Critical digital pedagogy: Initial abstract for the chapter

Update (12-02-18): You can now download the full chapter here (A critical pedagogy for online learning in physiotherapy education) and the edited collection here.

This post is linked to a short series I’ll be sharing on the process of writing a book chapter for a publication by the Critical Physiotherapy Network. I’ll add links to posts as we move forward. In the meantime, here is some background to this post.

Initially the chapter was going to be called Physiotherapy education for the 21st century, but as I worked through the ideas I found myself unsatisfied with the lack of a critical perspective in my thinking. As I tried to find the link between critical pedagogy and online and digital learning, I realised that the original abstract wasn’t saying what I wanted it to. I began by thinking that the chapter was going to look more like the image at the top of this post but it soon became clear that it wasn’t going to work. Anything that was that specific would never age well. Anything I wrote would – like the technology it described – would be obsolete within a few year.

It took me a few iterations to begin linking together the bits and pieces of the texts I was working with, including Freire’s Pedagogy of the Oppressed (1970), hooks’ Teaching to Transgress (1990), Giroux’s On Critical Pedagogy (2011) and a few others. But when it started to come together I was hopeful that my choice to switch direction would pay off. I’m still not 100% sure that it’s going to work but over the next few posts I’ll get closer to figuring that out.

Anyway, here’s the original abstract.


The beginning of the 21st century has seen more technological progress than any other time in our history, at an accelerating rate of change. The introduction of robotics, gene therapy and nanotechnology into ever increasings domains of health care, combined with advances in computing power, see us on the brink of a new understanding of what it means to be human. As society and the health systems within it become increasingly complex and the needs of populations change accordingly, it seems appropriate to ask if our current education system is capable of preparing physiotherapy students to not only work in such environments, but to thrive. Given the scope of these changes we should expect to see a significant shift in how physiotherapists are prepared for practice. Yet, physiotherapy education continues to follow traditional lines of thinking and implementation that fails to consider the changing needs of society.

In order to graduate professionals who are capable of adapting to complex systems, we cannot afford to continue teaching in spaces that have not changed in 500 years. There is little evidence that physiotherapy educators have acknowledged society’s changing conceptions of therapy and health, nor that they have adapted their teaching methods accordingly. We need to ask ourselves what attributes physiotherapists require in order for them to effectively negotiate the challenges of future working environments and if our current learning spaces help students become capable, effective leaders in complex health systems? As we develop a more nuanced vision of what it means to be human in an increasingly complex world, we must ask critical questions that challenge the profession to think differently about what it means to be a physiotherapist and consequently, how physiotherapy education needs to change.

Critical digital pedagogy: Theory and practice

Update (12-02-18): You can now download the full chapter here (A critical pedagogy for online learning in physiotherapy education) and the edited collection here.

This post is actually about setting up the context for a few other posts, all related to my upcoming book chapter for the Critical Physiotherapy Network. The idea I pitched for the chapter really was just the seed of an idea that I wanted to explore in more depth, and I thought that writing about it would push me to invest more time and energy in the idea than if I wasn’t working to a deadline.

The other thing worth noting is that I’m also trying to figure out where to go next with my teaching practice. For a while I’ve been thinking that what I do in the classroom isn’t enough. There’s not enough depth. Not enough connection. Not enough meaning. I feel like I’m not pushing the boundaries enough. Like I’m not pushing my students enough. So I wanted to try and understand what options are available to me. The book chapter is a way for me to challenge my thinking around what my course could be.

Which brings me to the title of this post, A critical digital pedagogy: Theory and practice. The theory part is the idea I’m exploring that relates to what I’m pushing up against in the classroom, and what ideas I can really get behind in terms of shaking things up a bit. The practice part is going to be a few posts on what I’m actually changing in the classroom as a result of what I’m learning in the theory. I thought it would be useful – for me and for others – to get a sense of this process as I’m going through it.

I have no order in which the posts will come, but I’ll make sure to highlight which ones are related to this little project. The book chapter is due this Friday, so over the next few days I’ll probably try and push out a few posts directly linked to the content of the sections in the chapter as I finish them. I’ll also try to do a few that are linked to the changes I’ve already made in my Ethics class.

I’ll share the original abstract (probably immediately after I post this) so you can see how much the idea has changed since I originally planted the seed. I think it’s good to look back and see how ideas change over time. We often forget that the finished product is often the result of countless revisions and that all creative work went through a process.

Using online multimedia to teach practical skills

During 2016 I supervised an undergraduate research group in my department and we looked at the possibility of using multimedia – including video, images and text – to teach students practical skills. Traditionally, we teach these skills by having the lecturer demonstrate the technique on a model while the class watches. Students then break into small groups to practice while the lecturer moves around class, giving feedback, correcting positions and answering questions.

This process was pretty much the only option for as long as we’ve been teaching practical techniques, but it has it’s disadvantages:

  • As class sizes have grown, it’s increasingly difficult for every student to get a good view of the technique. Imagine 60 students crowded around a plinth trying to see what the lecturer is demonstrating.
  • Each student only gets one perspective of the technique. If you’re standing at the head of the module (maybe 1 or two rows back) and the demonstration is happening at the feet, you’re not going to get any other angle.
  • There are only so many times that the technique will be demonstrated before students need to begin practising. If you’re lucky the lecturer will come around to your station and offer a few more demonstrations, but owing to the class size, this isn’t always the case.

We decided that we’d try and teach a practical technique to half the class using only a webpage. The page included two videos of the technique, step by step instructions and images. We randomly selected half the class to go through the normal process of observing the lecturer demonstrate the technique and half the class were taken to another venue,  given the URL of the webpage and asked to practice among themselves. Two weeks later we tested the students using an OSCE. Students were evaluated by two researchers using a scoring rubric developed by the lecturer, where both assessors were blinded to which students had learned the technique using the webpage.

We found that the students who only had access to the multimedia and no input from the lecturer performed better in the OSCE than the students who had observed the lecturer. This wasn’t very surprising when you consider the many advantages that video has over face-to-face demonstration (rewind, pause, watch later, etc.) but nonetheless caused a stir in the department when the students presented their findings. We had to be careful how we framed the findings so as not to suggest that this could be considered as a replacement but rather as a complement to the traditional approach.

There were several limitations to the study:

  • The sample size was very small (only 9 students from the “multimedia” class took the OSCE, as it was voluntary)
  • We have no idea whether students in the multimedia class asked students from the “traditional” class to demonstrate the technique for them
  • We only taught and tested one technique, and it wasn’t a complex technique
  • Students knew that we were doing some research and that this was a low stakes situation (i.e. they may not have paid much attention in either class since they knew it would not affect their final grades)

Even taking the above into consideration though, in principle I’m comfortable saying that the use of video, text and images to teach undergraduate students uncomplicated practical techniques is a reasonable approach. Instead of being defensive and worrying about being replaced by a video, lecturers could see this as an opportunity to move tedious, repetitive tasks outside the classroom, freeing up time in the classroom for more meaningful discussion; Why this technique and not this one? Why now? At what level? For which patients? It seems to me that the more simple, content-based work we can move out of the classroom, the more time we have with students to engage in deeper work. Wouldn’t that be a good thing?

IPE course project update

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

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

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

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.