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
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Dear Ben Ellis,
Thank you for your review, feedback, and suggestions. You have raised a number of interesting questions. We have done our best to address these as follows:
Abstract: We have completely re-written the abstract. We have highlighted that ‘cost’ is the focus of this editorial.
Paragraph 1: The word ‘cost’ is now explicitly used in the first paragraph. We have also hinted towards the relationship of cost with outcomes which we expand on further in paragraph 4.
Paragraph 2: You ask whether the themes of education cost research in other fields would be similar to physiotherapy. The principles of educational cost presented in this editorial are applicable across fields. However, an evaluation of the actual findings from cost research, of physiotherapy or otherwise, is outside the scope of this editorial. We think such a discussion would be best informed through a systematic or scoping review.
Paragraph 3: We are not aware of any papers explicitly evaluating the link between autonomous practice and education cost. However, it seems reasonable that if we believe autonomous practice will require more content to be taught, that more resources must be invested. We have added this train of thought to the text.
Paragraph 4: You raise the question about whether an institution would accept slightly worse outcomes for a significant reduction in cost. We would argue that this happens all the time, although perhaps not consciously. For example, we know that the reliability of the Objective Structured Clinical Examination increases with a larger number of stations. However, different programs chose different numbers of stations, and may trade-off a lower reliability in favour of a cost saving. The same logic applies to decisions around the number of student contact hours, the staff-student ratio etc.
Personnel costs: We have added reference to an RCT on online vs face-to-face learning for physiotherapy practical skills.
Box 1: We agree that a 2:1 ratio does not equate to a halving of cost. We have modified the text to reflect this.
Client-input costs: We have added some discussion on country differences and the implications of public vs private systems.
Facility costs: A discussion about the impact of specific pedagogies is outside the scope of this editorial. However, we hope that the basic framework we have provided will give readers enough information for them to make their own comparisons. Considering the effect of changes in dominant pedagogy not only relates to facility costs, but all costs described in this editorial.
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Once again, thank you for contributing to this editorial through your review.
Kind regards,
Jonathan Foo and Stephen Maloney