altPhysio | Technology as infrastructure

This is the fourth post in my altPhysio series, where I’m exploring alternative ways of thinking about a physiotherapy curriculum by imagining what a future school might look like. This post is a bit longer than other because this is an area I’m really interested in and spend a lot of time thinking about. I’ve also added more links to external sources because some of this stuff sounds like science fiction. The irony is that everything in this post describes technology that currently exists, and as long as we’re thinking about whether or not to share PowerPoint slide we’re not paying attention to what’s important. This post was a ton of fun to write.

Q: Can you talk a little bit about the history of technology integration in health professions education? Maybe over the last decade or so.

In the early part of the 21st century we saw more institutions starting to take the integration of technology seriously. Unfortunately the primary use of digital services at the time was about moving content around more efficiently. Even though the research was saying that the content component was less important for learning than the communication component, we still saw universities using the LMS primarily to share notes and presentations with students.

The other thing is that we were always about 5-10 years behind the curve when it came to the adoption of technology. For examples, wikis started showing up in the medical education literature almost 10 years after they were invented. The same with MOOCs. I understand the need to wait and see how technologies stabilise and then choosing something that’s robust and reliable. But the challenge is that you lose out on the early mover advantages of using the technology early. That’s why we tend to adopt a startup mentality to how we use technology at altPhysio.

Q: What do you mean by that? How is altPhysio like a startup?

We pay attention to what’s on the horizon, especially the emerging technologies that have the potential to make an impact on learning in 1, 2 and 5 year time frames. We decided that we weren’t going to wait and see what technologies stabilised and would rather integrate the most advanced technologies available at the time. We designed our programme to be flexible and to adapt to change based on what’s happening around us. When the future is unknowable because technological advances are happening faster than you can anticipate, you need a system that can adapt to the situations that emerge. We can’t design a rigid curriculum that attempts to guess what the future holds. So we implement and evaluate rapidly, constantly trying out small experiments with small groups of students.

Once we decided that we’d be proactive instead of reactive in how we use and think about technology, we realised that we’d need a small team in the school who are on the lookout for technologies that have the potential to enhance the curriculum. The team consists of students and staff who identify emerging technologies before they become mainstream, prepare short reports for the rest of the school, recruit beta testers and plan small scale research projects that highlight the potential benefits and challenges of implementing the technology at scale.

We’ve found that this is a great way for students to invest themselves in their own learning, drive research in areas they are interested in, take leadership roles and manage small projects. Staff on the team act as supervisors and mentors, but in fact are often students themselves, as both groups push each other further in terms of developing insights that would not be possible working in isolation.

Q: But why the emphasis on technology in health professions education? Isn’t this programme about developing physiotherapists?

The WHO report on the use of elearning for undergraduate health professional education called for the integration of technology into the curriculum, as did the Lancet Commission report. And it wasn’t just about moving content more efficiently in the system but rather to use technology intentionally to change how we think about the curriculum and student learning. The ability to learn is increasingly mediated by digital and information literacy and we want our students’ learning potential to be maximised.

Low levels of digital literacy in the 21st century is akin to a limited ability to read and write in the past. Imagine trying to learn in the 20th century without being able to read and write? Well, that’s what it’s like trying to learn today if you don’t have a grasp of how digital technologies mediate your construction of knowledge. Integrating technology is not about adding new gadgets or figuring out how to use Facebook groups more effectively.

Technology is an infrastructure that can be used to open up and enhance student’s learning, or to limit it. Freire said that there’s no such thing as a neutral education process, and we take seriously the fact that the technologies we use have a powerful influence on students’ learning.

Q: How do you develop digital and information literacy alongside the competencies that are important for physiotherapists? Doesn’t an emphasis on technology distract students from the core curriculum?

We don’t offer “Technology” as something separate to the physiotherapy curriculum, just as you don’t offer “Pen and paper” as something that is separate. The ability to use a pen and paper used to be an integral and inseparable aspect of learning, and we’ve just moved that paradigm to now include digital and information literacy. Technology isn’t separate to learning, it’s a part of learning just like pen and paper used to be.

Digital and information literacy is integrated into everything that happens at the school. For example, when a new student registers they immediately get allocated a domain on the school servers, along with a personal URL. A digital domain of their own where they get to build out their personal learning environment. This is where they make notes, pull in additional resources like books and video, and work on their projects. It’s a complete online workspace that allows individual and collaborative work and serves as a record of their progress through the programme. It’s really important to us that students learn how to control the digital spaces that they use for learning, and that they’re able to keep control over those spaces after they graduate.

When students graduate, their personal curriculum goes with them, containing the entire curriculum (every resource we shared with them) as well as every artefact of their learning they created, and every resource that they pulled in themselves. Our students never lose the content that they aggregated over the duration of the programme, but more importantly, they never lose the network they built over that time. The learning network is by far the most important part of the programme, and includes not only the content relationships they’ve formed during the process but includes all interactions with their teachers, supervisors, clinicians and tutors.

Q: Why is it important for students to work in digital space, as well as physical space? And how do your choices about online spaces impact on students’ learning?

Think about how the configuration of physical space in a 20th century classroom dictated the nature of interactions that were possible in that space. How did the walls, desks and chairs, and the position of the lecturer determine who spoke, for example? Who moved? Who was allowed to move? How was work done in that space? Think about how concepts of “front” and “back” (in a classroom) have connotations for how we think about who sits where.

Now, how does the configuration of digital space change the nature of the interactions that are possible in that space? How we design the learning environment (digital or physical) not only enables or disables certain kinds of interactions, but it says something about how we think about learning. Choosing one kind of configuration over another articulates a set of values. For example, we value openness in the curriculum, from the licensing of our course materials, to the software we build on. This commitment to openness says something about who we are and what is important to us.

The fact that our students begin here with their own digital space – a personal learning environment – that they can configure in meaningful ways to enhance their potential for learning, sends a powerful message. Just like the physical classroom configuration changes how power is manifested, so can the digital space. Our use of technology tells students that they have power in terms of making choices with respect to their learning.

To go back to your question about the potential for technology to distract students from learning physiotherapy; did you ever think about how classrooms – the physical configuration of space – distracted students from learning? Probably not. Why not?

Q: You mentioned that openness is an important concept in the curriculum. Can you go into a bit more detail about that?

Maybe it would be best to use a specific example because there are many ways that openness can be defined. Our curriculum is an open source project that gives us the ability to be as flexible and adaptable as a 21st century curriculum needs to be. It would be impossible for us to design a curriculum that was configured for every student’s unique learning needs and that was responsive to a changing social context, so we started with a baseline structure that could be modified over time by students.

We use a GitHub repository to host and collaborate on the curriculum. Think of a unique instance of the curriculum that is the baseline version – the core – that is hosted on our servers. When a student registers, we fork that curriculum to create another, unique instance on the students personal digital domain. At this moment, the curriculum on the student’s server is an exact copy of the one we have but almost immediately, the students’ version is modified based on their personal context. For example, the entire curriculum – including all of the content associated with the programme – is translated into the student’s home language if they choose so. Now that it’s on their server, they can modify it to better suit them, using annotation and editing tools, and allowing them to integrate external resources into their learning environment.

One of the most powerful features of the system is that it allows for students to push ideas back into our core curriculum. They make changes on their own versions and if they’d like to see that change implemented across the programme, they send us a “Pull” request, which is basically a message that shows the suggested change along with a comment for why the student wants it. It’s a feedback mechanism for them to send us signals on what works well and what can be improved. It enables us to constantly refine and improve the curriculum based on real time input from students.

On top of this, every time we partner with other institutions, they can fork the curriculum and modify it to suit their context, and then push the changes back upstream. This means that the next time someone wants to partner with us, the core curriculum they can choose from is bigger and more comprehensive. For example, our curriculum is now the largest database of case studies in the world because most institutions that fork the curriculum and make their own changes also send those changes back to the core.

Q: You have a very different approach to a tutorial system. Tell us about how tutors are implemented in your school.

The tutors at altPhysio are weak AI agents – relatively simple artificial general intelligence algorithms that perform within very narrow constraints that are linked to basic tasks associated with student learning. Students “connect” with their AI tutors in the first week of the programme, which for the most part involves downloading an app onto their phones. This is then sync’d across all of their other devices and digital spaces, including laptops, wearables and cloud services, so that the AI is “present” in whatever context the student is learning.

As AI has become increasingly commoditised in the last decade, AI as a service has allowed us to take advantage of features that enhance learning. For example, a student’s tutor will help her with establishing a learning context, finding content related to that context, and reasoning through the problems that arise in the context. In addition, the AIs help students manage time on task, remind them about upcoming tasks and the associated preparation for those tasks, and generally keep them focused on their learning.

Over time the algorithms evolve with students, becoming increasingly tied to them and their own personal learning patterns. While all AI tutors begin with the same structure and function they gradually become more tightly integrated with the student. Some of the more adventurous students have had the AIs integrated with neural lace implants, which has obviously significantly accelerated their ability to function at much higher levels and at much greater speeds than the rest of us. These progressions have obviously made us think very differently about assessment, obviously.

Q: What about technology used during lectures? Is there anything different to what you’ve already mentioned?

Lectures have a different meaning here than at other institutions, and I suspect we’ll talk about that later. Anyway, during lectures the AI tutors act as interpreters for the students, performing real time translation for our international speakers, as well as doing speech-to-text transcription in real time. This means that our deaf students get all speech converted to Braille in real time, which is pretty cool. All the audio, video and text that is generated during lectures is saved, edited and sync’d to the students personal domains where they’re available for recall later.

Our students use augmented reality a lot in the classroom and clinical context, where students overlay digital information on their visual fields in order to get more context in the lecture. For example, while I’m talking about movement happening at the elbow, the student might choose to display the relevant bones, joints and muscles responsible for the movement. As the information is presented to them, they can choose to save that additional detail into the point in the lecture that I discussed it, so that when they’re watching the video of the lecture later, the additional information is included. We use this system a lot for anatomy and other movement- and structure-type classes.

microsoft-hololens-medical-studies

Q: That sounds like a pretty comprehensive overview of how technology has some important uses beyond making content easier to access. Any final thoughts?

Technology is not something that we “do”, it’s something that we “do things with”. It enables more powerful forms of communication and interaction, both in online and physical spaces, and to think of it in terms of another “platform” or “service” is to miss the point. It amplifies our ability to do things in the world and just because it’s not cheap or widely distributed today doesn’t mean it won’t be in the future.

In 2007 the iPhone didn’t exist. Now every student in the university carries in their pocket a computer more powerful than the ones we used to put men on the moon. We should be more intentional about how we use that power, and forget about whatever app happens to be trending today.

 

How my students do case studies in clinical practice

Our students do small case studies as part of their clinical practice rotations. The basic idea is that they need to identify a problem with their own practice; something that they want to improve. They describe the problem in the context of a case study which gives them a framework to approach the problem like a research project. In this post I’ll talk about the process we use for designing, implementing, drafting and grading these case studies.

There are a few things that I consider to be novel in the following approach:

  1. The case studies are about improving future clinical practice, and as such are linked to students’ practices i.e. what they do and how they think
  2. Students are the case study participants i.e. they are conducting research on themselves
  3. We shift the emphasis away from a narrow definition of “The Evidence” (i.e. journal articles) and encourage students to get creative ideas from other areas of practice
  4. The grading process has features that develop students’ knowledge and skills beyond “Conducting case study research in a clinical practice module”

Design

Early on in their clinical practice rotations, the students identify an aspect of that block that they want to learn more about. We discuss the kinds of questions they want to answer, both in class and by email. Once the topic and question are agreed, they do mini “literature” reviews (3-5 sources that may include academic journals, blogs, YouTube videos, Pinterest boards…whatever) to explore the problem as described by others. They also use the literature to identify possible solutions to their problems, which then get incorporated into the Method. They must also identify what “data” they will use to determine an improvement in their performance. They can use anything from personal reflections to grades to perceived level of comfort…anything that allows them to somehow say that their practice is getting better.

Implementation and drafting of early case studies

Then they try an intervention – on themselves, because this is about improving their own practice – and gather data to analyse as part of describing a change in practice or thinking.  They must also try to develop a general principle from the case study that they can apply to other clinical contexts. I give feedback on the initial questions and comment on early drafts to guide the projects and also give them the rubric that will be used to grade their work.

Examples of case studies from last semester include:

  • Exploring the impact of meditation and breathing techniques to lower stress before and during clinical exams, using heart rate as a proxy for stress – and learning that taking a moment to breathe can help with feeling more relaxed during an exam.
  • The challenges of communicating with a patient who has expressive aphasia – and learning that the commonly suggested alternatives are often 1) very slow, 2) frustrating, and 3) not very effective.
  • Testing their own visual estimation of ROM against a smartphone app – and learning that visual estimation is (surprise) pretty poor.
  • Exploring the impact of speaking to a patient in their own language on developing rapport – and learning that spending 30 minutes every day learning a few new Xhosa words made a huge difference to how likely the patient was to agree to physio.

Submission and peer grading

Students submit hard copies to me so that I can make sure all submissions are in. Then I take the hard copies to class and randomly assign 1 case study to each student. They pair up (Reviewer 1 and 2) and we go through the case studies together, using the rubric as a guide. I think out loud about each section of the rubric, explaining what I’m looking for in each section and why it’s important for clinical practice. For example, if we’re looking at the “Language” section I explain why clarity of expression is important for describing clinical presentations, and why conciseness allows them to practice conveying complex ideas quickly (useful for ward rounds and meetings). Spelling and grammar are important, as is legibility, to ensure that your work is clearly understandable to others in the team. I go through these rationales while the students are marking and giving feedback on the case studies in front of them.

Then they swap case studies and fill out another rubric for the case study that their team member has just completed. We go through the process again, and I encourage them to look for additional places to comment on the case study. Once that’s done they compare their rubrics for the two case studies in their team, explaining why certain marks and comments were given for certain sections. They don’t have to agree on the exact mark but they do have to come to consensus over whether each section of the work is “Poor”, “Satisfactory” or “Good”. Then they average their marks and submit it to me again.

I take all the case studies with their 2 sets of comments (on the rubric) and feedback (on the case study itself) and I go through them all myself. This means I can focus on more abstract feedback (e.g. appropriateness of the question, analysis, ethics, etc.) because the students have already commented on much of the structural, grammatical and content-related issues.

Outcomes of the process

For me, the following outcomes of the process are important to note:

  1. Students learn how to identify an area of their own clinical practice that they want to improve. It’s not us telling them what they’re doing wrong. If we want lifelong learning to happen, our students must know how to identify areas for improvement.
  2. They take definite steps towards achieving those improvements because the case study requires them to implement an intervention. “Learning” becomes synonymous with “doing” i.e. they must take concrete steps towards addressing the problem they identified.
  3. Students develop the skills they need to find answers to questions they have about their own practice. Students learn how to regulate their own learning.
  4. Each student gets 3 sets of feedback on their case study. It’s not just me – the external “expert” – telling them how to improve, it’s their peers as well.
  5. Students get exposed to a variety of other case studies across a spectrum of quality. The peer reviewers need to know what a “good” case study looks like in order to grade one. They learn what their next case study should look like.
  6. The marking time for 54 case studies goes down from about 10 hours (I give a lot of feedback) to about 3 hours. I don’t have to give feedback on everything because almost all of the common errors are already identified and highlighted.
  7. Students learn how I think when I’m marking their work, which helps them to make different choices for the next case study. This process allows them access to how I think about case study research in clinical practice, which means they are more likely to improve their next submission, knowing what I’m looking for.

In terms of the reliability of the peer marking and feedback, I noted the following when I reviewed the peer feedback and grades from earlier in the year:

  • 15 (28%) students’ marks went up when I compared my mark with the peer average, 7 (13%) students’ marks went up by 5% or more, and 4 (7%) students went from “Fail” to “Pass”.
  • 7 (13%) students’ marks went down, 3 (6%) by 5% or more, and 0 students went from “Pass” to “Fail”.
  • 28 (52%) students’ marks stayed the same.

The points I take from the above is that it’s really important for me to review the marks and that I have a tendency to be more lenient with marking; more students had mark increases and only 3 students’ marks went down by what I would consider a significant amount. And finally, more than half the students didn’t get a mark change at all, which is pretty good when you think about it.

 

 

Towards a competency-based curriculum in physiotherapy

I’ve been thinking about the concept of competency based education (CBE) in relation to the altPhysio series that I’m busy with. I’m drawn to the idea of CBE but am aware that there are some criticisms against it, especially from a theoretical and pedagogical perspective. This post is a short note to clarify some of my thinking around CBE.

I started with Frank et al. (2010) Toward a definition of competency-based education in medicine: a systematic review of published definitions to get a bit of an idea about how others think about CBE and to have a working definition of the concept. From the article:

We identified 4 major themes (organizing framework, rationale, contrast with time, and implementing CBE) and 6 sub-themes (outcomes defined, curriculum of competencies, demonstrable, assessment, learner-centred and societal needs)….From this research we have developed a proposed 21st century definition of CBE for medical education, namely:

Competency-based education (CBE) is an approach to preparing physicians for practice that is fundamentally oriented to graduate outcome abilities and organized around competencies derived from an analysis of societal and patient needs. It de-emphasizes time-based training and promises greater accountability, flexibility, and learner-centredness.

I quite like this definition of CBE and think that it addresses some of the concerns that are commonly levelled against a CBE approach. This is far from a foregone conclusion and there are still many contrasting points of view. But for my purposes this was a good place to start, especially since I’m looking at a physiotherapy curriculum, which has a significant emphasis on clinical performance, as opposed to another programme that emphasises different outcomes.

I’m obviously also interested in the use of technology, and Tony Bates’ The strengths and weaknesses of competency-based learning in a digital age was useful in this regard. From the post:

Competency-based learning is a relatively new approach to learning design which is proving increasingly popular with employers and suits certain kinds of learners such as adult learners seeking to re-skill or searching for mid-level jobs requiring relatively easily identifiable skills. It does not suit though all kinds of learners and may be limited in developing the higher level, more abstract knowledge and skills requiring creativity, high-level problem-solving and decision-making and critical thinking.

I’m not sure that I agree with the last bit; it may be limited in developing higher level, more abstract knowledge and skills like problem solving, decision making and critical thinking. I think that CBE does not inherently preclude the possibility of developing these skills. The fact that it may not doesn’t mean that it can’t (IMO).

Then there’s the CanMEDS framework, which is another piece of work that I’m a big fan of. Without going into the detail CanMEDS is a way of thinking about the different roles that a physician must demonstrate proficiency in. Again, this framework seems to be a great place to start when looking at a CBE curriculum.

canmeds-2015-diagram-e

So that’s how far I’ve gotten with looking at CBE as a possible basis for a physiotherapy curriculum. If you know of any physiotherapy curricula that are currently competency-based, or are aware of any other resources that you think would be good to read, I’d really like to hear from you.

Note: The featured image of this post is a map of the London underground that I wasn’t familiar with. The point I was trying to make is that there are many different ways of getting to the same end point, and it might be useful to allow people to take the route that most suits them.

altPhysio | Personal reflection on the series

As part of the altPhysio series I’ll be writing a few reflective posts where I think out loud about the process of writing the series. This is really for my own benefit of documenting the process, so you may not find it very interesting. Just saying…

Over the past 2 or 3 years I’ve been thinking about what it would take to set up a private physiotherapy school that looked and worked very differently to what we’ve come to expect in a mainstream programme. I started seeing how ineffective and inefficient the system is for student learning and realised that a lot of what we simply accept as being normal, is actually the basis for many of the problems we experience. For the most part I kept my thoughts to myself, sharing with those who I knew had a similar bent. It wasn’t much of anything besides a few of us bouncing around some ideas but it was enough to keep the concepts slowly evolving in the back of my mind.

But over the past few months I’ve been pleasantly surprised at how much these ideas resonate with others. It’s mainly people I’ve connected with through the Critical Physiotherapy Network, so it’s clearly a certain kind of physio – one who would join the CPN – that finds these ideas interesting. I had no idea that there would be so much support for a newly imagined curriculum and the positive feedback has been wonderful. On that note, I’ve also realised that there are pockets of innovation in physiotherapy education where some of the ideas I’m writing about are being implemented. I’d love to hear more about those programmes in the comments.

Another thing that I’ve noticed is that as I spend more time working on a post for an idea, the less novel it seems. I just published something on getting rid of modules and when I put it out there I had a moment where I thought how pedestrian the argument seems. It’s almost like I’ve convinced myself of the truth of it and now simply accept that it’s the way to go. I guess this is why it’s so important to me that others push back against these ideas and find reasons for why they might not work. Or, to tell me that your school has already been doing it for years and it’s really not that innovative at all.

To be clear, this is a thought experiment and many of these ideas might be terrible on closer inspection. I’m just wondering out loud what kinds of changes in the system might help us to address the problems that we currently experience in our curricula. I’m crash testing my own ideas, which is why feedback (and push back) is so important. I really do want to know all the ways that the concept doesn’t work. By reconsidering the things we accept as being inherently true, we may be able to figure out how to resolve some of our problems anyway.

altPhysio | Getting rid of modules

This is the third post in a series looking at the ideas and processes we take for granted in a mainstream physiotherapy curriculum. In the first post I looked at the background behind a decision to form a new kind of physiotherapy school, and then wrote a second post questioning the assumption that there is an inherent value in the things we ask students to do. In this post I wonder if modules are the best we can do when it comes to configuring the basic unit of a curriculum.

Q: You made a decision early on that there wouldn’t be any modules at altPhysio. Tell us a little more about the thinking behind that decision.

Modules exist in a curriculum so that we can divide complex ideas into something more manageable and because the curriculum needs discrete units around which learning activities can aggregate. For the most part, those units are the modules that we use to aggregate other things like lectures, textbooks, assignments and tests. We like to think that modules are neat collections of related concepts that are combined with each other, forming foundations upon which other modules can build. The reality is that modules are somewhat arbitrary divisions of complex concepts into increasingly smaller and simpler ideas.

Modules are the organising principle of a curriculum, used to link related concepts, around which teaching and learning activities are aggregated.

The problem with modules is that we spend 4 years teaching students which blocks the concepts fit into and assessing them within the constraints of those basic conceptual divisions. Tests and assignments are given within the context of a module and it’s actually quite difficult to give learning activities that cross modular boundaries. After students are comfortable with pigeon-holing ideas into neat boxes we ask them to integrate the concepts from different modules as part of clinical practice, another separate module. How does it make sense to break complex ideas into discrete units and then expect students to put it all back together again, often by themselves?

Q: OK, so no modules at altPhysio. What about a PBL approach?

In a PBL curriculum the clinical problem is the organising principle, rather than the module. The concern with the kinds of problems found in PBL curricula is that the problems are not complex enough to model real world clinical situations, and they don’t run over long enough periods for students to get sufficiently engaged. Another concern is that the problems are often decontextalised from the situations in which knowledge gained is to be applied.

We knew that knowledge must be constructed in the same contexts in which it is to be used, but our classroom activities were so contextually disconnected from how we expected students to practice that they were effectively useless. How often have you heard clinicians and teachers complain that students have trouble transferring knowledge learned in the classroom context to the clinical context?

If we want students to solve difficult problems in the real world, they must be trained by solving difficult problems in the real world. A module-based curriculum – and to a certain extent, a problem-based curriculum – doesn’t create enough space for sufficiently complex tasks to be designed.

Trying to design an authentic learning task that is sufficiently complex to model a real world phenomenon, within the constraints of a single module is difficult. It’s possible to do it within a PBL context but also unsatisfactory. We wanted to take a systems approach to designing the kinds of problems we wanted our students to solve, which we think more accurately describes real world clinical problems. When we started looking at relatively large-scale Projects as the organising principle in a curriculum, we found that it gave us the space we needed to build activities that would help students develop the characteristics we say are important.

Q: Tell us what a Project looks like. Where do they come from?

We work closely with clinicians from a variety of contexts who provide us with the basic framework for all of the Projects in our curriculum. They submit Contexts from their clinical experiences according to a framework that we provide for them. Any situations in their contexts that meet the boundary conditions that we set, can be included in the curriculum. A Project involves students working together in groups to achieve complex objectives, none of which are possible for students to complete on their own.

Our Projects usually run over 3-12 months and involve a variety of activities, which may include short lectures, research, practical sessions, field trips, virtual and augmented reality simulations, and interaction with qualified professionals in online and face-to-face environments.

Some Projects run over multiple year levels too, so students can begin a Project in their first year and only complete it in their second year. This is especially useful when Projects grow in complexity in real time – because the real world is dynamic – and are extended beyond their original lifespan.

Most of our Projects are also inter-disciplinary because any sufficiently complex real world problem cannot be addressed by any single discipline. We get special input from people in a variety of different domains, including engineers, artists, horticulturalists…you name it we get them to come and spend time with students on their Projects. We want our students working on real world problems from day one in the programme, with input from a diverse range of the kinds of people they’ll be expected to work with when they graduate.

Q: You mentioned the boundary conditions that Projects need to satisfy before you’ll take them on as part of the curriculum. What are those conditions?

We use Authentic learning – based on Situated cognition – as a framework to determine the basic structure of a Project. The framework is a way of thinking about task design so as to increase the probability of developing within students the competencies we want. Authentic tasks should meet the following criteria:

  1. Real-world relevance: Activities match as nearly as possible the real-world tasks of professionals in practice rather than decontextualized or classroom-based tasks.
  2. Ill-defined: Activities require students to define the tasks and sub-tasks needed to complete the activity.
  3. Complex, sustained tasks: Activities are completed in days, weeks, and months rather than minutes or hours. They require significant investment of time and intellectual resources.
  4. Multiple perspectives: Provides the opportunity for students to examine the task from different perspectives using a variety of resources, and separate relevant from irrelevant information.
  5. Collaborative: Collaboration is integral and required for task completion.
  6. Value laden: Provide the opportunity to reflect and involve students’ beliefs and values.
  7. Interdisciplinary: Activities encourage interdisciplinary perspectives and enable learners to play diverse roles and build expertise that is applicable beyond a single well-defined field or domain.
  8. Authentically assessed: Assessment is seamlessly integrated with learning in a manner that reflects how quality is judged in the real world.
  9. Authentic products: Authentic activities create polished products valuable in their own right rather than as preparation for something else.
  10. Multiple possible outcomes: Activities allow a range and diversity of outcomes open to multiple solutions of an original nature, rather than a single correct response obtained by the application of predefined rules and procedures.

If the Context submitted by clinicians meet the majority of these criteria, or if we see the potential to modify the Context enough that we can create a Project, we accept it into our workflow. Then we work with a variety of colleagues from different professions to refine the Projects over the course of 6-12 months. During this period we design the Project so that we can use it to accurately describe the kinds of competencies that we expect students will be able to develop while working in the Project. After that we incorporate the Project into the curriculum where they become another unit that students can sign up for.

Q: What do you mean when you say that students can sign up for Projects?

We don’t tell students what Projects to complete and allow them to choose from the full range of Projects available in that year level. Students know that they have a set number of competencies that need to be acquired in order to progress in the programme, and they know which competencies are integrated into which Projects. They make choices about the Projects they want to work on, based on which competencies they know they need to develop, as well as other factors that go into their decision making.

For example, consider a student who is going through some personal struggles; maybe a situation where someone close to them is ill. For that period they may choose a relatively low level Project that has a short duration. They know that the competencies developed in the Project will be fewer and maybe at a lower level than for other Projects, but this is OK because it buys them time to spend with their sick relative. In addition, since we don’t really have a timetable at altPhysio, students are able to organise their days and weeks in ways that give them space to focus on their personal lives, while at the same time continuing to work through the curriculum, albeit in a much less pressured environment.

The way that we’ve conceived of Projects gives us a level of flexibility and pedagogical range that we found impossible to achieve with modules or PBL. It means that we can have students working on complex, real world problems from day one. It means that at no point in the programme do we have to ask them to integrate concepts contained separately in different modules. Completing a Project at altPhysio requires that students think and behave like the professionals we say we want to develop.

 

altPhysio | Creating value

This is the second post in a series of exploring what a next-generation physiotherapy school might look like. Many of the ideas are not fully formed and some have very little evidence to support them. This is OK. Push back is welcome. Here’s the second interview.

Q: Now that you’ve provided the background and context for why the school was necessary, tell us what the first step was. Where did you begin?

As with all things in learning we knew we had to start with the students and their perceptions of the curriculum. The curriculum is a series of signals we send students about what we value but how those signals are mis/interpreted is important. We know that people’s beliefs inform their behaviour so we asked our students what they believed was important. Lecturers believe everything they do has value but students make their own judgements about about what is valuable independently of what lecturers say. The conventional wisdom in the past was that everything a lecturer said was valuable and it was valuable simply because they had said it.

However, if the student doesn’t see the value proposition of what you’re saying or asking them to do then its utility is limited. When we tell students to pay attention because what we’re saying will be important one day (e.g. in clinical practice in the third year) the message we’re actually sending is that they don’t need to pay attention now. If the information is only useful later then that’s when they’ll look it up. Why waste resources in the present if the benefits are only useful at some future, undetermined time?

Like it or not, students are doing a cost-benefit analysis for every task you set them. They evaluate the cost of the task in terms of time and effort, against the perceived benefits of doing the task. For example, what is the cost of attending a lecture versus the benefit? If the cost (time and effort) is perceived to be higher than the benefit, they might skip the lecture. And in many cases they are probably right to do so. If classroom time is spent sharing content then the student is making a strategic decision about better allocation of their limited resources (i.e. time and effort) because they can get content anywhere at any time.

Q: So what did you do about that? How did you correct the students’ reasoning?

We didn’t try to correct it. We tried to understand it and work with it. Now we’re always asking, “How is this task going to help to change our students’ thinking and behaviour in ways that are useful for them today?” In the case of a lecture we make sure that attendance has real world value today and don’t simply offer the promise of future value or threat of immediate punishment.

What would happen if there was no requirement to attend class and no negative consequence for being absent? Would students attend? If the answer is no, then you should think carefully about the value you think you provide.

At altPhysio we don’t take roll call and there is no attendance requirement in any part of the programme. Once we had taken that decision the pressure was on us to make sure that the time we spend with students has  measurable value for them. We begin by assuming that students come to altPhysio with ambition and the capacity to achieve great things. Then we help guide them to open up their thinking and give them space to take responsibility for their learning. Everything we do in the curriculum is about empowering students and developing their agency to act in the world. We give them challenging tasks that force them to go beyond what they believed they were capable of and in doing so, set up conditions that show them how far they can go.

Students don’t hate working hard; they hate being bored. It turns out that they really do care about learning, it’s just that we force them to care about marks instead.

Q: How do we get students to care about their learning, as opposed to caring about marks?

Learning happens in the mind of the student and only in the mind of the student. A learning environment is therefore just a series of contexts to try and get students to value their learning. An intrinsically motivated student could probably get through our exams with nothing but a curriculum outline and an internet connection. So we asked how to get our students intrinsically motivated rather than satisfy a set of external conditions that were not always tied to outcomes that they valued. The problem was that most of our curricular interactions sent very strong signals that 1) we were in charge, and 2) what we valued was all that mattered.

The locus of control for (almost) all students sits outside themselves. We tell them where to go, when to get there, what to read, what would happen if they pushed back, etc. In the past our students had no control over their learning and it was clear in every aspect of the curriculum that lecturers had all the power. It’s hard to be internally motivated when you have no power. For example, if classroom attendance is compulsory (i.e. there is a mandatory cost) and students perceive that it has little value, but they have no option to make a choice about attending, then you’re sending a signal that they have no power in the domain of their learning.

Q: What is wrong with students being externally motivated? Does it really matter, as long as they get the work done? Pass the exams?

The problem with an external locus of control is that it sets up a context where students are responding to a system of reward and punishment that is determined by others, rather than responding to what they value. “Success” in that system is determined by how well you learn the rules for gaining rewards and avoiding punishment. It has nothing to do with what students believe is important for their own learning. Our old curriculum – as the expression of what lecturers value – only required that students passed a series of assessment tasks. Their own beliefs about what was important were not integrated into the system. In effect, it didn’t matter what was important to them.

Q: OK, so you realised that the curriculum was “telling” students to think and behave in ways that were not consistent with what you valued. What next? How did you get students’ values to align with lecturers’ values?

We asked ourselves what conditions would help students think and behave in ways that would most likely approximate the patterns of thinking and behaviour we expected to see in qualified professionals. In other words, how do you get students to think and behave like professionals? To come to class; to show up on time; to put maximum effort into their assignments; to do extra reading?

Once we had a better idea of students’ strategic thinking about the curriculum and how they assigned value to tasks, it gave us insight into how we designed those tasks. Our curriculum therefore had to describe a learning environment where thinking and behaving like a professional had a higher value for students who aligned with it, than for those who didn’t. For example, if we said that attending class was important, then there had to be something that happened in that class that gave a strategic advantage to those who attended compared with those who did not.

Q: What is the take home message here about providing value for students?

We used to look at students’ learning needs as a series of physical, social, financial and psychological factors that would positively influence their learning. And those things are obviously important. But we realised that a missing piece in our framework for understanding students was their rationalisation for compliance (or non-compliance) with the curriculum requirements. What were the underlying beliefs they had with respect to the inherent value of the tasks we were asking them to complete?

We needed figure out how to design our curricular interactions in order to maximise the utility of that time for students. We could no longer expect them to comply with our instructions simply because we told them that they should. The curriculum does not have any inherent value simply because we say it does. We need to intentionally design activities so that the value proposition for students outweighs the costs.

We want students to do what we ask them but we want them to do it because it has real value for their current and future practice, not because of a system of reward and punishment that we control. We can no longer afford to take students’ presence and attention for granted.

altPhysio | Background of the school

This is the first of a series of posts on a vision for what a new school of physiotherapy might look like if it was designed from scratch; what it could be if we left behind the legacy systems that almost all new programmes are built around. I’ve written the series as an interview set in 2025, a few years after the school has opened, just as a different way of trying to get some of these ideas out of my head and onto the page. Much of what I present here is untested and is simply informed by my own research, my conversations with colleagues and students, and my own thinking, rather than on any real world examples. I would love to hear any thoughts on the ideas in these posts. And with that, here is the interview.

We’re going to be spending a few weeks in conversation with a lecturer at altPhysio, described as a next generation school of physiotherapy, in order to get a better understanding of the underlying rationale behind the very different approach to education taken by the founders. Over the next month or so we’ll delve into different aspects of the curriculum, going into the details behind the changes and asking why they were necessary. For now though, let’s establish the context for the rest of the discussion.

Q: Tell us a little bit about altPhysio; when and why it started.

altPhysio started as a private physiotherapy school in 2020, after we realised that our more traditional programmes were not graduating physiotherapists with the competencies and attitudes towards practice that we said we valued. From our own experiences in practice we could see that we needed to do more if we wanted a new generation of clinical professionals who could work and thrive within the complex health systems of the 21st century.

Q: Was there anyone else who recognised these problems? How did you know that it wasn’t just your own programme?

Between 2010 and 2015 there were a few publications that came out, articulating the problems that we were experiencing first hand. The main ones were the Lancet commission’s report on Health professionals for a new century and the WHO Transforming and Scaling up Health Professions Education. There were others but these two really highlighted some of the challenges with allied health professions education, making strong recommendations around the institutional and educational reforms that were necessary. One of the primary concerns raised in the Lancet report was that professional education had not kept up with contemporary health challenges “largely because of fragmented, outdated curricula and static pedagogy that produced ill-equipped graduates.” There were several other systemic problems that were also highlighted, many of which we could see in our own curriculum.

The report recommendations included calls for the promotion of transformative education and interdependence among institutions, greater integration of information technology, deeper links with the health system and a more critical, inquiry-focused learner. These changes would have required significant changes to the higher education system, mostly supported by deeply held beliefs that would have been very difficult and time consuming to change. We decided that it would be easier to simply start again by asking what it was that we wanted to develop within our students and then working backwards to design the environments we would need to achieve those outcomes.

Q: And what about the decision to design something so radically different to what has come before? What was wrong with the traditional system?

Like most other institutions at the time we were used to a process of gradual and incremental changes to the curriculum, where we evolved slowly over time. But we soon realised that small scale iteration will only produce evolutionary change at a pace and scale that we decided was unacceptable for changes we wanted to see. The only realistic way to implement the recommendations of the Lancet Commission and WHO reports was to start over, beginning with taking a serious look at our curriculum. It was a difficult – but liberating – experience, seeing that a lot of what we were doing in the curriculum had very little evidence to support it.

“The first step to thinking clearly is to question what we think we know about the past.” – Peter Thiel, Zero to One

We decided that the only way to truly innovate in this space was to begin with a blank slate. We asked what changes we should make considering the world we actually live in, as opposed to designing a programme based on the world as it existed 500 years ago. Traditional universities started at about that time and, besides a few changes aimed at increasing efficiencies in the system, the general structure is pretty much the same. We asked which parts of that system actually improved learning and which parts should go. And it didn’t take long to realise that a lot of what is currently encoded into a university is not aimed at enhancing learning.

altPhysio is a next generation physiotherapy school that began by questioning the assumptions we accept as being fundamental to the curriculum. Think of it as rewriting the code that we base our curricular thinking on.

Instead of relying on legacy systems that the research says is flawed why not start again, except this time using what we know to create a more equitable, socially just, student-centred classroom? Research pushes back the boundaries of knowledge to create new spaces into which practices should move. But higher education institutions are large, old and risk averse – people are set in their ways and reluctant to move into the new spaces that we create through our inquiries into the world. It seemed to make sense that, instead of investing our limited resources in the small, incremental changes that a traditional institution would find palatable, we should just begin afresh. So in 2020, after 4 years of planning, we opened altPhysio; a re-imagined vision of physiotherapy education for the 21st century.

Our students succeed despite their education, not because of it

Note: Thank you to Dave Nicholls from the Critical Physiotherapy Network for his insight and comments that helped inform this post.

Foucault said that the most dangerous ideas were the ones that we’re not even aware of; the ones we accept as being fundamentally true. He emphasised the need to examine our everyday practices and to critically analyse the discourses that make these practices possible. He believed that the most powerful disciplinary ideas are the ones that are most benign – the ones that we readily accept. This post is an introduction to a series of critiques (some might say, rants) against the ideas that we most take for granted in our teaching practices. The things that we readily accept as being self-evidently true.

These ideas form the foundation of every professional education programme, yet I will argue that they are also the most dangerous obstacles to real learning. I think that our current educational system not only prevents students from working towards deeper understanding with open minds but actually provides incentives to do the opposite. In this series of posts I’ll present some of the ideas that we accept to be foundational in the undergraduate curriculum but which actually lead students away from developing the outcomes we say we value.

I think that our students succeed despite their education, not because of it.

After decades of research in the fields of cognitive psychology and neuroscience we can be confident of one thing…we can do better. If I look at what a modern health system needs – creative problem solvers, innovative leaders, collaborative team players, critical thinkers – it seems evident that these are exactly the characteristics that our current programmes cannot provide. Our legacy systems are broken, outdated and unfit for the purpose of graduating clinicians with the attributes necessary to address the complex health needs of people in the the 21st century.

What if we designed a curriculum from scratch using everything that we’ve learned from the research into learning and cognition? What would a curriculum look like if we critically questioned every aspect of it, asking if those components lead effectively towards the achievement of our goals? How would we choose the curriculum configuration if we were not constrained by what the institutional LMS and the timetable required? I wonder what a curriculum might look like if it didn’t have to conform to the requirements of a system that hasn’t changed much in 500 years. I think that that it could be an exciting and inspiring thing of beauty.

As a thought experiment I’m going to write a series of posts looking at the ideas that we simply accept as being fundamental to the curriculum, and then argue for why those are the very things that need to go. In each post I’ll take a future position where we have already implemented the changes that I think are necessary, and then argue for why the changes were made. The series is called altPhysio.

Research is about pushing and extending the boundaries of knowledge in order to create new spaces for practice. But despite all the evidence that change is necessary we continue teaching in much that same way that we always have. We’re creating the conceptual spaces for new and innovative practices in physiotherapy education…it’s time we started occupying them.

Creative-Wallpapers-1920x1200-087

Action research as liberation

"Paulo Freire" by Slobodan Dimitrov - Own work. Licensed under CC BY-SA 3.0 via Wikimedia Commons - https://commons.wikimedia.org/wiki/File:Paulo_Freire.jpg#/media/File:Paulo_Freire.jpg

Kemmis & Mctaggert’s (1990) definition of action research is that it is about improving the lives of people through transformation. It is an emancipatory approach to the research process that does as much for the participants as for the researchers. I’m busy reading Paulo Freire’s Pedagogy of the Oppressed, so the idea of a research process in the educational context as being a form of emancipation for students stands out. The idea that, through trying to learn more about learning and teaching, we can improve both, sits well with me.

“Education either functions as an instrument which is used to facilitate integration of the younger generation into the logic of the present system and bring about conformity or it becomes the practice of freedom, the means by which men and women deal critically and creatively with reality and discover how to participate in the transformation of their world.”

Paulo Freire (Pedagogy of the Oppressed)

 

Writing about the software that I use to write

Note: I started writing this post more than a year ago and have regularly pushed it back in the queue. It began as a list of text editing software that I thought might be useful for people who are stuck using MS Word but has since grown beyond a simple list.

I like to think that I write a lot. I’m not nearly as prolific as I’d like to be but I think I do a decent job of getting words onto the page, either here on the blog, journal articles, research proposals, lengthy emails to students, conference presentations, or notes in workshops I attend. I thought I’d give an overview of the different places I write because I know that many of my colleagues think that Microsoft Word is the only option, which makes me sad.

Web-based editors

There is a certain appeal to the idea of writing tools that are web-based. They’re always up-to-date, you don’t have to worry about backing up or even saving, and they don’t burden you with too many features that you’ll never use. By and large, they get out of the way and let you write. Of course, the downside is that you have to be online to use them, which isn’t always possible.

The first service I tried was Draft. It has some amazing features (great for productivity, rather than power), is regularly updated and has a really nice UI that gets out of the way when it’s not needed. My only concern is that the offline access isn’t entirely intuitive and is still under development. I tend to use Draft to get the ideas out of my head and onto a “page”. It has a really minimalist interface, and with the browser in full screen mode, I can just write without any distractions. Once I’ve put as much as I can into Draft, I export the document as a plain text file and either move it into a desktop editor or something like Google Drive (if it’s something I’m going to share with others).

Draft aims to not only provide you with a writing service, but to help make your writing better.
Draft aims to not only provide you with a writing service, but to help make your writing better.

I should probably also mention the Google Drive app, which runs on Android and iOS devices, as well as through the browser. While Google has made enormous improvements in the file management features of Drive and the new Docs has done a lot for offline access, native editing of Word documents and collaborative writing, it sometimes feel like it’s trying to kill a mosquito with a cannon. However, if you need your writing editor to do heavy lifting, then Drive and Docs may be good choices for you.

I use Google Docs / Drive regularly as part of various collaborative research projects I’m involved in, as well as some classes that we team teach. While I think it’s probably best in class when it comes to collaborative writing and editing because of the range of services (Docs, Sheets, Forms and Slides), the online requirement can be problematic. The early versions of the Docs app on iOS and Android were also a bit clumsy. However, Drive is constantly getting better and it is now a service that I really can’t live without.

Google-Drive

Desktop editors

I also do a lot of more formal writing for research projects and for that I have always used a combination of LibreOffice and Dropbox to sync between machines. However, there’s a growing movement among academics who are switching from writing in Microsoft Word (or LibreOffice) and simply using markdown and plain text editors. If you’re thinking that, as an academic, Word has features that you absolutely must have, it seems that with a little bit of thought, you can avoid it completely.

I’ve also worked with Focuswriter, Gedit, and ReText on Linux, and MarkdownPad on Windows. They’re great text editors (as opposed to word processors) that I use almost solely for the initial stages of my academic writing and I’ve switched almost entirely to text-only editors for the original drafting of my work. One of the huge advantages of using text only is that I can edit any document on any device. Dropbox keeps them all in sync and every device can edit text. I do however, still use LibreOffice for the final editing of documents.

As you can see, Gedit is a very simple text editor.
As you can see, Gedit is a very simple text editor.

I should also note that I recently moved all of my note-taking to Evernote. What I really like about Evernote is that it has native desktop and mobile clients, as well as being browser-based, which means I can use it anywhere to capture almost anything.

Mobile editors

On mobile devices it’s a bit more complicated because there are literally hundreds of options. Also, the tools that are available for mobile are often not cross-platform, which means you really do have to go with text editors. I wanted something that integrated with Dropbox – which is where I keep all of my writing – and that allowed me to edit in plain text. Without going into the details of all the writing apps I’ve installed (and subsequently uninstalled), I finally settled on Plaintext on the iPad and Jotterpad X on my Nexus 7 and HTC One X. They’ve got the right balance between useful features that make writing easier and light enough that I can just write and not get distracted with features.

JotterpPad X running on an Android tablet.
JotterpPad X running on an Android tablet.

Something that has become very clear to me while writing this post is that it’s becoming increasingly difficult to differentiate between a desktop, web-based or mobile writing app. Services like Drive (with it’s associated Docs, Sheets and Slides) are easily accessible across all three, and with the offline access available in Chrome and on mobile, it’s hard not to think seriously about moving there altogether.