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'Important but Risky': Attitudes of Global Thought Leaders towards Cost and Value Research in Health Professions Education

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Title: 'Important but Risky': Attitudes of Global Thought Leaders towards Cost and Value Research in Health Professions Education
Language: English
Authors: Cleland, J. A. (ORCID 0000-0003-1433-9323), Cook, D. A. (ORCID 0000-0003-2383-4633), Maloney, S. (ORCID 0000-0003-2612-5162), Tolsgaard, M. G. (ORCID 0000-0001-9197-5564)
Source: Advances in Health Sciences Education. Oct 2022 27(4):989-1001.
Availability: Springer. Available from: Springer Nature. One New York Plaza, Suite 4600, New York, NY 10004. Tel: 800-777-4643; Tel: 212-460-1500; Fax: 212-460-1700; e-mail: customerservice@springernature.com; Web site: https://link.springer.com/
Peer Reviewed: Y
Page Count: 13
Publication Date: 2022
Document Type: Journal Articles
Reports - Research
Descriptors: Risk, Decision Making, Accountability, Feedback (Response), Costs, Barriers, Telecommunications, Handheld Devices, Videoconferencing, Health Personnel, Allied Health Occupations Education, Professional Autonomy, Professional Identity, Economic Factors, Knowledge Level, Generalization
DOI: 10.1007/s10459-022-10123-9
ISSN: 1382-4996
1573-1677
Abstract: Studies of cost and value can inform educational decision making, yet our understanding of the barriers to such research is incomplete. To address this gap, our aim was to explore the attitudes of global thought leaders in HPE towards cost and value research. This was a qualitative virtual interview study underpinned by social constructionism. In telephone or videoconference interviews in 2018-2019, we asked global healthcare professional thought leaders their views regarding HPE cost and value research, outstanding research questions in this area and why addressing these questions was important. Analysis was inductive and thematic, and incorporated review and comments from the original interviewees (member checking). We interviewed 11 thought leaders, nine of whom gave later feedback on our data interpretation (member checking). We identified four themes: Cost research is really important but potentially risky (quantifying and reporting costs provides evidence for decision-making but could lead to increased accountability and loss of autonomy); I don't have the knowledge and skills (lack of economic literacy); it's not what I went into education research to do (professional identity); and it's difficult to generate generalizable findings (the importance of context). This study contributes to a wider conversation in the literature about cost and value research by bringing in the views of global HPE thought leaders. Our findings provide insight to inform how best to engage and empower educators and researchers in the processes of asking and answering meaningful, acceptable and relevant cost and value questions in HPE.
Abstractor: As Provided
Entry Date: 2022
Accession Number: EJ1353222
Database: ERIC
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  Value: <anid>AN0159866642;oak01oct.22;2022Oct28.05:35;v2.2.500</anid> <title id="AN0159866642-1">"Important but risky": attitudes of global thought leaders towards cost and value research in health professions education </title> <p>Studies of cost and value can inform educational decision making, yet our understanding of the barriers to such research is incomplete. To address this gap, our aim was to explore the attitudes of global thought leaders in HPE towards cost and value research. This was a qualitative virtual interview study underpinned by social constructionism. In telephone or videoconference interviews in 2018–2019, we asked global healthcare professional thought leaders their views regarding HPE cost and value research, outstanding research questions in this area and why addressing these questions was important. Analysis was inductive and thematic, and incorporated review and comments from the original interviewees (member checking). We interviewed 11 thought leaders, nine of whom gave later feedback on our data interpretation (member checking). We identified four themes: Cost research is really important but potentially risky (quantifying and reporting costs provides evidence for decision-making but could lead to increased accountability and loss of autonomy); I don't have the knowledge and skills (lack of economic literacy); it's not what I went into education research to do (professional identity); and it's difficult to generate generalizable findings (the importance of context). This study contributes to a wider conversation in the literature about cost and value research by bringing in the views of global HPE thought leaders. Our findings provide insight to inform how best to engage and empower educators and researchers in the processes of asking and answering meaningful, acceptable and relevant cost and value questions in HPE.</p> <p>Keywords: Cost and value; Qualitative research; Economic theory</p> <hd id="AN0159866642-2">Introduction</hd> <p>Health professions education (HPE) is an expensive business. Estimates put the global cost of investment in HPE at over 100 billion USD per year (Frenk et al., [<reflink idref="bib35" id="ref1">35</reflink>]). Given this spend, and in an era of increasing accountability of public funding, there is widespread pressure on health education providers (e.g., medical schools) to justify their activities and processes in terms of costs and benefits (Cook & Beckman, [<reflink idref="bib20" id="ref2">20</reflink>]; Maloney et al., [<reflink idref="bib49" id="ref3">49</reflink>]).</p> <p>Studies of cost and value offer insight for decision making and provide evidence to consider the ramifications of choices and actions at the level of individuals, groups and institutions (Cleland et al., [<reflink idref="bib13" id="ref4">13</reflink>]). For example, Ford et al. ([<reflink idref="bib34" id="ref5">34</reflink>]) showed that the cost (mostly staff time) of a simulated ward round was significantly reduced but education value (assessed via student satisfaction and performance assessment) was maintained when they switched from individual to group feedback. This allowed the institution to take an evidenced-informed decision to adopt group feedback, and release staff (a finite resource) for other educational activities. Conversely, an institution may take the decision to incur greater costs where they have collected evidence of learning gains or other benefits (e.g., shifting from large group to smaller group teaching may cost more in terms of educator time but may have a beneficial impact on student learning).</p> <p>However, few rigorous studies examining cost and value have been published despite their potential contribution to high-value, sustainable healthcare professions education [which can also be termed "cost-conscious education" to reflect the drive for cost-conscious care (Weinberger, [<reflink idref="bib69" id="ref6">69</reflink>])]. Systematic reviews of published research on the cost of simulation-based education, continuing professional education and HPE broadly all found few studies (relative to the total number of research publications), poor reporting of cost elements, and significant methodological shortcomings (Cook et al., [<reflink idref="bib21" id="ref7">21</reflink>]; Foo et al., [<reflink idref="bib33" id="ref8">33</reflink>]; Hippe et al., [<reflink idref="bib41" id="ref9">41</reflink>]; Zendejas et al., [<reflink idref="bib72" id="ref10">72</reflink>]).</p> <p>This contrasts with education more generally. The economics of education for K-12 and college students is a long-established field of inquiry, and several journals have this as their focus (e.g., <emph>Educational Evaluation and Policy Analysis, Education Finance and Polic</emph>y, <emph>Economics of Education Review, International Journal of Education Economics</emph>). Research questions address local and broad issues of policy and educational best practices such as: the impact of class sizes in higher education; the impact of peer-to-peer teacher training; the problems of repaying college loans; barriers to accessing higher education, and so on. Similar questions exist in HPE yet remain largely unanswered. The economics of clinical healthcare is likewise well-developed, leaving us to wonder: Why has the quantity and quality of cost and value research in HPE remained so limited?</p> <p>Unfortunately, we are not aware of empirical evidence from HPE to inform the answer. Looking outside of HPE to education more generally, the limited research on educator attitudes about cost research suggests two things. First, if cost is considered, it may be a barrier to adopting new innovations and approaches (Farhan et al., [<reflink idref="bib30" id="ref11">30</reflink>]; Ndlovu & Mostert, [<reflink idref="bib56" id="ref12">56</reflink>]). Second, and arguably more relevant to our focus, is that teachers seem to balance costs and value relying on their perceptions, intuition and experience rather than seek evidence to guide cost-related decisions (Khawaji, [<reflink idref="bib44" id="ref13">44</reflink>]).</p> <p>Exploring this gap in our understanding is important. With reference to the theories of rational (Kaheman and Twersky, [<reflink idref="bib42" id="ref14">42</reflink>]) and intuitive decision making (e.g., Behling & Eckel, [<reflink idref="bib5" id="ref15">5</reflink>]; Wu, [<reflink idref="bib71" id="ref16">71</reflink>]) some researchers and educators will consciously choose—after careful consideration, drawing on knowledge accumulated through evidence or experience respectively—not to pursue cost and value research for various reasons. However, less deliberate "choices" not to engage may place researchers and educators outside the rational decision-making processes, ultimately limiting their potential influence over their own activities of ensuring educational quality and professional self-governance. Assuming that cost and value research is indeed important, it seems imperative to elucidate existing attitudes, to assess if and what interventions to change attitudes might be merited.</p> <p>To address this gap, we conducted a qualitative interview study to explore the views and perceptions of cost and value research in a group of health professions education (HPE) thought leaders (those who have authority in the field, whose expertise is recognised and sought by others; see later). Our specific research question was: what are the attitudes of thought leaders in HPE towards cost and value research?</p> <hd id="AN0159866642-3">Methods</hd> <p>In line with the worldview that meaning is constructed through social interaction, this research was epistemologically grounded in social constructionism (Crotty, [<reflink idref="bib23" id="ref17">23</reflink>]). We used individual virtual interviews to collect multiple perspectives and interpretations of reality in relation to the research question.</p> <hd id="AN0159866642-4">Sampling and recruitment</hd> <p>We used purposive sampling to recruit participants who could contribute rich data in respect of our research question(s). We drew on our personal networks to identify senior HPE educators/researchers who could be considered thought leaders in their local context, or internationally, and who collectively represented a diversity in local contexts (USA, Canada, The Netherlands, Denmark, Australia, The Middle East and China). We purposefully selected participants reflecting different professional training (medical and other health care professionals and social scientists) and job roles (journal editors, program directors, centre directors, and senior scientists), and different contexts in respect to how education and healthcare are funded (e.g., public/government versus private/neoliberal models) and HPE research presence (countries with high versus low research productivity). These individuals would be expected to have "high economic literacy", are aware of the existing research in the field and have practical experience of handling issues of cost and value from a research, education and/or management perspective. More participant details are provided in the Results section.</p> <hd id="AN0159866642-5">Data collection</hd> <p>The invitation to take part in the study was sent by e-mail, which explained the purpose of the study and asked the recipient if he or she would consider taking part. Participants provided written consent.</p> <p>We generated and iteratively updated an interview guide comprised of semi-structured questions to direct the interviews. Initial questions drew upon existing literature and the expertise of the research group. We asked participants their views of the most relevant research questions to be answered in the study of cost and value in HPE, why they thought these were important, and what types of cost and value research they would like to read about in health professions journals. We were also interested in participants' views about context versus generalisability given that the differences in systems and priorities across countries may make it difficult to compare cost and value studies and outcome measures from one place with another (Tolsgaard & Cook, [<reflink idref="bib65" id="ref18">65</reflink>]). Questions were added or modified based on findings from early interviews, to enable the pursuit of novel insights.</p> <p>Individual interviews were carried out remotely by telephone or video conferencing. All interviews were carried out by MGT. Each interview continued until the participant felt he or she had shared their views sufficiently.</p> <hd id="AN0159866642-6">Data management and analysis</hd> <p>All interviews were digitally audio-recorded with permission then transcribed. Interview texts were anonymised. Initial data coding and analysis were led by MGT and JC, and were inductive, using thematic analysis to generate a coding scheme (Braun & Clarke, [<reflink idref="bib10" id="ref19">10</reflink>]). Analysis progressed via (remote) meetings, where ongoing coding and comparisons were explored by JC and MGT. Comparisons were made between codes and participants to explore differences and similarities in participants' perspectives. Any disagreements were discussed. The initial patterns in the data were then explored through critical conversations amongst the wider research team.</p> <hd id="AN0159866642-7">Rigour</hd> <p>Rigour in data collection and analysis was enhanced in a number of ways (Guba & Lincoln, [<reflink idref="bib38" id="ref20">38</reflink>], Miles and Huberman, [<reflink idref="bib54" id="ref21">54</reflink>]). All authors contributed to the design of the semi-structured interview schedule, drawing on their knowledge of the topic. All interviews were undertaken by the first author (MGT) for continuity. JC, who is an experienced qualitative researcher, led the data coding and interpretation. Those involved directly in the data collection and analysis (MGT, JC) considered their positions and relationships with the data continually and critically (McMillan, [<reflink idref="bib53" id="ref22">53</reflink>]).</p> <p>All human studies involve some kind of interaction between the researcher and the researched. We were keenly aware of our status as research insiders (Kanuha, [<reflink idref="bib43" id="ref23">43</reflink>]) given our active interest in cost and value in health professions education and own status as journal editors and (arguably) leaders in the field. The transcribed data illustrated that the interviews were "shared conversation(s)" in which MGT had worked to "produce knowledge with others" (Pink, [<reflink idref="bib57" id="ref24">57</reflink>], p. 232), and then the data were interpreted dialogically, between our own explanations and judgements and the data itself. We firmly believe this co-construction of knowledge production was valuable, but at the same time it was necessary to ensure our voices did not dominate those of the participants (Mason, [<reflink idref="bib52" id="ref25">52</reflink>]). We did so by actively involving the research participants again, to review the analysed data set (Birt et al., [<reflink idref="bib6" id="ref26">6</reflink>]; Cho & Trent, [<reflink idref="bib12" id="ref27">12</reflink>]). In line with our constructivist stance, we sent participants a draft manuscript outlining our initial interpretations, asked them if they could see their attitudes and experiences within the results and if they wanted to add anything for us to consider (Harvey, [<reflink idref="bib40" id="ref28">40</reflink>]). Our approach was akin to Birt et al.'s (Birt et al., [<reflink idref="bib6" id="ref29">6</reflink>]) "synthesized member checking". We subsequently incorporated the comments obtained during our synthesized member checking within the final analysis.</p> <p>Although the number of participants is small, the aim was narrow and the information power of their input was high (Malterud et al, [<reflink idref="bib50" id="ref30">50</reflink>]). The original data collection stopped when we felt we had reached the point of 'theoretical sufficiency' (Bowen, [<reflink idref="bib8" id="ref31">8</reflink>]). As stated above, member checking took place approximately 18 months after the original data collection, contributing to data interpretation and introducing some new data (Estroff, [<reflink idref="bib28" id="ref32">28</reflink>]). We have made clear in the results section where new data extended the themes, to increase transparency and auditability. Quotations are included in the results section to aid confirmation of findings.</p> <hd id="AN0159866642-8">Ethics</hd> <p>This study was considered exempt from formal ethical approval processes according to the Regional Ethical Committee for the Capital Region, Denmark (protocol no. 21028380).</p> <hd id="AN0159866642-9">Results</hd> <p>We conducted 11 interviews between May 2018 and January 2020. All participants (seven men and four women) either led or had led a health professions education research or education delivery unit/centre in their own country. Most also had editorial roles with international medical education or science journals and/or leadership roles in national and international professional organisations.</p> <p>About half (5/11) of participants were trained as medical doctors, whereas the remaining half had background in economics or social science. The large majority of participants published mostly quantitative research. Some participants practiced in resource constrained countries and others in resource-rich countries: representing North America (USA/Canada), Oceania (Australia), Asia (China, Bangladesh), Middle East (Emirates), and Europe (Denmark, the Netherlands, UK). About half of all participants were mainly employed as scientists, and the other half had their main employment in hospital or university administration. In short, our participants included a wide range of can be considered accomplished front-line decisions makers in the core HPE activities of delivering, managing and researching health professions education.</p> <p>Participants are labelled solely by number (1–11) and without reference to country, to ensure quotes cannot be linked to any one individual. Nine of the 11 responded to our member checking request, sending their views by email.</p> <p>We identified four themes in the data: 1. Really important but potentially risky; 2. I don't have the knowledge and skills; 3. It's not what I went into education research to do; and 4. It is difficult to generate generalizable findings. We elaborate on these below.</p> <hd id="AN0159866642-10">Theme 1: really important but potentially risky</hd> <p>Many participants were clear that cost and value research was absolutely critical for HPE and reiterated this when we checked with them later in the research process. However, although cost and value research was considered important and essential, there was concern that in considering the larger concept of value (balancing cost and impact), undue weight may be given to outcomes that are easy to measure rather than those that are most important. This concern was perceived for both sides of the value equation (both costs and non-cost outcomes).The things that are easy to measure like knowledge, skills and attitudes, to me, have very limited utility in knowing if an educational intervention has really made a difference. P10I see a tendency right now towards putting structure on a pedestal so milestones, competencies, [and] fixed standard competencies are put on top of our value pyramid. .... We are putting value to something very objective and measurable instead of looking at what is it actually we want. P2.</p> <p>Another issue concerned the potential negative consequences of quantifying costs and reporting cost of education to those with power and control over funding.Once you start the cost value discussion ... there would be a lot of resistance because people would be afraid that we would use this type of research to close down this or that course ... P4</p> <p>In other words, if we start studying cost and value in HPE, education/educators could end up being more accountable and may inadvertently disadvantage themselves. Although this may seem linked to "measuring the wrong things", our participants were talking here that, in the absence of cost information, the sole basis for decision-making may be information about effectiveness. Providing cost evidence changes the balance and (depending on who is making decisions, and how they weigh the relative value of cost and effectiveness) could lead to decreased educator autonomy and loss of funding or support for some activities that appear to offer lower returns for the effort consumed.</p> <p>Finally, participants noted that many HPE teachers and administrators already speak using cost and value terms such as "return on investment" (P9). However, such phrases and concepts are typically used in informal, idiomatic ways rather than reflecting formal data-drive cost research. This informal usage limits decision making and results in "<emph>writing like opinions, dreams because there's no data on which you can depend" (P8).</emph> Participants reflected that cost is inherent in all aspects of academic and clinical life, and it is up to us, the educators, to generate cost and value evidence to ensure a balance of power between academics and management—to ensure choices do not continue to be "<emph>based on ignorance." P4.</emph></p> <hd id="AN0159866642-11">Theme 2: I don't have the knowledge and skills</hd> <p>Many participants freely admitted a lack of economic literacy—that there were important gaps in their knowledge about the language, theories and methods of economic-type research:What is missing in the beginning is the methods. We as education, if we don't have economic background, we don't know how to make it. So, this is number one. Number two, that there is a confusion between cost effectiveness, value, those things because we don't have this background when you study medicine or when we do education. P8.Inter-disciplinary working with economists was seen as a way to address lack of knowledge and skills ("<emph>have an economist to pair up with</emph>" [P10]), particularly by participants with clinical backgrounds or relevant experience who drew parallels with cost-efficiency studies in health services research. However, this was not seen as straightforward. There was the perception of little common ground where HPE and economists could meet "<emph>I'm not sure that the two specialists—the medical doctors and the economists—have a shared language that they can use to communicate"</emph> (P4).</p> <hd id="AN0159866642-12">Theme 3: it's not what I went into education research to do</hd> <p>Some participants did not see cost and value research as of interest, because "<emph>it's not sexy. I think it's not hip. It's ... boring</emph>." P6. Thinking about money was seen as something administrative, something one does as a head of department or when writing a grant proposal, rather than an interesting and legitimate area of HPE research. It was also linked to seeing cost and value solely in respect of monetary value (pounds, dollars, euros) rather than broader interpretations (e.g., educator time or effort): "<emph>it's the framing of how you think about costs (time rather than money)" P9</emph>. There was a sense from some that money was not something one entered medicine or academia to think about, although the realities of senior roles in large organisations often forced consideration of financial issues: "<emph>I have brutal cost discussions on a weekly basis</emph>" P4 follow-up.</p> <hd id="AN0159866642-13">Theme 4: the difficulty of generating generalizable findings</hd> <p>Many talked about difficulties with comparisons and building an evidence base because of differences in context, lack of consistency or transparency<emph>—"I hear often that 'oh yes, but that was in the States and everything is about dollars over there so I can't use it ..." P3.</emph> One potential solution proposed was that if studies of cost and value provide sufficient detail about the relevant context, it will allow readers to use this to judge the applicability of findings to their own context: <emph>You would have to include contextual factors regarding the countries and systems [that] are working in the different contexts before you can interpret the data coming out of a study (P2).</emph></p> <p>An alternative view was that if a sufficiently large body of research on cost and value could be gathered on a particular issue of relevance, from different contexts, it would allow the field to be able to reach conclusions which are broadly relevant<emph>: And I believe that we have to go through the same laborious work in cost-value studies as we did in all the studies showing benefit for the patient. So first, we need to take one procedure at a time and create this overwhelming amount of evidence. (P3).</emph></p> <p>These concerns about generalisability of findings extended beyond the context and funding of education, and also encompassed differences in: <emph>How our culture, how our society, how our healthcare systems are organized. And there are quite large differences there in terms of who pays for what and how much things costs, and then the role of cost and value in general. (P10).</emph></p> <p>This was picked up further in the member checking when respondents reflected that the healthcare organization and local practices of their country may influence an individual's views on cost and value more generally. For example, those based in the USA are very used to discussions around cost-conscious care, whereas this discourse may be less common in countries with more cost-controlled, government-supported healthcare and education systems. On the other hand, those working in low-resource settings thought about cost a lot because of budget constraints. In short, the systems within which one is located may influence one's stance in relation to cost and value HPE research (as has been found in school education e.g., (Li et al., [<reflink idref="bib46" id="ref33">46</reflink>])). Furthermore, the political or cultural environment may also bias the importance of evidence or the willingness to adopt findings "... <emph>budgets are also a power-struggle, which is not necessarily 'won' or 'lost' based on evidence and rationality</emph>." (P9).</p> <hd id="AN0159866642-14">Discussion</hd> <p>This study gathered the views of HPE thought leaders towards cost and value research. Participants had mostly positive perceptions of the scientific and practical utility of studies in this area but there were some tensions. Key themes were: concern about quantification of what is easy to measure rather than what is meaningful, and the risks of doing so; little understanding of economics and its methodologies; a perceived lack of fit between their professional identity as health professions educators/researchers and cost and value research; and concerns about the generalisability/transferability of cost and value studies.</p> <p>The plethora of commentary and research on the perils of commodifying higher education indicates that our respondents' concern that an increased focus on cost and value research may increase emphasis on the measurable rather than the important is well-founded (e.g., Brown & Carasso, [<reflink idref="bib11" id="ref34">11</reflink>]; Sellar, [<reflink idref="bib60" id="ref35">60</reflink>]; Tomlinson, [<reflink idref="bib66" id="ref36">66</reflink>]; Williams, [<reflink idref="bib70" id="ref37">70</reflink>]). For example, metrics such as student retention or student satisfaction are relatively easy to measure but limited as they typically do not adjust for student or systems factors (for a fuller discussion, see Cleland et al., [<reflink idref="bib13" id="ref38">13</reflink>]). As per Einstein, not everything that can be counted counts, and not everything that counts can be counted. We propose that to assess the important as well as the measurable requires drawing on the wider literature to identify methods and theories which position cost and value research within clear <emph>value</emph> frameworks. This could include explicitly considering—and researching—the intrinsic value of health professions learning in terms of learner gains and systems sustainability. In terms of learner gains, educators and researchers could focus on, for example, designing and evaluating education that effects genuine change amongst students (empowering them to live more meaningful future lives e.g., Sen, [<reflink idref="bib61" id="ref39">61</reflink>], [<reflink idref="bib62" id="ref40">62</reflink>]); enhances student agency and "capital", including personal and identity capital (Marginson, [<reflink idref="bib51" id="ref41">51</reflink>]); and helps students self-regulate as learners and make independent choices (Coates & McCormick, [<reflink idref="bib19" id="ref42">19</reflink>]).</p> <p>In terms of systems sustainability, we suggest that while it would be naïve to say cost is unimportant, we suggest that it is crucial extend thinking to look beyond the financial (the monetary cost alone) to also look at value. Inherent in doing so is being explicit about the influence of the multiple, and fluid, social, cultural and political contexts in which medical and health professions education is situated (e.g., Bates & Ellaway, [<reflink idref="bib3" id="ref43">3</reflink>]; Cleland et al., [<reflink idref="bib14" id="ref44">14</reflink>]). For example, many medical schools in the UK and elsewhere invest heavily in initiatives to widen participation and access (e.g., outreach to high schools, mentoring possible applicants, summer schools, preparatory programmes, the use of different selection criteria, additional support throughout the year [e.g., Cleland & Nicholson, [<reflink idref="bib18" id="ref45">18</reflink>]; Cleland et al., [<reflink idref="bib16" id="ref46">16</reflink>]; Duenas et al., [<reflink idref="bib25" id="ref47">25</reflink>]; Vick et al., [<reflink idref="bib67" id="ref48">67</reflink>]). If one was to look at efforts to increase the diversity of medical students purely in terms of cost, then the return on investment in respect of recruitment, retention and graduate outcomes would arguably not represent value for money as the numbers of these applicants remains relatively low. However, using a <emph>value</emph> lens, these activities are driven by wider societal goals, a desire to change society and medical practice by supporting social mobility, improving care to marginalised or vulnerable patient groups and achieving equity (e.g., Coyle et al., [<reflink idref="bib22" id="ref49">22</reflink>]). Understanding and appropriately valuing these and other intangible (or less tangible) "outcomes" in health professions education (personal growth, intercultural awareness, patient-centredness, etc.) depends on theoretically framed qualitative and exploratory studies, not simple metrics.</p> <p>At an individual level, participants were wary of embracing cost and value research for at least three reasons: lack of necessary knowledge and skills, the view that cost and value research is "just" about money (see above) and the perception that thinking about money is not necessarily part of their professional identity. Skills and knowledge can be acquired (Foo et al., [<reflink idref="bib32" id="ref50">32</reflink>]; Maloney et al., [<reflink idref="bib48" id="ref51">48</reflink>]); attitudes are more difficult to change (e.g., Ajzen & Fishbein, [<reflink idref="bib1" id="ref52">1</reflink>]). However, embracing cost and value research does not necessarily require changing one's main research focus or jeopardising one's professional identity (Hackett, [<reflink idref="bib39" id="ref53">39</reflink>]). Rather it can be viewed as an opportunity to engage in interdisciplinary research [for example, collaborating with health/economist colleagues who have the necessary skills and "ways of talking" (Becher & Trowler, [<reflink idref="bib4" id="ref54">4</reflink>]; Bozeman & Corley, [<reflink idref="bib9" id="ref55">9</reflink>])]. This parallels long-established interdisciplinary working in healthcare, where clinicians and researchers collaborate with health/economists in comparative effectiveness research to consider the burdens, including financial costs, of clinical and other health-focused interventions (Luce et al., [<reflink idref="bib47" id="ref56">47</reflink>]). The few studies in health professions education which have been in partnership with health economists have produced useful intelligence which has informed practice and policy. For example, Cleland's series of discrete choice experiments looking at the relative importance of, and trade-offs between, job-related factors that influence UK doctors' decisions about post-graduate training, informed national-level interventions on how to address the maldistribution of junior doctors in the UK (e.g., Cleland et al., [<reflink idref="bib15" id="ref57">15</reflink>]; Scanlan et al., [<reflink idref="bib58" id="ref58">58</reflink>]).</p> <p>Concerns regarding the (limited) generalizability of findings is true for every aspect of HPE research, not just cost and value research (Ellaway et al., [<reflink idref="bib27" id="ref59">27</reflink>]; Schrewe et al., [<reflink idref="bib59" id="ref60">59</reflink>]). However, we perceive it may be perhaps more salient in cost and value research since both the use and local pricing of resources varies widely across institutions, health care systems, and nations. One option to address this would be producing a large number of comparable cost and value studies, thus enabling quantitative comparison through systematic reviews and meta-analysis (as suggested by some of our participants). However, this approach has been widely criticized in both health care and education (e.g., Anderson, [<reflink idref="bib2" id="ref61">2</reflink>]; Gomersall et al., [<reflink idref="bib36" id="ref62">36</reflink>]). Other options include reporting detailed data on cost estimation (the selection, quantitation, and pricing of each cost element) to allow re-estimation using local values (e.g., Levin et al., [<reflink idref="bib45" id="ref63">45</reflink>]); examining and reporting local issues to facilitate transferability (Cleland et al., [<reflink idref="bib17" id="ref64">17</reflink>]); and the use of theory.</p> <p>Expanding on this last point—the use of theory—health professions education research has advanced in recent years in its use of theory to anchor problems and conceptualise data (e.g., Bolander Laksov et al., [<reflink idref="bib7" id="ref65">7</reflink>]). However, we have anecdotally noted that economics theories are rarely evoked. While any theory borrowing must be carefully considered (Murray & Evers, [<reflink idref="bib55" id="ref66">55</reflink>]), economics is a field rich in theories which can be drawn upon to inform cost and value research in education, such as bounded rationality (Simon, [<reflink idref="bib63" id="ref67">63</reflink>]); conjoint analysis (Green & Srinivasan, [<reflink idref="bib37" id="ref68">37</reflink>]), prospect theory (Kahneman & Tversky, [<reflink idref="bib42" id="ref69">42</reflink>]) and nudge theory (Thaler & Sunstein, [<reflink idref="bib64" id="ref70">64</reflink>])]. As with all theories, economic theories can help generalise findings and concepts from one context to other settings; enhance the robustness, rigour, relevance, and impact of the findings (Eccles et al., [<reflink idref="bib26" id="ref71">26</reflink>]; Eva & Lingard, [<reflink idref="bib29" id="ref72">29</reflink>]; Walsh et al., [<reflink idref="bib68" id="ref73">68</reflink>]); and connect pieces of research data to generate findings which fit into a larger framework of other studies.</p> <hd id="AN0159866642-15">Strengths and limitations of the study</hd> <p>The research design and objectives called for a small participant group, as we sought to understand and explore the range and complexity of participants' perceptions—not to quantify or generalize them (Crouch and MacKenzie, [<reflink idref="bib24" id="ref74">24</reflink>]). Moreover, the use of member checking of our interpretation of the whole data set identified further points of agreement and questioning, which enriched the data and data analysis (Estroff, [<reflink idref="bib28" id="ref75">28</reflink>]).</p> <p>Participants were drawn from countries with different socio-political and cultural underpinnings and so represent diversity. However, the selection of participants was inevitably influenced by our personal networks, and it is difficult to compare across diverse contexts.</p> <p>Participants represented a small selection of men and women who have achieved success within health professions education and research. It would be interesting to repeat this study with early- and mid-career researchers and educators who may have different attitudes and views towards cost and value in HPE research. Moreover, we do not know if the views of our participants are widely held. A large-scale survey could explore the prevalence of these and other opinions and allow comparisons across career stage and context.</p> <p>It is also important to consider the nature of the research team. As thought leaders ourselves who have published on this topic, we have insider perspectives and personal viewpoints. We argue both these positions were advantageous by allowing use to integrate the narrative data as part of a "bigger picture" of cost and value research. Obviously, a different research team might have gleaned different insights (Finlay, [<reflink idref="bib31" id="ref76">31</reflink>]).</p> <hd id="AN0159866642-16">Conclusion</hd> <p>This study contributes to a wider conversation in the literature about cost and value research by bringing in the views of global HPE thought leaders. Our findings provide insight which can inform how best to engage and empower educators and researchers in the processes of asking and answering meaningful, acceptable and relevant cost and value questions in HPE. Embracing cost and value research has the potential to provide novel perspectives on old problems, open up new areas of understanding and enquiry, and ensure that as a professional group we have the knowledge to ensure educational quality and professional self-governance. To quote Benjamin Franklin: <emph>An investment in knowledge pays the best interest</emph>.</p> <hd id="AN0159866642-17">Acknowledgements</hd> <p>Our thanks to the colleagues who took part in this study as participants and reviewed the manuscript as part of the member checking process.</p> <hd id="AN0159866642-18">Author contributions</hd> <p>MGT had the original idea for this study. All authors made substantial contributions to the conception and design of the study. MGT carried out the interviews. JC led on the data analysis and drafting the paper. All authors contributed to writing the paper, reviewed the final manuscript and agreed to be accountable for all aspects of the work.</p> <hd id="AN0159866642-19">Funding</hd> <p>The authors did not seek external funding for this study.</p> <hd id="AN0159866642-20">Declarations</hd> <p></p> <hd id="AN0159866642-21">Conflict of interest</hd> <p>The authors declare that they have no competing interests.</p> <p>Ethical approval</p> <p>Ethics (IRB) approval for educational research was not required. 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  Data: 'Important but Risky': Attitudes of Global Thought Leaders towards Cost and Value Research in Health Professions Education
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  Data: <searchLink fieldCode="SO" term="%22Advances+in+Health+Sciences+Education%22"><i>Advances in Health Sciences Education</i></searchLink>. Oct 2022 27(4):989-1001.
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  Label: Availability
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  Data: Springer. Available from: Springer Nature. One New York Plaza, Suite 4600, New York, NY 10004. Tel: 800-777-4643; Tel: 212-460-1500; Fax: 212-460-1700; e-mail: customerservice@springernature.com; Web site: https://link.springer.com/
– Name: PeerReviewed
  Label: Peer Reviewed
  Group: SrcInfo
  Data: Y
– Name: Pages
  Label: Page Count
  Group: Src
  Data: 13
– Name: DatePubCY
  Label: Publication Date
  Group: Date
  Data: 2022
– Name: TypeDocument
  Label: Document Type
  Group: TypDoc
  Data: Journal Articles<br />Reports - Research
– Name: Subject
  Label: Descriptors
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Risk%22">Risk</searchLink><br /><searchLink fieldCode="DE" term="%22Decision+Making%22">Decision Making</searchLink><br /><searchLink fieldCode="DE" term="%22Accountability%22">Accountability</searchLink><br /><searchLink fieldCode="DE" term="%22Feedback+%28Response%29%22">Feedback (Response)</searchLink><br /><searchLink fieldCode="DE" term="%22Costs%22">Costs</searchLink><br /><searchLink fieldCode="DE" term="%22Barriers%22">Barriers</searchLink><br /><searchLink fieldCode="DE" term="%22Telecommunications%22">Telecommunications</searchLink><br /><searchLink fieldCode="DE" term="%22Handheld+Devices%22">Handheld Devices</searchLink><br /><searchLink fieldCode="DE" term="%22Videoconferencing%22">Videoconferencing</searchLink><br /><searchLink fieldCode="DE" term="%22Health+Personnel%22">Health Personnel</searchLink><br /><searchLink fieldCode="DE" term="%22Allied+Health+Occupations+Education%22">Allied Health Occupations Education</searchLink><br /><searchLink fieldCode="DE" term="%22Professional+Autonomy%22">Professional Autonomy</searchLink><br /><searchLink fieldCode="DE" term="%22Professional+Identity%22">Professional Identity</searchLink><br /><searchLink fieldCode="DE" term="%22Economic+Factors%22">Economic Factors</searchLink><br /><searchLink fieldCode="DE" term="%22Knowledge+Level%22">Knowledge Level</searchLink><br /><searchLink fieldCode="DE" term="%22Generalization%22">Generalization</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1007/s10459-022-10123-9
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 1382-4996<br />1573-1677
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Studies of cost and value can inform educational decision making, yet our understanding of the barriers to such research is incomplete. To address this gap, our aim was to explore the attitudes of global thought leaders in HPE towards cost and value research. This was a qualitative virtual interview study underpinned by social constructionism. In telephone or videoconference interviews in 2018-2019, we asked global healthcare professional thought leaders their views regarding HPE cost and value research, outstanding research questions in this area and why addressing these questions was important. Analysis was inductive and thematic, and incorporated review and comments from the original interviewees (member checking). We interviewed 11 thought leaders, nine of whom gave later feedback on our data interpretation (member checking). We identified four themes: Cost research is really important but potentially risky (quantifying and reporting costs provides evidence for decision-making but could lead to increased accountability and loss of autonomy); I don't have the knowledge and skills (lack of economic literacy); it's not what I went into education research to do (professional identity); and it's difficult to generate generalizable findings (the importance of context). This study contributes to a wider conversation in the literature about cost and value research by bringing in the views of global HPE thought leaders. Our findings provide insight to inform how best to engage and empower educators and researchers in the processes of asking and answering meaningful, acceptable and relevant cost and value questions in HPE.
– Name: AbstractInfo
  Label: Abstractor
  Group: Ab
  Data: As Provided
– Name: DateEntry
  Label: Entry Date
  Group: Date
  Data: 2022
– Name: AN
  Label: Accession Number
  Group: ID
  Data: EJ1353222
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ1353222
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        Value: 10.1007/s10459-022-10123-9
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      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 13
        StartPage: 989
    Subjects:
      – SubjectFull: Risk
        Type: general
      – SubjectFull: Decision Making
        Type: general
      – SubjectFull: Accountability
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      – SubjectFull: Feedback (Response)
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      – SubjectFull: Costs
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      – SubjectFull: Barriers
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      – SubjectFull: Knowledge Level
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      – SubjectFull: Generalization
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    Titles:
      – TitleFull: 'Important but Risky': Attitudes of Global Thought Leaders towards Cost and Value Research in Health Professions Education
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