Stories, not containers: What is a course?

We think of courses as containers; containers for the outcomes, content and assessments related to a topic. Students move through the course – from one concept to another – until they get to the assessment at the end, which signals the end of the course. The course is bound in time; it has a definite beginning and end and it requires us to map out the course structure long before we meet the participants. How then, can this structure recognise the unique characteristics of individuals? Courses as containers are formalised, and standardised and ultimately, far more about compliance and conformity than creativity, ingenuity, innovation, or even mastery. There may be some administrative benefits to thinking of courses in this way but there are few benefits that are pedagogical. In other words, the course as container metaphor doesn’t enhance learning in any way.

If we want a student-centred, inquiry-based course we must disregard the course as container and come up with another way to think about courses. Lately I’ve been wondering if the course could be structured as a user-generated story; an unscripted narrative that integrates participant experience with course concepts leading to unpredictable and delightful outcomes. Instead of thinking of the course as a container – closed and inflexible – what if it was a stage upon which the process of learning could be enacted in order to tell stories? What if the course was an open space that enabled personal learning to progress in directions that we cannot anticipate. The course framework could include some things that participants would need to tell their version of the story – provocations, an audience, collaborators, basic structure – while also allowing for them to bring in their own elements – experience, knowledge, beliefs, etc.

What if a course began like a great story; with an opening scene that grabbed your attention? What if we started with a provocative context that generated a “Whoa!” moment; a cascade of questions that threatened someone’s core beliefs. This opening scene could establish a learning context where every participant realises that their understanding and practices are going to be questioned. It becomes clear that this course will not have a neat and tidy resolution, and that this is going to require a confrontation with the messiness and uncertainty of the world. Participants know, from the beginning, that this course is not for the faint of heart.

After the opening scene the course begins to unfold, allowing each participant to take a different direction. The structure of the course not only acknowledges every participants’ unique context and history, but actually aims to embrace and use it. There is an unfolding sequence of action and reflection where each participant chooses which “storyline” to follow. One might watch the embedded video while another is caught up in the patient scenario. Other participants are drawn to the poems and art section where course concepts are explored with multimedia artifacts. Yet others choose to read the research paper or the book review. Depending on where they see “the evidence” residing, participants make choices about how they wish to explore the topic.

There is therefore both controlled and uncontrolled content where the (un)structure of the course enables participants to engage with different perspectives, right from the start. Content is negotiated by the participants within the context of the course and decisions made about what is important to include. This enables the course to be built – as it unfolds – around the critical examination of concepts, hierarchies and assumptions that exist at the centre.

As participants engage with the course concepts via different media, questions are triggered which lead to the development of research queries that aim to provide information that participants need in order to build their story. These resources then become a course “reading” list (it could include videos and art) generated by participants during the course. Course content is therefore created in the moment as participants write their own stories using personal experience, concepts from the course, group conversations and the additional resources generated by other participants. They aggregate resources from multiple sources, remix these in various ways, adapt and repurpose them to suit their own needs, and then share them. The content is therefore created as it is needed. It will also be different every time the course is enacted because different participants will take the narrative in different directions, leading to different outcomes.

The course also provides the time and space for participants to step back and reflect. To “put down the book” and step outside. We need a moment where, before we can move on with the story we must first come to terms with what we’ve just learned. There are some ideas that are too big to take in at once and we need to step away to think about what they mean for us. Sometimes – when the ideas are big enough and uncomfortable enough – we need to think about whether or not we even want to to continue with the story. We need courses that are cognisant of the need to “step back” and that give participants the space they need to work with difficult ideas.

While the course itself is bound with beginning and end points (we can’t have facilitators and participants forever enrolled), the interactions and community that develop during the course could continue when it ends. The course is designed to outgrow itself and to leave space for community engagement and response that extends beyond the boundaries set for each iteration of the course. Just like stories can stay with you long after you finish the last page, so the thinking and reflections generated in the course as story continue long after the final task is completed. In fact, completing the final task doesn’t signal the end of something; instead it highlights that this is the beginning of a change in how you think about the world.

At the begining of the course as story, it is the group who collectively decide what “success” looks like and how it will be assessed at the end. Perhaps they decide that a short book will be the final product, where each participant takes the lead in developing a collaboratively created chapter, where each chapter is a topic in the course. Maybe “success” for another cohort is a website where they describe their process, including reflections, drawings, photos, video diaries and audio recordings. Maybe someone in the group composed a song that they all perform and that gets published. Maybe “success” is an exhibition at a gallery. We must remember that there are few limitations to what should be attempted in the pursuit of sustained, meaningful learning. The total number of possible ways that “success” can be determined is much higher than performance on a test, or submission of an essay. Thinking of the course as an unscripted story without a predetermined outcome helps us get to the point where it’s easier to see what those other descriptions of success might look like.

The best stories aren’t the ones that take you down a predictable and narrowly focused path. The best stories open you up to the possibility that everything you thought about something is being questioned. The best stories don’t answer all the questions and aren’t neatly wrapped up at the end. The best stories are starting points that leave you asking, “What next?”. Shouldn’t our courses do the same?

What conversation about curriculum should we be having?

There are tensions between all the relevant stakeholders in the training of health professionals, largely as a result of differences in expectations. These tensions can easily be seen between:

  1. The Department of Education and the Department of Health
  2. Academics at university and clinicians in the practice environment
  3. Government (usually rural) and private (usually urban) clinical contexts

Each of these groups (rightly) have different priorities with respect to the outcomes they value, and it’s very difficult to satisfy everyone. But what everyone seems to agree on is the nature of the conversation that we end up having. Except in very rare cases, the conversation about undergraduate health professions education almost always comes down to the acquisition of knowledge and skills; what do we want our new graduates to know and to do.

But this is the wrong conversation. In complex contexts and uncertain futures we can’t afford to focus our attention on what graduates know and do, but should rather pay attention to how they think and how they learn. Yet this is something that is almost universally absent from any conversation about the curriculum. As long as we’re talking about what content to include in the curriculum we’re missing the point that the biggest gap in our students’ repertoire when they graduate is that they don’t know how to think about learning.

Learning how to adapt to new and dynamic contexts is the most important skill that any new graduate can have, and yet this is probably the thing that we pay the least attention to.

The future of education in complex systems

This is the first draft of an Editorial I wrote for the open access African Journal of Health Professions Education, which will be coming out soon.

Health and education systems are increasingly recognised as complex adaptive systems that are characterised by high levels of uncertainty and constant change as a result of rich, non-linear interactions (Fraser & Greenhalgh, 2001; Bleakley, 2010). This means that complex systems are inherently ambiguous and uncertain, and that they lack predictable outcomes or clear boundaries. As health and education systems have become more complex and integrated at the beginning of the 21st century, it is no longer possible for single individuals – or even single disciplines – to work effectively within these systems (Frenk et al., 2010).

The problems generated by complex systems have been called wicked problems and are not simply difficult to solve, they are impossible to solve (Conklin, 2001; Ritchey, 2013). They’re “messy, devious, and they fight back when you try to deal with them.” (Ritchey, 2013). They’re the kinds of problems where different stakeholders have different frameworks for even trying to describe the problem, and where the constraints and resources necessary to work on the problem change over time (Conklin, 2001).

Wicked problems are also about people, vested interests and politics – making them very subjective, which is why they do not have stable problem formulations, pre-defined solution concepts, and why their outcomes are unpredictable (Ritchey, 2013). Even though we cannot solve wicked problems we can move them forward by learning how to adapt to change, generate new knowledge, and continue improving performance (Fraser & Greenhalgh, 2001). The uncertainty of complex systems is therefore something that we need to be comfortable with, learn to engage with, and be curious about. Wicked problems are not amenable to resolution through formal, structured methods; we must rather adapt to working within them.

The ability to drive progress in complex systems is a function of the ability to generate and connect ideas across groups and disciplines, and then implement new processes based on them. Not only do these activities take time, they are highly social as success often depends on who we work with (Jarche, 2016). In other words, teams are not only important for effective work but also for the kinds of generative, creative work that 21st century problems require. The ability to work in effective, interdisciplinary and creative teams is what we need to address the health problems of the future.

If the knowledge and skills required to work with wicked problems in complex systems are so diverse that it is impossible for a single individual or profession to make any appreciable impact, it is clear that we need teams that work across disciplinary boundaries. Therefore, interprofessional education is one possible strategy that we can follow to try and develop the requisite competencies for working within complex systems. These competencies include – among others – the ability to develop relationships, emotional intelligence, group work, communication and self-management, all of which are difficult to develop and assess within students (Knight & Page, 2007).

In fact, higher education is not at all well-positioned to help students develop the competencies that enable them to work with wicked problems in complex systems. Social learning theories that can help practitioners become more effective in non-linear, dynamic systems through inter-professionalism and shared tolerance of ambiguity are generally absent, especially in medical education (Bleakley, 2010). Adopting these approaches at the programme level in health professions education requires the kind of radical change that traditional health and education systems are highly resistant to. (Frenk et al., 2010). If we want to make any real progress in improving health and education outcomes in an increasingly complex world, we must start taking seriously the idea that radical curriculum reform is not only indicated, but required.


Bleakley, A. (2010). Blunting Occam’s razor: aligning medical education with studies of complexity. Journal of Evaluation in Clinical Practice, 16(4), 849–855.

Conklin, J. (2001). “Wicked Problems and Social Complexity.” CogNexus Institute. [Online]. Available from:

Fraser, S. W., & Greenhalgh, T. (2001). Coping with complexity: educating for capability. BMJ, 323, 799–803.

Frenk, J., Chen, L., Bhutta, Z. A., Cohen, J., Crisp, N., Evans, T., … Zurayk, H. (2010). Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. The Lancet, 376(9756), 1923–1958.

Jarche, H. (2016). valued work is not standardized.

Knight, P. T., & Page, A. (2007). The assessment of “wicked” competences: A report to the Practice-based Professional Learning Centre for excellence in teaching and learning in the Open University. Retrieved from…/460d21bd645f8.pdf

Ritchey, T. (2013). Wicked problems: Modelling Social Messes with Morphological Analysis. Acta Morphologica Generalis, Vol. 2 No. 1.

Who cares about “referencing”?

Why do we teach our students how to reference? Mendeley, EndNote, Refworks, etc. all do it for you. In my experience the emphasis for students in higher education is almost always on what the citation looks like and not on the work the citation does. When it comes to learning about referencing for students, the focus is almost always on:

  1. Plagiarism: If you don’t reference, you’re stealing.
  2. Format: If it doesn’t conform to [insert style guide], it’s wrong.

This is problematic. The first point begins with the assumption that our students are cheats and frauds. I prefer not to go into the relationship with that as a starting frame of reference. The second point is irrelevant because style guides explain exactly how to format the citation and software formats it for us.

What matters is that students understand the underlying rationale of attribution and of building on the ideas of others. I’m way more interested in talking about ideas with my students, than on where the comma goes. Instead of talking about the importance of referencing maybe we should aim to instil in students a love of ideas. Sometimes those ideas originated from someone else (citation required) and sometimes those ideas are your own. What does the world look like when we use ideas – some our own and some from others – to think differently? That seems like a more interesting conversation to have.

Public posting of marks

My university has a policy where the marks for each assessment task are posted – anonymously – on the departmental notice board. I think it goes back to a time when students were not automatically notified by email and individual notifications of grades would have been too time consuming. Now that our students get their marks as soon as they are captured in the system, I asked myself why we still bother to post the marks publicly.

I can’t think of a single reason why we should. What is the benefit of posting a list of marks where students are ranked against how others performed in the assessment? It has no value – as far as I can tell – for learning. No value for self-esteem (unless you’re performing in the higher percentile). No value for the institution or teacher. So why do we still do it?

I conducted a short poll among my final year ethics students asking them if they wanted me to continue posting their marks in public. See below for their responses.


Moving forward, I will no longer post my students marks in public nor will I publish class averages, unless specifically requested to do so. If I’m going to say that I’m assessing students against a set of criteria rather than against each other, I need to have my practice mirror this. How are students supposed to develop empathy when we constantly remind them that they’re in competition with each other?

altPhysio | Describing a novel curriculum

I’ve spent the last 2 weeks or so trying to get my head around what a new curriculum might look like in practical terms, largely to the detriment of everything else that I’m supposed to be doing. It seems to be a harder problem than I anticipated (or maybe I’m just missing something). One of the main issues I’m struggling with is how to describe the new curriculum if we abandon the idea of discrete collections of facts (i.e. modules) that encourage students to compartmentalise their learning. Consider the following:

  • If you break the concepts down into very small, granular pieces (making it easy to link concepts and to generally describe the curriculum), it’s hard to create a structure that allows for independent pathways through the concepts. You’re more inclined to provide a structured, linear path through what (the lecturer decides) should be known. While this approach does provide security for students navigating unfamiliar territory and also makes it easier to administrate the curriculum, it encourages students to split their thinking too. This is a “neuro” test, this is a “resp patient”, this is a “paeds block”, etc. This is pretty much how our current curricula are represented i.e. by grouping related concepts into collections called modules / papers.
  • If you go the other direction and organise the curriculum into large, complex, relatively undefined projects that allow students the space to create their own learning pathways, you lose the ability to accurately describe what concepts are presented in those relatively undefined projects. While this approach has a greater chance of leading to self-directed and lifelong learning, critical and creative thinking, and comfort with ambiguity, it also means that the curriculum becomes harder to describe. It’s not like in the first approach where you can be certain that “informed” consent” is included in the “Ethics” module. What project explicitly includes the concept of consent? It’s hard to tell from the name of the project alone.

A module (or paper) describes – in it’s name – what related concepts can reasonably be expected to arise in that module. You know what ideas are going to come up when you’re thinking about the Neuro module. A project – in it’s name – might describe at some high level what to expect but it cannot describe with any accuracy everything that can reasonably be expected to emerge in the project. The one thing that gives me some solace is knowing that in actual fact, we struggle to describe our own curriculum anyway, even with our very granular, silo’d structure. For example, the concept of CVA comes up in so many places and in so many contexts that it’s really hard to say “where” it exists in the curriculum.

The only solution I can think of is to take the approach that, once designed – with all major concepts included in the projects – you trust the curriculum to run it’s course and don’t spent too much time worrying where a certain concept is embedded. You know that consent is included somewhere in some project and when someone asks where exactly it is, you simply search for it?

Note: I’m assuming that the content of the curriculum would stay the same. In other words I’m still trying to teach the same “stuff”,  I’m just trying to find a way to package it differently. Dave Nicholls has suggested a different approach where we begin with a question around what the curriculum is for. What is it for? This would naturally lead us to think about the curriculum in a very different – and far more interesting – way. I need to spend some time with this idea.

On a side note, I came across this paper while looking into the challenges of describing alternative curriculum approaches: Moore, A. & House, P. (1973). The open access curriculum—an approach to individualization and student involvement. Science Education, 57(2):215-218. Ironically the paper is not available with an open access license so I couldn’t get the full text. The paper – from 1973 – articulates what I think are some pretty important approaches that a new physiotherapy curriculum should include:

  1. Multiple entry points to each large body of content, usually beginning at the exploratory level and proceeding toward in-depth facts (I really love this idea and will be looking into it in some depth for the course)
  2. Guidelines for student study that facilitate a self-commitment to fully personalised projects (Obviously I’m a fan of the project approach to learning, so this resonates with me as well)
  3. Students assuming direct responsibility for a significant part of their own education
  4. Differentiated teacher roles
  5. Both the teachers and the students helping to define and implement the meaning of the concept of open access
  6. Making the assumption that all students will succeed

Systematic constraints as “structure” for learning

Foucault said that the ideas we think are benign are often the most dangerous. If students accept and believe that the constraints we build around them (i.e. the curriculum) are beneficial for scaffolding their learning they will always be passive. Freire might say that we are oppressing – as opposed to liberating – them by providing this structure.

The structured system convinces students that the structure is “right” and that they have a place within it. Success is determined by the student’s ability to navigate through the structure. However, this doesn’t lead to questioning of the system, or even questioning within the system. For example, we build a course that “supports self-directed learning” but we structure the course so that all engagement happens within an LMS. When we say “self-directed” we actually mean “the content is here for students to browse independently”.

If we really mean to liberate students by enabling self-directed learning we would remove the constraints entirely and encourage students to find their own content by asking their own questions.

What If High School Were More Like Kindergarten?

What if high school were more like kindergarten? by Ashley Lamb-Sinclair

I have a strange-looking, handmade bust of Yoda sitting atop my desk at school. I made this statue in a high-school art class because the teacher asked us to create a life-like bust of a human face. While molding my sculpture, I was exploring a little and pulled the ears into a point. I laughed to myself because it looked just like Yoda. Suddenly, the task transformed from a school assignment to a fun experiment. When I finished, I proudly presented my art to my teacher, who promptly failed me for not following instructions.

We are encouraged to help our students develop 21st century skills – including creativity – but often aren’t given the space to do it. If you want to add something to the curriculum then something else has to go. I know that I’d start by removing about 25% of the content in each module. What would you take out?

IPE course project update

This post is cross-posted from the International Ethics Project site.

My 4th year students have recently completed the first writing task in the IEP course pilot project. I thought I’d post a quick update on the process using screenshots to illustrate how the course is being run. We’re using a free version of WordPress which has certain limitations. For example it’s hard to manage different cohorts of students, but there are many more advantages, which I’ll write about in another post.

My students will keep writing for their portfolios using the course website, which I’ll keep updating and refining based on our experiences. The idea is that by the end of the year we’ll have figured out how to use the site most effectively for students to work through the course for the project.

Interrogating the mistakes

We tend to focus our attention on the things that students got right. This seems perfectly appropriate at first glance because we want to celebrate what they know. Their grades are reported in such a way as to highlight the number of questions answered correctly. The cut score (pass mark) is set based on what we (often arbitrarily) decide a reasonably competent student should know (there is no basis for setting 50% as the cut score, but that’s for another post). The emphasis is always on what is known rather than what is not known.

But if you think about it getting the right answer is a bit of a dead end as far as learning is concerned. There’s nowhere to go from there. But the wrong answer opens up a whole world of possibility. If the capacity to learn and move forward sits in the spaces taken up by faulty reasoning shouldn’t we pay more attention to the errors that students make? The mistakes give us a starting point from which to proceed with learning.

What if we changed our emphasis in the curriculum to focus attention on the things that students don’t understand? Instead of celebrating the points they scored for getting the right answer could we pay closer attention to the areas where they lost marks? And not in a negative way that makes students feel inferior or stupid. I’m talking about actually celebrating the wrong answers because it gives us a starting point and a direction to move. “You got that wrong. Great! Let’s talk about it. What was the first thing you thought when you read the question? Why did you say that? Did you consider this other option? What is the logical end point of the reasoning you used? Do you see now how your answer can’t be correct?” Imagine a conversation going like that. Imagine what it would mean for students’ ability to reflect on their thinking and practice.

We might end up with some powerful shared learning experiences as we get into students’ heads as we try to understand what and how they think. The faulty reasoning that got them to the wrong answer is way more interesting than the correct reasoning that got them to the right answer. A focus on the mistakes that they make would actually help improve students ability to learn in the future because you’d be helping to correct their faulty reasoning.

But we don’t do this. We focus on counting up the the right answers and celebrating them, which means that we deflect attention from the wrong answers. We make implicit the idea that getting the right answer is important and the getting the wrong answers are bad. But learning only happens when we interrogate the faulty reasoning that got us to the wrong answer.