Cost Effectiveness in Medical Education

Kieran Walsh

• Publisher: CRC Press
• Year: 2021
• Print ISBN: 9781138431317
• eBook ISBN: 9780429533365
• Edition: 1
• Topic: Business
• Subtopic: Pharmaceutical, Biotechnology & Healthcare Industry
• Index: Business

With economic winter facing many healthcare and health education budgets, the high costs of medical education are bringing it under close scrutiny. However, the costs of not providing high quality medical education - not least human costs in morbidity and mortality from medical error - are also high, presenting medical educators, funding managers, policy makers and economists with an unenviable dilemma. To add to their difficulties, remarkably little has been written on cost effectiveness in medical education, including how to calculate costs, how to get maximal value for money and even what constitutes value for money. In this book, the first of its kind, world leading experts comprehensively outline what is known about cost effectiveness in each of their fields. Undergraduate, postgraduate and continuing professional education are all explored, as are e-learning, simulation, cost benefit analysis and numerous other areas. Lecturers and researchers in medical education, clinical tutors and educational supervisors and appraisers, managers responsible for funding medical education and health economists and health policy makers and shapers will find this an invaluable resource. 'An excellent analysis and explanation of an under-explored subject' - from the Foreword by Sir Liam Donaldson.

CHAPTER 1
Cost effectiveness in medical education: an introduction

Kieran Walsh

The man in the street is highly sceptical of the value of cost-effectiveness analysis: their unpopularity is scarcely surprising, if only because when beliefs come into conflict with evidence, beliefs tend to win.

—Drummond Rennie

Medical education is an expensive business. It takes hundreds of thousands of pounds to educate each medical student to a state where he or she is fit to become a doctor and start work. And on day 2, the new doctor will start his or her postgraduate education, which may take another 10 years. Then, there is another 30 years of continuing professional development until retirement. Each year, the United Kingdom alone produces 7000 doctors, and so, the sums quickly become enormous. In addition, there are nurses, pharmacists and allied health professionals—each of whom should receive the best possible initial and continuing education to help them achieve what everyone wants to achieve: a workforce that is educated to world-class standards.

However, to become world class is expensive, and it is always worthwhile to wonder whether you are getting value for money. So, are we getting value for money from the education of our health professionals? First, is the education of health professionals effective, and second, is it as cost-effective as it could be? The short answer to both these questions is that no one really knows. The first question on the effectiveness of medical education is perhaps the easier to answer. Medical educational research is still in its early years, but it has made progress, and we now know much more than we did about what constitutes effective medical education. For example, we know that the active participation of learners in small groups is likely to be better than passive attendance at a lecture along with 200 other learners.¹ We know that assessment and exams should be practical, reliable and valid tests of applied knowledge, problem-solving skills and simulated behaviours rather than assessment of academic and seldom-applied knowledge.² We know that learning works best when it is practical and tied as closely as possible to the learner’s everyday working life, and that learners are much more likely to change and improve their actual practice when they are educated in this way.³ As our knowledge of the evidence base for effective learning has built up, many medical schools and postgraduate deaneries and providers of continuing professional education have stepped up to the mark and created new outcomes-based curricula, renovated their assessment methods and, in some cases, created workplace learning programmes. There is still a long way to go and we don’t frankly know if medical education is as effective as it should be, but we do know that it is more effective than it was.

Many would say that the current state of medical education is healthy or at least that it is taking a penetrating look at its weaknesses, is seeing how best to address these and is developing a coherent vision of what medical education should be like. For example, most health professionals are now signed up to the need for medical education to be explicitly focussed on improving the knowledge, skills and behaviours of such professionals with the clear and ultimate outcome of improving patient care.⁴ Most are signed up to the principle that, as health professionals work together in teams, they should learn together in teams and that the medical education community should pay more attention to integrated care and care pathways than it has in the past.⁵ Finally, most agree that medical education provision should be based on the needs of individual clinicians and the needs of patients and communities for whom they are responsible.⁶

However, one big issue for medical education that has not really been addressed until now is cost effectiveness. That is where our real lack of knowledge comes to the fore. There have been very few systematic studies of the cost effectiveness of medical education, and so we don’t really know the most cost-effective way to provide undergraduate, postgraduate or continuing medical education. Stated simply, we don’t know the most cost-effective way of designing a curriculum, rolling it out or doing a final evaluation of it a few years later. Considering the cost of medical education, there is remarkably little known about its cost effectiveness. There is little known about how to calculate costs, about what constitutes costs or how to get maximal value for money. Up to now, there have been no books on this subject and precious few articles. Most of the articles that do exist are reviews that bemoan the lack of original research in this area. So, this is exciting territory. In the current international economic climate, cost effectiveness in medicine and in medical education is likely to come to the fore in the coming months and years. If providers and commissioners of medical education have limited budgets or budgets that have been cut back, then they are likely to want to know how best to spend their money. For these reasons, the problems and potential solutions outlined in the following chapters are likely to be timely and important.

The costs of not providing high-quality medical education should also be considered. The most important one is the human cost—medical error accounts for a massive amount of morbidity and mortality, and error is very common. Approximately 2% to 14% of medication orders contain an error, and this is just prescribing error.⁷ Then, there is the financial cost to the health service in rehabilitating and caring for patients who have survived medical error as well as the costs to the economy in terms of lost productivity due to short- or long-term disability.⁸ To close the circle, there are the costs of rehabilitating those health professionals whose standards are no longer up to scratch or may never have been up to scratch in the first place—possibly because of inadequate undergraduate or postgraduate education or inadequate continuing professional development. Remediating health professionals who need to improve their clinical or non-clinical skills can be a long and expensive process.

There will be those, like Drummond Rennie in the opening quote, who are sceptical of the value of cost-effectiveness analysis. His quote will find echoes in a health-professional audience who have slowly come to terms with the concept of analysis of the cost effectiveness of healthcare and know the difficulties of changing long-held opinions even with new and compelling evidence that these opinions are wrong. But, this is a policy of despair: like evidence-based medicine, evidence-based medical education must become the only show in town—regardless of how uncomfortable we may feel with the outcomes of new research or analyses into medical education and its cost effectiveness.

There will be still more critics who will bemoan the emergence of a new cadre of medical education cost-effectiveness analysts poring over direct and indirect costs of medical education resources. A famous and favourite quote for educationalists is that of Yeats–‘education is not the filling of a pail but the lighting of a fire’, which is a sentiment that will always sit uncomfortably with closely managed education that is held to strict fiscal account. However, the worldwide recession and economic winter facing many healthcare and health education budgets will mean that the cost of medical education will need to be measured and economies made when possible.

The questions that remain are how best to make such measurements and how and where to make economies—the following chapters will hopefully shed some light on how best to come up with answers to these questions. One question, though, can be answered at the start: high-quality and effective medical education is essential—we must never sacrifice this at the altar of cost.

REFERENCES

• 1. Mansouri M, Lockyer J. A meta-analysis of continuing medical education effectiveness. J Contin Educ Health Prof. 2007 Winter; 27(1): 6–15.
• 2. Schuwirth LW, van der Vleuten CP. ABC of learning and teaching in medicine: written assessment. BMJ. 2003 Mar 22; 326(7390): 643–5.
• 3. Evans K, Guile D, Harris J, et al. Putting knowledge to work: a new approach. Nurse Educ Today. 2010 Apr; 30(3): 245–51.
• 4. Forsetlund L, Bjørndal A, Rashidian A, et al. Continuing education meetings and workshops: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2009 Apr 15; 2: CD003030.
• 5. Reeves S, Zwarenstein M, Goldman J, et al. The effectiveness of interprofessional education: key findings from a new systematic review. J Interprof Care. 2010 Feb 23; 24(3): 230–41.
• 6. Miller BM, Moore DE Jr, Stead WW, et al. Beyond Flexner: a new model for continuous learning in the health professions. Acad Med. 2010 Feb; 85(2): 266–72.
• 7. Lewis PJ, Dornan T, Taylor D, et al. Prevalence, incidence and nature of prescribing errors in hospital inpatients: a systematic review. Drug Saf. 2009; 32(5): 379–89.
• 8. Ackroyd-Stolarz S, Guernsey JR, MacKinnon NJ, et al. Adverse events in older patients admitted to acute care: a preliminary cost description. Healthc Manage Forum. 2009 Autumn; 22(3): 32–6.

CHAPTER 2
Cost-effective undergraduate medical education

Paul Finucane and Peter McCrorie

Some kids want to know why the teachers get paid when it’s the kids who have to do all the work.

—Milton Berle

INTRODUCTION

We live in an era where consumers are better informed and demand a greater say in how their needs are addressed. Consumers are also increasingly cost conscious and demand value for their money, whether paying directly or indirectly through taxation. In response, governments are obliged to seek value when they spend tax revenue; this in turn impacts service providers. Those who deliver medical education are not immune from these societal and political pressures.

In the business world, a particular phenomenon has been the development of products that over time become more sophisticated and expensive, particularly when there is no competition. At some stage, the erstwhile monopoly provider is challenged by a competitor with a new and less sophisticated product that meets basic needs and that is delivered at reduced cost.¹ There are numerous examples (e.g., from the steel, aviation and retail grocery industries) where acceptable though unsophisticated cheaper products have displaced those that are both unnecessarily complex and more expensive. Stated simply, given the option of a cheaper alternative, consumers are often loath to pay for more costly and discretionary goods and services.

A central thesis in this chapter is that the educational processes that produce doctors have become increasingly expensive and are not well targeted at the needs of society. The scene is therefore ripe for the development of alternative educational processes that produce competent doctors but at reduced cost to society.

THE CURRENT STATE OF UNDERGRADUATE MEDICAL EDUCATION

Over the past 40 years in particular, medical education has been in a state of flux. Two important factors moulding its new shape are the changing face of medical practice and a better understanding of how students learn. Regarding the former, the stereotype of the solo and all-knowing medical practitioner whose competence was seldom questioned has been replaced by the team-worker with the ability to stay abreast of advances in medical knowledge and who is obliged to demonstrate continuing professional competence. In response, most medical schools now promote interprofessional education, embrace information technology and aim to produce graduates with lifelong learning skills. An increased emphasis on professionalism and social accountability translates into strategies to foster communication skills, ethical behaviour and the ability of graduates to recognise and respond to local and national health priorities.

During the last century, educational psychologists highlighted the limitations of rote learning and instead suggested that learners be stimulated to think, to confront their ignorance and to use this as a stimulus to acquire new knowledge. It was realised that knowledge is best gained in the context of how it is subsequently used and that adults learn most effectively when they control what and how they learn. Such insights have stimulated a move away from didactic and instructor-centred teaching towards more interactive and student-centred learning. Problem-based learning (PBL...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Contents
• Foreword
• About the editor
• List of contributors
• Dedication Page
• 1 Cost effectiveness in medical education: an introduction
• 2 Cost-effective undergraduate medical education
• 3 Cost-effective postgraduate medical education
• 4 Cost-effective continuing professional development
• 5 Cost effectiveness in interprofessional education
• 6 Cost-effective e-learning in medical education
• 7 Cost-effective face-to-face learning
• 8 Cost-effective simulation
• 9 Problem-based learning: is a cost-effective approach possible?
• 10 Cost-benefit analysis of curriculum design for medicine
• 11 Cost-effective assessment
• 12 Cost-effective educational evaluation
• 13 Quality assurance systems for medical education
• 14 Research into cost effectiveness in medical education
• 15 Cost effectiveness in medical education: conclusion and next steps
• Index