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

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.

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 | 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.