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

Our students succeed despite their education, not because of it

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

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

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

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

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 Our legacy systems are broken, outdated and unfit for the purpose of graduating clinicians with the attributes necessary to address the complex health needs of people in the the 21st century.

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

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

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

Creative-Wallpapers-1920x1200-087

Stop complaining about the “knowledge-practice gap”

The “knowledge-practice gap” is a well known problem in health professions education and an enormous amount of time is spent complaining about how difficult it is to narrow the gap. The truth is, the knowledge-practice gap is a problem of our own making, and the name we’ve given this problem hints at the answer.

We’ve set it up so that there is a tension between what happens in the classroom (acquire knowledge) and what is supposed to happen in practice (use knowledge). Or, to be more specific, there is a tension between how students think and behave in the classroom and how we want them to think and behave in the clinical context. This is the “gap” that we’re always talking about bridging; the difference between the knowledge that students acquire in the classroom, and the practical application of that knowledge in clinical practice.

However, instead of treating the problem as something natural to be overcome (“this is just the way it is”), we can just accept that the reason the gap exists is simply because what most of what we expect students to do in the classroom is not a practice at all. We set up a situation where we create different contexts for knowledge acquired and knowledge applied and then complain when students struggle to move between the different contexts.

The truth is that we already have good evidence to suggest alternative ways of thinking about the “different contexts” problem, and we know what to do about it. Situated cognition is a learning theory that proposes that:

“…knowledge is situated, being in part a product of the activity, context, and culture in which it is developed and used.”

In other words, knowledge must be acquired in similar contexts to the ones in which it must be used. If you think about the classroom context, what ways of thinking and being are students required to practice? Are they required to practice at all? In order to satisfy most physiotherapy educators, our students simply need to show up, sit down and listen. Even if we assume that they are able to construct knowledge in some meaningful way from this traditional approach to learning (generally speaking, they are not), how does this practice enable them to apply what they learn in classroom to the clinical context? Simply put, it doesn’t. The reality is that the knowledge-practice gap exists because of the way we teach.

In order to address the problem of the knowledge-practice gap we need to accept that students’ ways of thinking and being in the classroom must be similar to the ways of thinking and being we expect in the clinical context. We must therefore give students learning tasks in the classroom that require them to think and behave in the same way as we expect them to think and behave while on clinical rotation. The classroom practice and the clinical practice must therefore be similar. Seen from this perspective, there would be no knowledge-practice gap because there would be no difference in the contexts in which knowledge is acquired and how it is used.

So, how do we create a classroom context where students are expected to think and behave in ways that are similar to how we expect them to think and behave in the clinical context? I think that Authentic learning is a good place to start. It’s a teaching framework that operationalises situated cognition. In other words, it’s a way of thinking about learning task design that includes attributes that would cause students to think and behave in one context that would help develop those processes for other contexts. I’ve written some notes on Authentic learning before, so won’t go into detail here, other than to share the characteristics of authentic learning, which are that tasks:

  • Should have real-world relevance i.e. they match real-world tasks
  • Are ill-defined (students must define tasks and sub-tasks in order to complete the activity) i.e. there are multiple interpretations of both the problem and the solution
  • Are complex and must be explored over a sustained period of time i.e. days, weeks and months, rather than minutes or hours
  • Provide opportunities to examine the task from different perspectives, using a variety of resources i.e. there isn’t a single answer that is the “best” one. Multiple resources requires that students differentiate between relevant / irrelevant information
  • Provide opportunities to collaborate should be inherent i.e. are integral to the task
  • Provide opportunities to reflect i.e. students must be able to make choices and reflect on those choices
  • Must be integrated and applied across different subject areas and lead beyond domain-specific outcomes i.e. they encourage interdisciplinary perspectives and enable diverse roles and expertise
  • Seamlessly integrated with assessment i.e. the assessment tasks reflect real-world assessment, rather than separate assessment removed from the task
  • Result in a finished product, rather than as preparation for something else
  • Allow for competing solutions and diversity of outcome i.e. the outcomes can have multiple solutions that are original, rather than a single “correct” response

Looking at the above list it should be easy to see how tasks designed with these characteristics in mind would be similar to the ways we would think about successful clinical practice. In other words, you could see how students who could successfully solve problems designed with this framework might also be able to solve clinical problems. The tasks we give them in the classroom would require them to think and behave in ways that we expect them to think and behave in clinical practice. No more knowledge-practice gap?

References

Teaching physiotherapy in Kenya

A few weeks ago I visited colleagues in the Physiotherapy Department at Jomo Kenyatta University in Nairobi. I was invited as an external examiner and also to give advice on their developing MSc programme, which they are going to offer with both online and face-to-face components. This is just a short post of a few things that struck me about what it’s like trying to teach physiotherapy in Kenya.

Until recently, Kenya, like most other African countries, did not offer a 4 year Bachelor’s degree in Physiotherapy. Many countries on the continent still only offer physiotherapy as a 3 year diploma. Over the past decade or so my university has been one of the few institutions in Africa that has worked with our international colleagues to upgrade their degrees from Hon to MSc – and sometimes to PhD. Those colleagues have then gone back to their own countries and developed their local programmes to offer both the BSc (Physiotherapy) degree, as well as to upgrade local colleagues from their Diploma to BSc (Hon).

What this means is that the four members of staff in this department run two curricula in parallel – one for the new BSc students and another for the Diploma upgrade students. There obviously isn’t enough time in the week for them to do this, which is why the Diploma upgrade programme runs on Friday evenings and weekends. Think about that. They’re so committed to improving the profession in their country that they work seven days a week. I wonder how that notion would be taken up by academic physiotherapists in South Africa.

Now, also consider the fact that they’re working on developing a new MSc programme. It’s not enough that they’re already working with two separate cohorts of students (BSc and Diploma-upgrade); they also want a group of postgraduate students…just to keep themselves busy in those few moments of the day when they’re not already teaching. And this is why they need to offer the course partly online; not be trendy or because “flipped classrooms” are in but because there simply isn’t enough space in the normal day for them to pack in more classes.

On one of the days I was there I spent an hour or so with their 3rd year class because the lecturers were still busy with a practical test that had gone on for more than 4 hours. The reason that it had gone on for so long is that there were only 2 lecturers available to do the test. They finished at 18:30. The attitude of the teachers in the department is that the work has to get done and that they’re the only ones to do it, so there’s no point in complaining because complaining just takes up more time. There simply is no other option. And this is not unusual in the African context. There is one other university in the country that offers physiotherapy, and their situation is no different to JKUAT. And, from what I understand, these two departments are better off than many others on the continent.

What really struck me when I left Kenya was the fact that, no matter what challenges we might face in my own department, we cannot really understand the difficulties that our colleagues across Africa are dealing with in their physiotherapy programmes. While we complain about the fact that our air conditioning unit is broken, they don’t have lights in some parts of the building. It really reminded me, in a very physical way, that teaching is not about the equipment or access to resources. Yes, those things are important but what matters most of all is the commitment of the teachers to the students, and their passion for the profession.

All in all, I had a wonderful time in Nairobi. Everyone was incredibly friendly and welcoming and made we feel so very welcome. But most of all I was impressed at the level of professionalism and motivation shown by my colleagues in the Physiotherapy Department at JKUAT. I look forward to going back next year.

First draft of article on Informed Consent for the Clinical Teacher

Featured image “Diverging paths” by SDJ on Deviant Art.

I’ve just finished the first draft of my 13th article in the Clinical Teacher mobile app. It’s been a LONG time since I’ve managed to put some effort into this project, mainly for personal reasons (my second daughter was born in March last year and we moved house in September) but also because I found 2015 to be a very challenging year in terms of prioritising my writing projects (I have another post in progress where I talk about some new strategies for prioritisation in my workflow).

Anyway, here is the draft of my article on Informed Consent, which I’ll be publishing in the app within the next couple of weeks.

Introduction

A successful relationship between patient and health care practitioner is based on trust, which is developed partly by respecting the autonomy of the patient i.e. their right to make their own decisions about their bodies. Informed consent is the exercise of informed choice by a patient who has the capacity to give consent and is therefore a component of developing a trusting relationship between patient and therapist (Wilders, 2013). Patients need complete and honest information about various aspects of their health care, including diagnosis, prognosis, treatment options, likely treatment outcomes, common or serious side effects, and the timescale of the treatment in order for them to give their informed consent (Tippet, 2005).

Informed consent

The patient is the one who determines what is in their best interests, not the practitioner. Practitioners may recommend a course of action but should not pressurise patients to accept their advice. The practitioner must ensure that their opinion is a balanced point of view, providing the patient with enough detail from the various perspectives that they are able to give their own, voluntary consent. It is possible for patients to nominate a third party (provided they are still competent to make such a decision) to give consent on their behalf. This must be provided by the patient in writing.

Health care professionals must be confident that they have received consent from a patient – or other valid authority – before they perform an examination or investigation, provide treatment, or involve patients in teaching and research (General Medical Council, 2008). It should be based on the sharing of correct information, appropriate communication, and understanding and agreement on the part of the patient. In order for the process of informed consent to be correct and legal, the patient must have (Wilder, 2013):

  1. Knowledge of the nature or extent of the harm or risk
  2. Appreciated and understood the risk
  3. Consented to the risk
  4. The consent must have been comprehensive

All aspects of health care involves decision-making by patients and healthcare providers and the principles of informed consent apply to those decisions, from the treatment of minor conditions, to major interventions with significant risks or side effects. Whatever the context in which medical decisions are made, the health care professional must work in partnership with patients to ensure appropriate care. In order to achieve this, you should (General Medical Council, 2008):

  • Listen to patients and respect their views about their health
  • Discuss patients’ diagnosis, prognosis, treatment and care with them
  • Share the information that patients want or need in order to make decisions about their health
  • Maximise patients’ opportunities, and their ability, to make decisions for themselves
  • Respect the decisions that patients make

Written consent

Patients can express consent either orally or in written form. However, it is strongly recommended that consent be obtained in writing. This can be done either in the case notes, or on a specific consent form. The consent form should contain the information provided to the patient, specific requests by the patient and the scope of the consent given.

Once written consent has been given once, the practitioner can simply remind patients of the initial instance, if they present at a later date with a similar condition. However, this consent should be revisited regularly to ensure that the patient is still comfortable with the procedure. Verbal reminders and responses should still be noted in writing in the patient’s file. When a patient presents with a new condition, fresh consent must be obtained and appropriately documented.

Implied consent

Practitioners should use caution if relying on a patient’s compliance with a procedure as an indicator of consent because submission in itself may not indicate consent (Wilder, 2013). Just because a patient goes along with what is happening, does not mean that they understand the nature, extent and risks that are associated with it. Consent must be expressed explicitly at all times.

Sharing information

Informed consent is premised on the concept of sharing information with the patient. There is no single approach that will suit every patient, or apply in all circumstances. Some patients may want more or less information or involvement in the decision making process, depending on their needs. In addition, some patients may need additional support to understand information and express their views and preferences (General Medical Council, 2008).

The way you choose to discuss the various aspects of a patient’s condition, including diagnosis, prognosis and the treatment options that are available, can be just as important as the information itself (General Medical Council, 2013). When sharing information with a patient (or their family), you should:

  • Share information in a way that the patient can understand and when possible, in a place and at a time when they are best able to understand and retain it.

  • Be considerate when sharing information that the patient may find distressing.

  • Involve other members of the healthcare team in discussions with the patient, if this is appropriate.

  • Give the patient time to reflect, before and after they make a decision, especially if the information is complex or what you are proposing involves any risk.

  • Make sure the patient knows if there is a time limit on making their decision, and who they can contact if they have any questions or concerns.

  • Give information to patients in a balanced way. For example, if you recommend a course of action, you should explain your reasons for doing so but also be aware of putting unnecessary pressure on a patient to accept your advice.

  • Support your suggestions with written material or other visual aids (make sure the information is accurate and up to date).

  • Check to determine if the patient needs any additional support in order to understand the information you shared, to communicate their wishes, or to make a decision.

Bear in mind that some barriers to understanding and communication may not be obvious. For example, a patient may have certain anxieties that they have not mentioned before, or may be affected by pain or other underlying problems. Support for patients might include using an advocate or interpreter, asking those close to the patient about the patient’s communication needs, or giving the patient a written or audio record of the discussion and any decisions that were made.

The information provided to the patient should include the following:

  • The nature and extent of the procedure, using language that the patient understands
  • Whether students will be involved in the procedure, and the extent to which they will be involved
  • Reminders that the patient can withdraw consent at any time i.e. change their minds
  • Reminders that the patient can seek a second opinion
  • Details of the costs applicable (if relevant)

Possible reasons for not sharing information

Remember that patients are vulnerable and that overzealous truth-telling may be harmful to them. As a result they have an equal right to refuse to receive information about themselves and their condition (Tippet, 2005). From the General Medical Council (2008): “You should not withhold information necessary for decision making unless you judge that disclosure of some relevant information would cause the patient serious harm”.

If a patient has the capacity to make their own decisions but appears to not want to have relevant information shared with them, the health care practitioner should consider the following steps (General Medical Council, 2008):

  1. No-one else can make a decision on behalf of an adult who has the capacity to give their consent. If a patient asks you to make decisions on their behalf or wants to leave decisions to a relative, partner, friend, carer or another person close to them, you should explain that it is still important that they understand the options open to them, and what the treatment will involve. If they do not want this information, you should try to find out why.

  1. If, after discussion, a patient still does not want to know in detail about their condition or the treatment, you should respect their wishes, as far as possible. But you must still give them the basic information they need in order to give their consent to a proposed investigation or treatment.

  1. If a patient insists that they do not want even this information you must explain the potential consequences of them not having it, particularly if it means that their consent is not valid. You must record the fact that the patient has declined this information making it clear to them that they can change their mind at any time.

  1. You should not withhold the information that is necessary for making decisions for any other reason, including when a relative, partner, friend or carer asks you to, unless you believe that giving it would cause the patient serious harm. In this context serious harm means more than the patient simply becoming upset or deciding to refuse treatment.

  1. If you withhold information from the patient you must record your reason for doing so in the patient’s medical records and be prepared to explain and justify your decision. You should regularly review that decision and consider whether you could give information to the patient later, without causing them serious harm.

Obstacles to sharing information

Because of time or resource limitations, it might be difficult to give patients as much information or support in the decision making process as you, or they, would like. To help with this, consider the role that other members of the healthcare team might play and what other sources of information and support are available. For example, do you have access to patient information leaflets, advocacy services, expert patient programmes, or support groups for people with specific conditions?

Do your best to make sure that patients with additional needs, such as those with disabilities, have the time and support they need to make a decision. In all cases, treat patients fairly and make sure that you do not discriminate against them by providing them with less detailed information than you might do for others. If you believe that limits on your time or the information that is available for patients is compromising their ability to make an informed choice, you should raise your concerns with your line manager or other authority (General Medical Council, 2008).

Conditions for consent

In order for a patient to give valid informed consent, there are three components that must be present; disclosure, capacity and voluntariness (Faden & Beauchamp, 1986). Disclosure requires the therapist to provide the patient with the necessary information to make an independent decision. However, it is not enough that the therapist merely provides the information; they must also ensure that the patients have adequate comprehension of the information they provide. This latter aspect of the process implies that the consent form be written in language that is understandable by the general population, in addition to determining the level of the patient’s understanding during the initial assessment. Capacity refers to the ability of the patient to both understand the information provided and to subsequently form a reasonable judgement of the potential consequences of their decision. Finally, voluntariness refers to the patient’s right to freely exercise their decision-making without being subjected to external pressure such as coercion, manipulation, or undue influence (Beauchamp & Childress, 1994).

Capacity to give informed consent

In order to give consent patients must be able to understand the procedure that is being recommended, apply reasoning to consider the consequences of the procedure and its alternatives, appreciate the way in which this information applies to them, and be able to make a subsequent logical choice. Although psychiatric illness, in and of itself, does not change the presumption that an individual is competent, a patient’s ability to appreciate the consequences of a particular decision maybe shaped by specific mental symptoms. Thus, cognitive deficits (e.g., due to dementia or associated with depression) can impair the ability to recall and understand information about the procedure, suicidal ideas can affect perceptions of mortality risks, and the ambivalence and indecision that often occurs with depression can limit patients’ ability to make a choice about treatment. If a patient lacks decisional capacity, substituted consent (possibly by a family member) or a judicial hearing may be necessary (Lapid, Rummans, Pankratz & Appelbaum, 2004).

Therapists must always work from the premise that every adult patient has the capacity to make decisions about their health. This includes the ability to make decisions about whether to agree to, or refuse, an assessment, investigation or treatment. You should only regard a patient as lacking capacity once it is clear that, having been given all appropriate help and support, they cannot understand, retain, use or weigh up the information needed to make that decision, or communicate their wishes. It is essential that the therapist does not make the assumption that a patient lacks the capacity to make a decision because of their age, a disability, their appearance, behaviour, medical condition (including mental illness), their beliefs, their apparent inability to communicate, or the fact that they make a decision that you disagree with (General Medical Council, 2008).

If patients are not able to make decisions for themselves, the health care professional must work with those who are close to the patient and with other members of the team. They must take into account those views or preferences that were expressed by the patient and must also be aware of the legal context when a patient lacks the capacity to make their own choices (General Medical Council, 2008).

Children and informed consent

As children often lack the ability or legal power to provide true informed consent for medical decisions, it falls on parents (or legal guardians) to provide permission for medical assessments or procedures to be conducted on children. This “consent by proxy” usually works reasonably well but can lead to ethical dilemmas. This is particularly true when the judgement of the guardians differ with the therapist with regard to what constitutes an appropriate decision.

Children who are legally emancipated and unemancipated minors who are deemed to have medical decision making capacity, may be able to provide consent without the need for parental permission, although this depends on the laws of the country the child lives in (Committee on Bioethics, 1995).

Children are usually presumed to be incompetent to consent, but depending on their age and the influence of other factors, they can sometimes be asked to provide Informed assent.

Informed assent means a child’s agreement to medical procedures in circumstances where he or she is not legally authorised or lacks sufficient understanding for giving consent competently.

De Lourdes Levy, Larcher & Kurz (2003)

Medical professionals are advised to seek the assent of older children and adolescents by providing age appropriate information to these children to help empower them in the decision-making process (Committee on Bioethics, 1995). It should be noted that only legal guardians are able to provide informed consent for a child, and not adult siblings. In addition, parents may not order the termination of a treatment that is required to keep a child alive even if they feel it is in the best interests of the child.

Responsibility for seeking consent

It is the responsibility of the practitioner who will be providing the treatment, to obtain consent, since they will have a comprehensive understanding of the process, how it is to be carried out and the risks involved. In cases where the responsibility to obtain consent must be delegated to another party, they must ensure that the person they are delegating to:

  • Is suitably trained and qualified to take on the responsibility
  • Has sufficient knowledge of the investigation or treatment, and understands the risks involved
  • Understands, and agrees to act in accordance with established guidelines and legal frameworks that are related to issues of informed consent

If you delegate the responsibility of seeking consent to another party, you are still responsible for ensuring that the patient has been given enough time and information to make an informed decision, and has given their consent, before you start any investigation or treatment (General Medical Council, 2008).

Informed consent in research

Medical research is overseen by an institutional ethics committee that usually also oversees the informed consent process as part of any research project involving human beings or animals. Ethics clearance is applied for by researchers via a detailed proposal document, that lays out in detail – among other things – the ways in which the ethics inherent in the project are being considered.

Differences in local contexts (e.g. language and social norms) make the issue of informed consent in research a complex topic. There are five benchmarks for evaluating informed consent procedures in local contexts, with particular reference to developing countries (Emanuel, Wendler, Killen & Grady, 2004):

  1. The community should be involved in drawing up recruitment and incentive procedures that are consistent with local cultural, political and social practices. For example, in some cultures an incentive might be expected, while in others it could be considered offensive.

  2. Disclosure of information should be sensitive to the local context, using local languages, culturally appropriate idioms, and analogies that the local population will understand.

  3. Researchers may need to obtain consent from a range of different “spheres”, including community leaders, elders or other respected community members, and the heads of family. Note that this is not to imply that these individuals grant consent on behalf of other adults, only that they give permission for the researchers to enter the community.

  4. Researchers should use informed consent procedures that are contextually acceptable within a community but which also enable independent observers to verify that voluntary consent was obtained.

  5. Individuals must be made aware that their right to refuse to participate, or to withdraw from the study is actually enforced. Community or familial coercion or retribution needs to be guarded against, especially if compensation for participation is offered.

The World Health Organisation (WHO) has published a series of templates for Informed Consent in a variety of contexts, including research that involves children requiring parental consent, qualitative and clinical studies. These templates may be used to guide principal researchers as they develop an approach to informed consent in their research practices.

Seeking consent in the research process brings with it another set of challenges, especially in the social sciences where there is often little or no risk to participants. In addition, the fact that participants are aware that they are involved in a study may cause them to change their default behaviour (the Hawthorne Effect). In cases where the researcher is concerned that seeking consent will modify the outcomes of the study, the requirement for consent may be waived. However, this is only done after an Ethics Committee has weighed the possible risk to the study participants versus the benefit to society, as well as whether participants are present in the study of their own will and that they will be treated fairly.

Reviewing consent

Informed consent – especially in the clinical context – should be thought of as an ongoing dialogue between patient and healthcare practitioner (Emanuel, et al., 2004). The decision made by the patient should be reviewed at different points before treatment begins, to ensure that the patient’s point of view is consistent and can therefore be relied on. Before beginning treatment you or a member of the healthcare team should check that the patient still wants to go ahead and you should respond to any new or repeated concerns or questions they raise. This is particularly important if:

  1. A significant amount of time has passed since the initial decision was made.
  2. There have been material changes in the patient’s condition, or in any aspect of the proposed investigation or treatment.
  3. New information has become available, for example about the risks of treatment or other treatment options.

You need to make sure that patients are kept informed about the progress of their treatment and that they are able to make decisions at all stages, not just in the initial stage. If the treatment is ongoing you should make sure that there are clear arrangements in place to review decisions and if necessary, to make new ones (General Medical Council, 2008).

Conclusion

Informed consent is an essential aspect of clinical practice and medical research. The process of sharing relevant information with a patient to ensure that they can make an informed choice about their bodies and their health, is a central principle of ethics. Patient autonomy is premised on the idea that they – not the healthcare practitioner – are best positioned to make decisions about the relative risks and benefits of choosing a particular course of action.

Sharing information is an important aspect of consent, although what information to share, how much and when, are sometimes difficult to determine, especially in cases where patients are not competent. It is the responsibility of the healthcare practitioner to ensure that consent is obtained before proceeding down a particular path of management, and in cases where the actual process is delegated, it is the practitioners responsibility to ensure that the person the task is delegated to is trained to carry it out.

Seeking informed consent is complex, time consuming, possibly frustrating, and may even require health professionals to reconsider the role of power in their patient relationships. However, not only is it a legal requirement to involve the patient in decision-making around management, but it is a foundational ethical principle to adhere to in clinical practice.

References

Beauchamp, T.L. & Childress, J.F. (1994). Principles of Biomedical Ethics (4th edition). New York: Oxford University Press.

Committee on Bioethics (1995). Informed consent, parental permission, and assent in pediatric practice. Pediatrics, 95(2):314-7.

De Lourdes Levy, M., Larcher, V., & Kurz, R. (2003). Informed consent / assent in children. Statement of the Ethics Working Group of the Confederation of European Specialists in Paediatrics. European Journal of Pediatrics. 2003 Sep;162(9):629-33.

Emanuel, E. J., Wendler, D., Killen, J., & Grady, C. (2004). What makes clinical research in developing countries ethical? The benchmarks of ethical research. The Journal of infectious diseases, 189(5), 930–7.

Faden, R.R. & Beauchamp, T.L. (1986). A History and Theory of Informed Consent. New York: Oxford University Press.

General Medical Council (2008). Consent guidance: patients and doctors making decisions together.

Health Professions Council of South Africa (2008) Ethical rules, regulations and policy guidelines: Informed consent.

Lapid, M.I., Rummans, T.A., Pankratz, V.S. & Appelbaum, P.S. (2004). Decisional capacity of depressed elderly to consent to electroconvulsive therapy. Journal of Geriatric Psychiatry and Neurology, 17(1):42–46.

Spandorfer, J., Pohl, C. A., Rattner, S. L., & Nasca, T. J. (2010). Professionalism in medicine: A case-based guide for medical students. Cambridge University Press.

Tippett, V. (2005). “Trust me…I’m a medical student”: Truth and trust for student doctors. The Clinical Teacher, 2(1), 21–24.

Wilder, C. Seeking patients’ informed consent: The ethical considerations. Health Professions Council of South Africa news bulletin, March, 2013

World Health Organisation (n.d.). Informed Consent form templates.

WCPT course: Creating and running an open online course

I’m in Singapore for the 2015 World Confederation for Physical Therapy Congress, which is the largest gathering of physiotherapists in the world. I’ve never been to a WCPT Congress before, so I’ve really been looking forward to this for a while now.

Tomorrow I’m presenting a half day course with Tony and Rachael Lowe from Physiopedia, called “Creating open online courses“. We’re going to try and figure out, together with participants, if there’s a place for these kinds of online (or blended) courses in formal physiotherapy education. I believe that it was one of the first courses to sell out at the conference, so there’s definitely an interest in the topic.

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We’ve set up our workshop so that the major concepts we’d like to cover are presented, not as PowerPoint slides but as an online course that anyone can work through (see image below). We included our topics, learning outcomes, content overviews and resources on the wiki at Physiopedia, as well as set up a shared online workspace in Google Drive. Course participants will work through the topics in small groups, using the topics in the online course as inputs for discussion, and then collaboratively document what they are thinking and learning during the course. We will act as facilitators and guides, presenting the initial concepts, adding a few thoughts from our own experiences and then facilitating group discussions. We thought that this might be an interesting approach (for this topic in particular) where instead of participants simply being introduced to the concepts involved in open online learning, they actually work in that space themselves.

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It’s a bit of an experiment so we’d really like to hear comments and feedback, not only from course participants but anyone else at the Congress who thinks that this might be a useful way to run future workshops. The hashtag for the workshop is #wcptooc, so please feel free to send a comment or question, whether you’re signed up for the course or not. We’d love to be able to incorporate thoughts and ideas from people who aren’t in the room.

On a related but separate note, part of the reason for me being here is also a funded research visit to try and set up meetings with potential collaborators for our International Ethics Project. If you’re interested in collaborating on an international research project that aims to develop and run a course in professional ethics across multiple institutions, I’d love to hear from you (there’s a Contact page on the site).

An international project in professional ethics

Earlier this year I began working with several colleagues on an international module in professional ethics. We’re going to spend 2015 collaboratively designing a module that students from a variety of undergraduate physiotherapy programmes can complete, in both online and face-to-face contexts. The project builds on the work I’ve done previously as part of my PhD research (these notes are in progress), as well as on a pilot project I completed in 2013.

We currently have collaborators from several countries, including Brazil, Belgium and South Africa, and I’m hoping to get a few more during the workshop I’m running on Open Online Courses at the WCPT congress in Singapore in May. If you’re interested in the idea of collaborating on an international course in ethics, please let me know.

You can read more about our plans at the project website.