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.

References

Bleakley, A. (2010). Blunting Occam’s razor: aligning medical education with studies of complexity. Journal of Evaluation in Clinical Practice, 16(4), 849–855. http://doi.org/10.1111/j.1365-2753.2010.01498.x

Conklin, J. (2001). “Wicked Problems and Social Complexity.” CogNexus Institute. [Online]. Available from: http://cognexus.org/wpf/wickedproblems.pdf

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. http://doi.org/10.1016/S0140-6736(10)61854-5

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 www.open.ac.uk/cetl-workspace/cetlcontent/…/460d21bd645f8.pdf

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

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?

altPhysio | Time allocation

This is the fifth post in my altPhysio series on a physiotherapy school set about 10 years from now. The idea is to explore alternative approaches to education by questioning the most fundamental aspects of curriculum infrastructure. Asking what we think are the essential components and then looking at those ideas from a different perspective. This post explores the idea of the timetable as a means of focusing students’ attention and then trying to see what things look like if we took it away.

Q: You don’t use a timetable at altPhysio. Do you want to tell us a little bit about that?

When we started altPhysio once of our guiding principles was to question everything that a traditional school takes for granted. What are the curriculum structures that we inherently accept? Well, what could be more mainstream than a timetable? But when we thought about it, we realised that a timetable is an organisational system designed to manage lecturers’ time and focus students’ attention. The problem is that it’s good at managing time but terrible for focusing attention because it really has nothing nothing to do with students’ learning.

How did we decide that an arbitrary 40 minute period was the optimal period of time to focus on a topic? Or that every student would progress in the same period of time? When we decided to get rid of modules we started asking what purpose the timetable served. If you don’t have modules – discrete pieces of subjects – then there’s no real need for a system to break the day into discrete pieces of time.

Q: OK, so how do you allocate time?

We started by asking what is the basis for our decision making around time allocation. We realised that we didn’t really have any useful criteria to determine how time is allocated to learning. We wanted to think differently about how we value learning tasks to see if we could make better choices about to allocate time to them. This made us ask whether some activities are worth more time than others?

For example, we have one lecturer who uses a full day to help students get used to the idea of being in each others personal space. They are all partially undressed around strangers – many of them for the first time in their lives – and they use that time to talk about different ways of being together in space. You could argue that we can make better use of that time by covering more techniques, but we think that the foundations laid in those few hours open up a space in the future that enables deeper learning. Depending on your perspective, you might place different value on that time and how it is spent. The point I’m making is that we started to think differently about the value we place on learning activities and consequently how we allocate time to those activities.

We eventually came to the point where we realised that one approach would be to ask students and lecturers to work together to decide what time should be allocated to which activity. This respects the different cognitive and functional levels of each group within each cohort. Some projects that we think should reasonably be completed in 6 months takes some groups 4 months. In these cases it’s usually because the combination of the student group, AI tutors and lecturers have come up with a novel solution to a problem that wasn’t anticipated. In other cases, a different group might take 7 months to complete the same project.

The problem of time allocation needs to be determined by students’ learning needs, not by the administrative requirements of the institution. To say that we respect students’ learning needs is to accept that different students needs different amounts of time to process the same information. A system that has pre-determined time slots cannot possibly take into account the different needs of different groups and cohorts. If we say we want flexible curricula that adapt to the needs of students, we have to get rid of the fixed timetable. A fixed timetable means that you can’t adapt.

Q: So how do you organise the curriculum without a timetable?

I’ve said that we started to think differently about time allocation for learning activities. When you have modules it makes sense to have a timetable that coheres to those curricular units. This many periods for module A, this many periods for module B. But we use projects as the organising principle in our curriculum and while they are constrained in time, the projects typically run over 1 to 6 months, rather than hours or weeks. So the concept of a timetable to focus students’ attention in discrete 40 minute periods didn’t make much sense.

Strictly speaking we do have a timetable, it’s just used to allocate time over months – and sometimes years – rather than hours. For example, the facilitator responsible for guiding students through a project knows that completion of the project is reasonable within a certain period of time. They know what competencies the students need to demonstrate at the end of the project and they know what inputs – in general – need to be provided during the project. But the order, duration and intensity of those inputs varies between groups and between cohorts. The facilitator, in collaboration with the students, makes decisions about how much time should be allocated to the learning activities aggregated around the project.

One way to reconceptualise the idea is to look at the visual representation of two different ways to allocate time in a curriculum: 1) a fixed table for time allocation usually printed on a piece of paper, and 2) software that allows for the flexible allocation of time based on progress in a project.

timetable_0

wrike-for-marketers

Q: Why does it make sense to structure the curriculum like that, instead of using shorter periods in a traditional timetable?

We say we want to be flexible and to take students’ learning needs into account. How is it possible to be flexible when your timetable is not? If you think of the curriculum as a static thing that defines and describes how you allocate time to activities then you really don’t need this approach. But we wanted our curriculum to be flexible and adaptable to the needs of the specific cohort within in. Not just any cohort, but a particular cohort.

There’s really no way to operationalise that concept without taking the time to regularly revise the work and the time allocation to the work. If you want to take seriously the idea that students have different learning needs and that the curriculum should be responsive to those needs, you must also accept the implication that the curriculum cannot have fixed time allocations.

Q: Can you give an example of how this plays out in practice? What does a typical day look like for your students?

Students work through projects in small groups. They have a coordinator or facilitator who works with them during the projects but who may not be physically present all the time. Everyone in the group knows what needs to be achieved within projects and sub-projects and they know the total time – give or take a few weeks – allocated for completion of the project. The group begins each day with a short meeting where they review what needs to be done, what is missing in order to progress and therefore what activities are relevant for the day. We have three main “types” of activities: formal or guided, informal or self-directed, and something that we call making.

The group – with the facilitator – may decide that a formal input is necessary (for example, if they realise that a certain concept is not well understood in the group), in which case the team facilitator sets up any lectures, readings or additional activities that provide scaffolding for the tasks required in that phase of the project. These formal sessions obviously mean that the facilitator has a greater responsibility to guide the students in that session. Formal sessions are typically more structured than others and are split into shorter periods that consist of a variety of different activities.

Alternatively, the group may decide that they have a good foundation for developing the next phase of the project, in which case they may decide that the day would be better spent in engaged in real world work activities. This what we call making because the group will be engaged in building and creating things in the real world, using the concepts they’ve learned. These may be generating reports, articles or other formal artifacts for submission and publication, or may require building a prototype (for example, one group is building an exoskeleton with low cost materials). The purpose of these maker sessions is that students are creating something that has a tangible impact in the world. If they’re not getting a formal input or making something, they may decide that an informal session is necessary.

An informal or self-directed session may be used to consolidate concepts from a formal session, plan for a making session or to generate new ideas for further advancing the project. Informal session usually involve developing research questions, conducting literature searches, filtering results, aggregating and synthesising ideas, and then teaching each other the new concepts. From this new conceptual platform, the group will decide on the next step.

Q: That sounds like students take a lot of the responsibility for how time is allocated. Do you trust them to make those decisions?

Well, we can’t say that we want students to be self-directed learners but then tell them what to learn, when to learn it and where to be when they’re learning. Our students used to have no responsibility for directing their own learning even while we were telling ourselves that they should be self-directed. Our system changes that.

In the beginning of the programme we find that we need to spend much more time in this area but over the first year or two we see that students are able to manage their time quite well with respect to their projects and daily learning activities. We’re always there to give guidance if necessary but we’ve found that when we give them responsibility to make real decisions that affect their learning, students take that responsibility seriously.

Q: But don’t you need a fixed time in some instances? For example, when does the “day” start and end?

Students negotiate with each other and their facilitators to decide when their day starts and ends. Sometimes it suits them to begin at 10:00 because of transport or family responsibilities, and sometimes they begin at 06:00 because they want to finish early and attend to other business. We give guidance and support, especially in the early stages but we want to acknowledge that students use different criteria to make choices about how to allocate their attention to learning tasks. This system gives them additional choices that opens up possibilities for learning at different times when that’s necessary.

The students know what needs to be done and they know how much time in total it will probably take. How they manage their daily time is largely up to them. We’ve found that, since adopting this new approach to time allocation, our students usually spend more time engaged in learning activities than we expect them to. It’s not unusual for our student groups to continue working into the night and on weekends. As long as the tasks are engaging and have value, we’ve found that our students want to put in the work. The day starts when the group decides it will, and it ends when they think they’ve done enough to register progress.

Q: Doesn’t this have an impact on graduation? What about students who take longer to work through projects?

There isn’t a single programme in the world where every student in every cohort graduates in the minimum time period. Most of our class graduates in the minimum of 4 years but some students take longer. We have set dates for graduation but some students take longer to complete their projects. Once they’ve demonstrated the appropriate competencies that are linked to completion they are eligible to graduate at the next ceremony. This is not unusual in any programme. We just don’t call them failures or repeat students.

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.

 

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.