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.
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.