy, 2015a), requires additional training in analytical and research skills (Bithell, 2007), as well as further professional mentorship and clinical experience (McMeeken, Webb, Krause, Grant, & Garnett, 2005) – all of which is likely to result in qualification inflation (i.e. increase from 3-year diploma to 4-year baccalaureate).

Improved management of educational resources will generate better learner outcomes (or a higher number of graduates) for the same cost, or the same learner outcomes for a lower cost (Maloney et al., 2015). Respectively, these features of improved management addresses the growing demand for physiotherapy services (Pretorius, Karunaratne, & Fehring, 2015), and the heightening budget constraints on educational programs (Walsh, 2010). From this, it is clear that ‘value’ in education is dependent on two factors, the educational outputs, and the cost of resource inputs. In this editorial, we explore how purposeful educational design can be used to address the latter of these two elements – cost.

We explore the concept of costs, drawing on Levin’s Ingredients Framework, a framework commonly used in the field of educational economics (Levin, McEwan, Belfield, Bowden, & Shand, 2017). Levin proposes several key categories of costs to consider, including personnel, facilities, equipment and materials, and client inputs (McEwan, 2012).

Personnel costs

The largest reoccurring cost in a physiotherapy program is likely to be personnel costs (Finucane & McCrorie, 2010). Personnel costs include direct teaching staff, administration, support services, and those related to clinical education. Curriculum designers may optimise personnel usage by considering economies of scale, and the associated concepts of fixed costs and variable costs. Fixed costs are educational costs that occur regardless of the number of students taught, whereas variable costs change based on the number of students.

Technology enhanced learning (e-learning) approaches provide useful examples of fixed and variable costs. They typically require large initial investments to develop (fixed cost), however once established, the program is often usable by a large number of dispersed learners and for multiple iterations (Cook, 2007) – thereby lowering the per student variable cost.  In their randomised controlled trial, Maloney et al. (2012) show that there is no difference between traditional face-to-face teaching and pre-recorded video teaching for physiotherapy practical skills when measured by Objective Structured Clinical Examination. Massive Open Online Courses (MOOCs), such as the one conducted by Harvey and colleagues teaching thousands of physiotherapists about spinal cord injuries, are an extreme example of the economies of scale principle (Harvey, Glinsky, Lowe, & Lowe, 2014). Several other factors related to economies of scale are presented in Box 1.

Box 1. Suggestions for applying economies of scale in physiotherapy education

  • Look beyond physiotherapy. E.g. physiotherapy and occupational therapy content is sufficiently similar to allow for sharing of educational resources (Brown & Jennifer, 1999). Sharing of resources can lower both fixed and variable costs, and may be applied more broadly to the generic elements of physiotherapy education, including anatomy, physiology, biomechanics, and evidence based practice (Maloney, Moss, Keating, Kotsanas, & Morgan, 2013).Optimise student-teacher ratios. E.g. there is currently no ‘gold standard’ model of clinical education, that is, a 1:1 student-teacher ratio has no clear benefits over a 2:1 ratio (Lekkas et al., 2007). Using a 2:1 ratio may potentially reduce clinical educator time per learner through economies of scale and peer-peer learning.
  • Match learning objects to period of use. E.g. developing an eLearning object is often expensive (Cook, 2014). This may be appropriate for anatomy content which can be used over a long period time, however may not be the best option for content on the latest evidence for back pain management.
  • Collaborate with other professions, institutions, and countries. E.g. the National Simulation Project is a collaboration of 16 Australian Physiotherapy programmes through which 45 simulated patient scenarios were developed, implemented, and evaluated. These scenarios and information about the project is available on their website. Through sharing the cost of development, the per institution fixed cost is likely to be lower than if the institution developed the same learning resource independently.

Facility costs

Facility costs refers to the physical space required for the educational intervention (Levin et al., 2017). Factors to consider include seating capacity, technological requirements (e.g. projectors, computers), and room fittings (e.g. oxygen ports, ceiling hoist tracking). Other hidden costs include utilities, cleaning, room maintenance, and building depreciation.

From a facility cost perspective, educational design should maximise outside-classroom content. Blended learning pedagogies may achieve this goal by reducing face-to-face contact hours in favour of e-learning objects. Flipped classroom models may reduce facility costs through enabling shifts in class time allocation and the type of rooms (Chen, Lui, & Martinelli, 2017), and has been shown to yield improved student learning compared to the traditional approach (Hew & Lo, 2018). 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).

Equipment and material costs

In this section we will be discussing ‘larger’ equipment costs such as real-time ultrasound machines, standing hoists, simulation mannequins and rehabilitation gym equipment. It is acknowledged that ‘smaller’ material costs also exist, such as alcohol swabs, ridged tape, and office stationary – which may be relevant particularly in a low-budget setting.

Equipment costs can benefit from the economies of scope principle, which is the efficiency formed by variety. Often, physiotherapy programs use specialist equipment for only one or two weeks in the year, only to go back in storage until they are needed the following year. If a university teaches a variety of health professional courses, then the use (and cost) of the equipment can be shared accordingly. For example, it may be less costly to purchase a top-of-the-line simulation mannequin to be shared between a physiotherapy and nursing program, rather than each program buying a mid-tier mannequin that fits their individual needs.

With equipment, it is also important to note that more expensive does not equal better education. For example, while high-fidelity simulators are typically much more expensive than their low-fidelity counterparts, evidence suggests that there is little difference in learning outcomes (Norman, Dore, & Grierson, 2012), although formal cost analyses in simulation are lacking (Zendejas, Wang, Brydges, Hamstra, & Cook, 2013). Overall, physiotherapy programs should carefully evaluate educational value and costs when looking to purchase equipment, and also consider alternatives such as lower-cost options or rentals.

Client input costs

All costs thus far have been discussed from the perspective of the educational institution. In physiotherapy education, costs may also be incurred by patients, governments, healthcare facilities, clinical educators, the broader community, and learners themselves (Haines, Isles, Jones, & Jull, 2011). The allocation of costs between stakeholders is largely driven by the education system, and the degree to which education is private or publicly funded. In his editorial, Walsh (2015) highlights an increase in private medical schools, referring to India and Brazil as examples, suggesting that privatisation may improve overall efficiency, although we must be cautious that this does not occur at the expense of the educational mission. Related to privatisation is the issue of student debt, which is widely recognised as an ongoing issue for medical education (Steinbrook, 2008). The issue of debt has been explored to a lesser extent in the physiotherapy literature, with the most recent estimate of student debt from a Doctor of Physiotherapy degree in the United States put at US$86,563 (Shields & Dudley-Javoroski, 2018).

Designers of physiotherapy education should keep relevant stakeholder groups in mind (the client), as what initially appears to be a cost-saving, may actually be a cost-shifting to another stakeholder (Maloney et al., 2017). For example, in the evaluation of an interprofessional student clinic, compared to a conventional hospital-based placement, Haines et al. found a cost saving of AU$115 from the government perspective, but an increase of AU$289 to the university per student day (Haines, Kent, & Keating, 2014).

Educators should consider the impact of their decisions on learner time, both in-class and out-of-class. In a study assessing the cost of a repeat physiotherapy clinical placement (after failure), the cost to students was found to be US$4574 (for a five-week repeat), but would reduce to US$856 if a one-week repeat structure was utilised – in which the largest contributor to cost was time (Foo et al., 2017). In addition to time, educational design can influence learner travel and accommodation costs.

Conclusion

In this editorial we have explored educational design concepts related to the cost of personnel, facilities, equipment, and client inputs – with key tips summarised in Box 2. The examples provided are not an exhaustive list, rather, they have been provided to stimulate your interest and thought towards the role of economics in advancing physiotherapy education practices. Understanding principles of cost-conscious design, known as ‘basic economic literacy’, is a key skill for educators (Maloney et al., 2017). Economic literacy not only promotes more efficient and sustainable education systems, but also supports educators in advocating for change through the ability to make economic arguments.

Evidence in this field is currently lacking. There is a need for organised, prospective research, grounded in educational and economic theory, and designed to compare multiple alternatives in terms of both costs and educational effects. Cost is just one element of the decision-making process, and should be considered together with factors such as educational value, equity, and inclusiveness in education.

We, the education community, have long avoided discussions of cost, perhaps in fear of sullying the sanctity of the scholastic mission. However, resource limitations are a reality, and we must learn to embrace a dialog about cost – or risk making ill-informed decisions.

Practical implications: Key tips for cost-aware educational design

Personnel costs
– Design for economies of scale
– Consider costs from the perspective of fixed and variable

Facility costs
– Aim to minimise the volume of in-room time
– Match educational needs with the lowest cost facility type

Equipment costs
– Design for economies of scope
– Cost is not always an indicator of educational value

Client input costs
– Consider all relevant stakeholders
– Look out for cost-shifting between stakeholders

References

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Pretorius, A., Karunaratne, N., & Fehring, S. (2015). Australian physiotherapy workforce at a glance: a narrative review. Australian Health Review, 40(4), 438-442. doi:10.1071/AH15114

Shields, R. K., & Dudley-Javoroski, S. (2018). Physiotherapy education is a good financial investment, up to a certain level of student debt: an inter-professional economic analysis. Journal of Physiotherapy. doi:https://doi.org/10.1016/j.jphys.2018.05.009

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Reviews

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.

Title

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.

Abstract

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.

Introduction

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?

Conclusion

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.

Title

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

Abstract

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.

Introduction

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.

Conclusion

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.

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