A few days ago, I blogged about the new graduating competencies that will begin to be used in Australia and New Zealand in the the next few years (click here to read this post.) To me, they represent the kind of radical (critical) thinking that is so desperately needed in the physiotherapy profession.
As I mentioned in the blogpost, the new competencies are drawn – almost verbatim – from the CanMED system which has been operating in Canada since 2000. The CanMED system was based on public consultations that took place as far back as the 1980s in Ontario (see Nuefeld et al, 1998) which pointed to the fact that ‘scientific knowledge has brought large benefits to patients in clinical practice, but it is not the only foundation necessary for medical education’ (Kuper & D’Eon, 2011 p.37).
We have known that physiotherapy practice, like all health professional practices, entails as much ‘art’ as ‘science’ (whatever you take these terms to mean.) But any objective observer would agree with Kuper and D’Eon’s assessment that ‘Although many recognise that there is also an ‘art’ to the practice of clinical medicine, becoming a doctor [subsitute physiotherapist, nurse, or other here] continues to entail, almost exclusively, the acquisition of large amounts of bioscientific knowledge’ (Kuper & D’Eon, 2011 p.37).
The reality from the experience of implementing the CanMED system in Canada is that it takes more than just an holistic competency framework to change a profession, and while the CanMED system has been widely welcomed by health funders, government departments, service users and many practitioners, there is an enormous amount of resistance emerging from within the affected professions themselves. The reasons for this are not hard to imagine. Many, if not most, of the people who are charged with making the change were often trained in traditional ways, with a heavy dose of classical medical science behind them. Their social capital is most often derived from their clinical or research expertise, not their appreciation of pedagogy or curriculum reform. They have invested the largest part of their professional careers in promoting biomedicine, but most of these new competencies ‘are culturally based and socially mediated'(Kuper & D’Eon, 2011 p.38) and cannot be understood with the same vocabulary, reductive scientific reasoning so familiar to biomedical scientists.
Biomedically-orientated practitioners can be forgiven for feeling frustrated and disillusioned when confronted with this ‘new world view.’ It must seem like the certainties and security of knowledge offered by biomedicine are being replaced by pseudo-science, biased, subjective and un-reasoned superstitions. It’s like a return to the Dark Ages when people thought that diseases were caused by malign Gods or evil spirits. They believe that subjects like communication skills and empathy hardly warrant the same serious consideration as a detailed knowledge of anatomy, physiology and pathology. And they are despondent to see clinical skills being replaced by wooly, fluffy, and touchy-feely subjects that are nice to have, but surely should not displace the ‘really important things’ when time spent with the students is already in such short supply.
Not surprisingly, advocates of ‘old school’ teaching and learning have developed highly effective resistance strategies. These can range from leaving all the new learning to others and being passive in the face of change; disengaging from team discussions or resisting opportunities to learn the ‘new ways;’ to actively undermining the efforts of proponents to bring about change. These acts of resistance have been a sideshow, however, concealing a bigger problem that advocates of the CanMED system (and many other similar systems) have so far failed to reconcile. And that is that the biological and (humanistic) social sciences are like oil and water, and no attempt to bring them into alignment will succeed unless their mutual differences are taken seriously.
The biological sciences are based on a belief in objective truths, while the social sciences argue that many truths are dependent on people’s individual or collective perspectives and are socially constructed. The biological sciences believe that it is the deranged cell and the pathogen that cause disease. The social sciences say that we don’t experience disease at all, rather we experience illness and this cannot be understood as a biological process. And so people who try to reconcile these two different world views without giving enough thought to the mutuality, end up teaching students in the morning that anatomy matters, and in the afternoon telling the students that it does not.
These are vast oversimplifications, of course. But the point is that the biological and social sciences operate on different registers, and anyone attempting to introduce cultural studies, educational theory, history, the humanities, politics, philosophy, and sociology into medical/nursing/physiotherapy or other curriculum need to understand that they risk deeply confusing the students or creating a graduating programme that takes 17 years to complete because it is so vast.
Evidence from health professional curriculum reform around the world points to this ongoing tension. Unfortunately, physiotherapists rarely engage with this literature because they are so entrenched in the biomedical sciences. This alone suggests that the radical promise of the new competency framework is likely to experience a rocky few birth in Australia and New Zealand, as we take our turn at obfuscation, passive resistance and hand-wringing.
References
Kuper, A., & D’Eon, M. (2011). Rethinking the basis of medical knowledge. Medical Education, 45(1), 36-43. doi:10.1111/j.1365-2923.2010.03791.x
Neufeld VR, Maudsley RF, Pickering RJ, Turnbull JM, Weston WW, Brown MG, Simpson JC. Educating future physicians for Ontario. Acad Med 1998;73 (11):1133–48.
We can do it! Working with both positivism and relativism: critical realism?
I think that the benefit of this document is not that it explicitly positions, for example, ¨Leader¨ as a legitimate role of a clinician but that it forces us to reconsider how we think about the undergraduate curriculum. It’s one thing to say that we value the ability to lead but another thing entirely to think about how we’re going to develop that competency in our students. You say you want your graduates to be leaders; OK, what teaching and learning activities are you going to build into your curriculum in order to develop those leaders? What content are you going to remove to make space for that? How are you going to assess the achievement of the competency?
I think that these are just a few of the challenges that physiotherapy educators will face if they are going to seriously engage with this curriculum, and because we don’t require our teachers to be teachers (they must only have clinical experience), this pedagogical change is going to be significant. Our training has prepared us – in large part – to be mechanics, leaving us unprepared to deal with the kinds of curriculum changes necessary to develop the competencies as described in the document.
The benefit of the document isn’t so much that it describes a set of roles that we expect our clinicians to fulfill (we’ve been paying lip service to them for years anyway). The benefit is that it challenges us to think differently about undergraduate physiotherapy education.
Couldn’t agree more Michael. I would also go further to say that a lot of our traditional approaches to practice actively obstruct people’s attempts to be more ‘holistic’ in their practice. Our strongly biomechanical heritage discourages us from seeing ‘other’ ways that people experience health and wellbeing. And yet, because we all live and practice in the real world, good physios somehow find a way to develop complex, person-centred practice. They do this despite their training though, not because of it. Physiotherapy educators now have the challenge of working out how to design more rounded curricula and, as you quite rightly point out, the key questions are; ‘what teaching and learning activities are [we] going to build into [y]our curriculum…[and] What content are [y]ou going to remove to make space for that?”
The new materialism perhaps?
I have a little bit of experience in this area i.e. of trying to develop a different approach to curriculum that takes into account a range of different competencies that go beyond knowledge and skills. It wasn’t pretty. I was accused – by colleagues – of harming our students because I was suggesting – horror – that “learning how to learn” was more important than learning facts (see http://ht.ly/MSVdX for details…apologies for the self-plug). The passive resistance is real and far more insidious than direct confrontation. At least when people are opposing you you can address their arguments head on, supporting your choices with data. When the discussion is happening largely behind your back, it’s a lot more difficult to deal with. Also, if the argument were rational it would be simple to convince them but more often than not, you’ll be dealing with an emotional (faith-based?) argument that is impossible to counter. As in other domains, “culture eats strategy for breakfast”.
Having said that, I should also point out that I’m not 100% sure about the main thrust of your post, which is that the underlying paradigms of biomedical / social science are incompatible. I agree that they are not easy to integrate but not that they cannot be integrated. There is evidence demonstrating the benefits of incorporating the humanities into medical education, and with organisations adopting these competencies (or similar derivatives) there will be increased pressure to change teaching and learning practices in order to integrate these ideas. If they’re in your curriculum, you have to show how you develop and assess them; what tasks do students have to complete in order to develop the competency? However, even with the most rigorous studies that show the usefulness of merging the social sciences with biomedicine, we won’t be able to change everyone’s mind – but we don’t have to. We just have to change enough minds in our younger colleagues…and then wait for the others to retire.
Regarding the concern about confusing students, that is (IMO) unfortunately true. After 12 years of primary and secondary education where “success” is determined largely by how many facts you can recall, there’s an expectation that higher education will be the same. And sadly, most of us are happy to reinforce that idea. If you’re the person trying to argue that “facts” are easily available and that our time together should rather be spent helping students learn how to think, you may find that they – at least initially – regard you with suspicion. But after a time they also begin to see the value in the approach. Sometimes it’s a long time. I’ve had students write to me several years after graduating, saying that they finally understand what I was trying to help them figure out in class.
Developing these competencies will be difficult and our biggest challenge is most likely to be presented by our colleagues, the very people who we have to work with in order to graduate competent and capable physiotherapists. But I’m of the opinion that a biomedical approach can live not only side by side, but together with the social sciences, in an undergraduate curriculum.
Hi Michael
Thanks for your considered and very valuable reply to the blog. To clarify my point about the incommensurability of biological and social discourses, it’s hard to make my point concisely without taking liberties with complex ideas, but I’m trying to say that because biological positivism views truth, facts, knowledge and ontology entirely differently to many of the humanities and social sciences, it’s not easy to merge, integrate or blend them. You can tack one on to the other and not address their fundamental differences, but I think this does a disservice to the student who will, at some point in their professional life, have to grapple with their radical separation. But now they’ll have to do this on their own and many will feel they are betraying their professional heritage in doing so.
To use a really trite example, the biological sciences are prefaced on the belief that the body is an objective fact that exists independent of one’s experiences and subjective judgement. Many of the humanities and social sciences believe that the body is a product of our experience or is a social construct. These are fundamentally different paradigms and shape how people think about health and illness, bodies, function, movement, research, etc. For that reason alone, they can’t just be taught alongside each other as if they were comfortable cousins. As you know, this is a really hard thing to explain, particularly to physiotherapists who think that the facts presented by the biological sciences are an inalienable truth.
I think it would be lovely if the two could live comfortably alongside one another within a curriculum, but I don’t think I’ve ever seen this done successfully whilst acknowledging that they offer entirely different world views. Do you have any examples of it working well?
Very interesting replies . I am stil a clinician at the ‘coalface’ after 20 odd years the only way I remain interested in my job (other than the necessity of earning a crust) is to try and make sense of pain behaviour and interact with people who attend. College education and subsequent post grad teaching simply does not prepare students for the reality of the uncertainty of clinical practice. Clinical life is ambiguious and uncertain , the pathways and ‘evidence’ base try to make sense of this by structuralist notions of pathology/biomechanics and interventions which often make little sense .
If the desire is to create university courses ie an education and reasoning approach towards health care rather than a technicican mindset (which is still the dominant model) than things should evolve. Science is evolving and dualistic notions are not so teneable but for most of us –clinicians and patients are the default setting . Students need to be exposed to this in a relevant way not the usual this is the logical body stuff v’s the wooly ‘yellow flag’ stuff ………….so a paper like this sent to me via a Danish colleague might fit the bill perhaps ? http://tidsskriftet.no/article/48374/en_GB/
Having integrated models such as the neuromatriix model and linking this with the humanaties for example may bridge the dualsitic divide and enable students to understand why information is both useful and necessary could be a start . Having students out on practice it becomes immediately apparent to them why thinking this way is both interesting and necessary. Practically, I have found thinking this way relevant since in our current era the goal financially is to more towards patient empowerment/self management -so understanding ‘people/culture and behaviour though a wider lens makes sense …………..There is endemic medicalisation and excessive expectations of curative intervention for many common problems that physiotherapists are exposed to . Biomedical interpretations of human behaviour and distress are limited in many situations . I also believe that a focus on brain neurophysiology for example without cultural understanding (see David Morris the culture of pain for example) misses the point very often … I would make topics such as health philosophy at a basic level more accessible and relevant ie looking at issues around coping /adaptation /expecation and cultural issues around behaviour. Although i have skewed my reply on issues around pain which is the dominant r eason people attend physiotherapy clinics where I am employed I believe some of the points relating to educational change are relevant to all areas of practice . Although off topic and relates to a discussion on music education I think this reply from a retired lecturer is relevant …..
Ian
A large part of education should be the growth of understanding; the broadening of the self; the experience of joy in learning, and in beauty and the creation of beauty. We have to think also about art and literature; philosophy; religion; the ancient languages – the things that are so rapidly falling off the educational radar because, lip-service apart, we have learnt to think of education simply as the acquisition of ‘skills’ and preparation for work. Concomitantly, we have become obsessed with testing, marks, box-ticking and the accumulation of validating bits of paper. I spent my last five years as a (university) teacher teaching undergraduates who, yes, had learnt to near-perfection how to do the tricks that please the grown-ups, but who (with a few distinguished exceptions) had no love for what they were doing, no real interest in it, and who found no joy in learning and discovery. Their attitude to education was purely instrumental – because that was the attitude they had been taught to have. If they had heard of Shakespeare (say), that was only because they’d had to ‘do’ a play for ‘A’ level – and so on and so forth.
Education should be so much more than mere training and the lifeless acquisition of marketable credentials. We need to learn again that intellectual exploration and the acquisition of knowledge and understanding is an end in itself and not just a means. Any chance that this point will receive official recognition? None whatever, I’m guessing. The philistines have won. That’s one of several reasons why I retired.
A lovely post thanks Ian and like Michael before I agree with almost everything you’ve said here. I really liked your comments on our student’s instrumental learning. Very insightful. The study of (chronic) pain seems to be becoming a touchstone for a new more embodied understanding of physiotherapy and a lot of practitioners are now exploring how pain speaks to the complexity of the biological, humanistic and social dimensions of health and illness that were always there, but conveniently ignored by physios. Now it seems, our patients, some of our colleagues and the ‘state’ want something more than just a ‘technical rationalist.’ I would make two observations about this: firstly, I wonder where the same level of interest is in other longstanding, complex health problems that we might equally engage with in the future (chronic breathlessness, frailty, longterm disability, mental health disorders, etc.) Also, I still don’t believe physiotherapists have grasped the radical alterity of humanistic and social philosophies, so people believe we can understand chronic and complex health problems with one over-arching perspective, and thereby teach a more complex curriculum reasonably coherently. We cannot. If you believe that pain is only that which you are immediately conscious of (as in some forms of phenomenology), or that it is socially constructed and has no essential biological basis of significance (as in some branches of social constructionism), you cannot simply put these beliefs aside and teach the neurobiology of pain. One theory directly contradicts the other. One says that the biology is real, the other says it isn’t. The problem then becomes one of deciding whether to teach only one approach (the choice physiotherapy made long ago to side with the biological argument), or to try to express different philosophies to the student and hope they don’t get confused. This isn’t easy to do without a solid grounding in the principles that underpin the philosophy…hence my argument that we risk creating 17 year undergraduate degrees and confusing the students. Some people argue that it’s simply a matter of adding some humanities, psychology and social science content into our curriculum. I think, like pain, it’s much more complicated than that.