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      Costs and assessment in medical education: a strategic view

      editorial
      Perspectives on Medical Education
      Bohn Stafleu van Loghum

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          Abstract

          Van der Vleuten and Heeneman have added another important piece to the emerging jigsaw that will eventually show us the full picture of cost in healthcare professional education [1]. Their idea of redistributing the resources of assessment in a curriculum is an attractive one. Their suggestion that we concentrate more on progress testing could make a real difference in how we allocate funding to different forms of assessment. Perhaps more importantly it could also make a real difference to the outcomes that we can achieve by means of assessment for a given cost. Inevitably there are gaps in their approach. Their estimates of costs are in their own words ‘rough’ and there is also limited data. However, the main strength of their approach is that they bring much needed radical thinking to the area of cost in assessment. In this short commentary I will try to articulate some more radical thinking in this field. The issue of cost and value in healthcare professional education generally and assessment in healthcare professional education specifically has been largely neglected until relatively recently. There has been little research and few systematic reviews. Academic endeavours in this field have not always been of high quality. Terms like cost-effectiveness are used loosely and sometimes lazily: interventions are described as cost-effective without a thorough analysis of their costs or their effectiveness or a comparison with other interventions of differing cost-effectiveness [2; 3]. Put simply, no intervention can be cost-effective in and of itself – it can only be considered to be cost-effective in comparison to an alternative. In the absence of such comparisons conclusions are merely rhetoric. A proper cost-effectiveness analysis ‘refers to the evaluation of two or more alternative approaches or interventions according to their costs and their effects in producing a certain outcome’ [4]. Cost is rarely referred to directly; we tend to prefer the pusillanimous word feasibility. Research studies on cost that have emerged are a mélange of different types, even though that is both a strength and a weakness [5; 6]. The strength is that it has allowed us to look at a range of interventions in a range of ways, which is important in an emerging field. However the weakness is that the resultant conclusions can sound like a cacophony and that sometimes there has been too close a focus on specific and small interventions that we might be able deliver in a more cost-effective way but, even if this were to happen, the cost savings would be minimal. Let’s look at the following tangible example. It is fictional but hopefully will find some resonance with readers. Say a department decides to produce an e‑learning resource on a clinical subject for year 4 students. The team debate what format it should take and realize that different formats will have different costs. They decide to do a cost-effectiveness analysis to compare the relative cost-effectiveness of a simple video programme and a sophisticated interactive multimedia programme. At the end of the study they find that both programmes are equally popular and are equally used and that students who take them have similar test results at the end. The cost of the simple programme is £7000 and the cost of the multimedia programme is £10,000. They correctly conclude that the simple programme is more cost-effective. But, looking at the issue critically, what have they really achieved? They have gone to considerable effort to achieve cost savings of £3000. In the context of healthcare professional education budgets this is a nugatory amount of money [7]. This saving might be scalable – they and others may be able to apply their approach to other fields – but equally they may not. What works in one clinical field may not work in another: learning and assessment are context specific [8]. In reality they have not thought radically, and there is still too much research like this in the healthcare professional education field more broadly but also in the specialized field of research into cost and value in healthcare professional education. There are other approaches to looking at this problem. We could look critically at parts of the curriculum that are larger and more expensive and where a small percentage reduction in costs could result in significant savings in real terms. To adopt this approach we need to stand back and look at the wider landscape. So as Van der Vleuten and Heeneman suggest, we could look at objective structured clinical examinations (OSCEs). These are expensive and so should only be used where they add real value to assessment [9]. We could stand further back and look at assessment as a whole and its relation to the rest of the curriculum and how it could be better integrated into the curriculum. The end-result might be a saving of separate costs for assessment – as assessment and learning become part of a greater whole. Standing further back still we could look at the outcomes that we are trying to achieve through healthcare professional education programmes and the fiscally optimal methods of achieving these outcomes. This might mean investment in short postgraduate programmes that help doctors in training to credential in different areas. The result might be more flexible programmes and more flexible healthcare professionals. Healthcare professional education is long and complicated – we are trying to educate young people to be the fully qualified professionals that the country will need in five or ten years’ time and yet we don’t know what the future will hold. The only certainty is uncertainty. However, a more flexible workforce should be better able to cope with uncertainty and the development of such a workforce need not be more expensive than the way that we do things today. We should also think about who bears the costs of healthcare professional education. Is it the learner, the institution or the government? Different stakeholders are likely to value different outcomes in different ways. Thinking through the issues from a completely different perspective might lead us to consider healthcare professionals in training as a resource rather than a cost burden. Encouraging these healthcare professionals to learn about quality improvement at the same time as they learn how to measure and improve quality is one such example of how this could work in practice [10; 11]. The assessment of their quality improvement activities could be related to the actual progress that they have made in improving quality, with of course the caveat that not all quality improvement projects succeed despite being managed to high standards. Commentaries in healthcare professional education often end with a call for more research. In this case I think that we need more profound and innovative thinking to develop new concepts and ideas in the field of cost and value in healthcare professional education. Then and only then should we test these ideas. The good news is that, even though our thinking is currently inchoate, healthcare professional education offers much fecund ground for further and more profound deliberation.

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          Cost: the missing outcome in simulation-based medical education research: a systematic review.

          The costs involved with technology-enhanced simulation remain unknown. Appraising the value of simulation-based medical education (SBME) requires complete accounting and reporting of cost. We sought to summarize the quantity and quality of studies that contain an economic analysis of SBME for the training of health professions learners. We performed a systematic search of MEDLINE, EMBASE, CINAHL, ERIC, PsychINFO, Scopus, key journals, and previous review bibliographies through May 2011. Articles reporting original research in any language evaluating the cost of simulation, in comparison with nonstimulation instruction or another simulation intervention, for training practicing and student physicians, nurses, and other health professionals were selected. Reviewers working in duplicate evaluated study quality and abstracted information on learners, instructional design, cost elements, and outcomes. From a pool of 10,903 articles we identified 967 comparative studies. Of these, 59 studies (6.1%) reported any cost elements and 15 (1.6%) provided information on cost compared with another instructional approach. We identified 11 cost components reported, most often the cost of the simulator (n = 42 studies; 71%) and training materials (n = 21; 36%). Ten potential cost components were never reported. The median number of cost components reported per study was 2 (range, 1-9). Only 12 studies (20%) reported cost in the Results section; most reported it in the Discussion (n = 34; 58%). Cost reporting in SBME research is infrequent and incomplete. We propose a comprehensive model for accounting and reporting costs in SBME. Copyright © 2013 Mosby, Inc. All rights reserved.
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            Is the OSCE a feasible tool to assess competencies in undergraduate medical education?

            The Objective Structured Clinical Examination (OSCE) was introduced by Harden et al. (1975) trying to answer the problems regarding the assessment of clinical competencies. Despite increasingly widespread use of OSCEs, debate continues with arguments as 'why using such a demanding format if other methods are available?'
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              Issues in cognitive psychology: implications for professional education.

              Education and cognitive psychology have tended to pursue parallel rather than overlapping paths. Yet there is, or should be, considerable common ground, since both have major interests in learning and memory. This paper presents a number of topics in cognitive psychology, summarizes the findings in the field, and explores the implications for teaching and learning. THE ORGANIZATION OF LONG-TERM MEMORY: The acquisition of expertise in an area can be characterized by the development of idiosyncratic memory structures called semantic networks, which are meaningful sets of connections among abstract concepts and/or specific experiences. Information (such as the assumptions and hypotheses that are necessary to diagnose and manage cases) is retrieved through the activation of these networks. Thus, when teaching, new information must be embedded meaningfully in relevant, previously existing knowledge to ensure that it will be retrievable when necessary. INFLUENCES ON STORAGE AND RETRIEVAL FROM MEMORY: A wide variety of variables affect the capacity to store and retrieve information from memory, including meaning, the context and manner in which information is learned, and relevant practice in retrieval. Educational strategies must, therefore, be directed at three goals--to enhance meaning, to reduce dependence on context, and to provide repeated relevant practice in retrieving information. PROBLEM SOLVING AND TRANSFER: Much of the development of expertise involves the transition from using general problem-solving routines to using specialized knowledge that reduces the need for classic "problem solving." Two manifestations of this specialized knowledge are the use of analogy and the specialization of general routines in specific domains. To develop these specialized forms of knowledge, the learner must have extensive practice in using relevant problem-solving routines and in identifying the situations in which a particular routine is likely to be useful. CONCEPT FORMATION: Experts possess both abstract proto-typical information about categories and an extensive set of separate, specific examples of categories, which have been obtained through individual experience. Both these sources of information are used in categorization and diagnostic classifications. Thus, it is important for educators to be aware that experience with sample cases is not just an opportunity to apply and practice the rules "at the end of the chapter." Instead, experience with cases provides an alternative method of reasoning that is independent of, but equally useful to, analytical rules. Experts clearly do not use classic formal decision theory, but rather make use of heuristics, or shortcuts, when making decisions. Nonetheless, experts generally make appropriate decisions. This suggests that the shortcuts are useful more often than not. Rather than teaching learners to avoid heuristics, then, it might be more reasonable to help them recognize those relatively infrequent situations where their heuristics are likely to fail.
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                Author and article information

                Contributors
                kmwalsh@bmj.com
                Journal
                Perspect Med Educ
                Perspect Med Educ
                Perspectives on Medical Education
                Bohn Stafleu van Loghum (Houten )
                2212-2761
                2212-277X
                14 September 2016
                14 September 2016
                October 2016
                : 5
                : 5
                : 265-267
                Affiliations
                BMJ Learning, BMJ Publishing Group, London, UK
                Article
                299
                10.1007/s40037-016-0299-8
                5035285
                27638388
                064049e7-32b7-4c40-b184-a0160917b4b1
                © The Author(s) 2016

                Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

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