To the Editor:
We read with interest the recent Innovation Report in Academic Medicine regarding the use of a simulation-based clinical curriculum as an adjunctive pedagogy in an anatomy program,1 and we commend the authors for guiding the medical education community toward cost and value analyses as an essential element of decision making concerning educational innovations. We would like to extend this suggestion by discussing some key considerations in applying economic analyses to education.
Health care and health professions education must allocate finite resources among competing alternatives. To determine cost-effective approaches, administrators and curriculum designers need a comparison of costs and of effects. Simply adding a cost-evaluation framework to the design of Coombs and colleagues’ study would be of little benefit to decision makers interested in adopting this approach. Rather, decision makers need cost comparisons. In the case of Coombs and colleagues, a viable alternative educational approach or pedagogy would need to be evaluated alongside the simulation innovation, which involved high-fidelity manikins. Comparative options might include simulation-based activities with cadavers, or plastinated models, or non-simulation activities such as online virtual patients or traditional tutoring. We emphasize that simulation need not always be high cost. Indeed, a low-cost version of the simulation-based activities might be an ideal option in some circumstances.
The Prato Statement on cost and value in medical education proposes that the goal of economic analyses in education is to create an evidence base that informs delivery of maximum value for a given spend, which in turn will steer educators toward sustainable educational practices.2 The issue of sustainability cannot be overemphasized. Simulation is often one of the most costly pedagogies available. It is also highly effective for many learning objectives. As such, the overall value requires us medical educators to consider simulation-based approaches against what we get in return.3 Only by accurately measuring the costs and effects of viable alternatives can we move toward optimal educational value.
Stephen Maloney, MPH, PhD
Associate professor and director of education, School of Primary and Allied Health Care, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia. Dr. Maloney is also chair, Society for Cost and Value in Health Professions Education; ORCID: http://orcid.org/0000-0003-2612-5162; e-mail: email@example.com.
Jonathan Foo, PhD
scholar, School of Primary and Allied Health Care, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia; ORCID: http://orcid.org/0000-0003-4533-8307.
David Cook, MD, MHPE
Professor of medicine and medical education, director, Education Science, Office of Applied Scholarship and Education Science, chair, Mayo Clinic Multidisciplinary Simulation Center Research Committee, consultant, Division of General Internal Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, and member, Executive Committee for the Society for Cost and Value in Health Professions Education; ORCID: http://orcid.org/0000-0003-2383-4633.
Kieran Walsh, MB BCH BAO
Clinical director of clinical improvement, British Medical Journal, United Kingdom, fellow of the Higher Education Academy, fellow of the Academy of Medical Educators, fellow of the Royal College of Physicians Ireland, and member, Executive Committee for the Society for Cost and Value in Health Professions Education; ORCID: http://orcid.org/0000-0003-1268-4676.
1. Coombs CM, Shields RY, Hunt EA, et al. Design, implementation, and evaluation of a simulation-based clinical correlation curriculum as an adjunctive pedagogy in an anatomy course. Acad Med. 2017;92:494–500.
2. Maloney S, Reeves S, Rivers G, Ilic D, Foo J, Walsh K. The Prato Statement on cost and value in professional and interprofessional education. J Interprof Care. 2017;31:1–4.
3. Zendejas B, Wang AT, Brydges R, Hamstra SJ, Cook DA. Cost: The missing outcome in simulation-based medical education research: A systematic review. Surgery. 2013;153:160–176.