Judging physiotherapy

WCPT President Emma Stokes, Professor Peter O'Sullivan and others have been engaged this week in a Twitter discussion about how to create a culture in physiotherapy that nurtures change (see @ekstokes twitter feed for 29th May).

The idea of 'space without judgement' was suggested as a more positive approach to change than physiotherapists perpetually 'bashing each other' (@karenlitzyNYC, 29 May).

A few days earlier, Laura Opstedal had written about Letting go of traditions in physical therapy, arguing that resistance to change was a big barrier to progress, and that exploring 'the new' might be a creative way to proceed.

This post followed nicely on from Roger Kerry's piece Physiotherapy will eat itself, and some recent questions I'd raised on this blog, notably: Should we give up physiotherapy? and If you’re looking for innovation, regulatory authorities need to change.

One of the basic arguments being put forward here is akin to Erik Meyer and Ray Land's notion of Threshold Concepts (a good brief summary here).  This goes that there are certain concepts that are central to the very fabric of a profession - in this case physiotherapy - and that these act as a way to understand what the profession is and isn't.  Significant and meaningful change means letting go of some of the threshold concepts that were once held dear, and replacing them with new ones.

Our role as a professional community is to debate and contest these threshold concepts, and explore them in our curricula and professional scopes of practice.

Physiotherapists haven't been good at this kind of debate in the past, a fact all too obvious in our physiotherapy curricula, which still bear all the hallmarks of the curricula of the 1950s.  (Interestingly, Meyer and Land identify bloated, content heavy curricula - so common to physiotherapy educational programmes - as a diagnostic feature of programmes that have failed to identify their threshold concepts).

[su_pullquote align="right"]"Traditionally, learning has been defined as a list of subject matters and facts you need to acquire - such as arithmetic and grammar - with some decoration, like citizenship, built in around it," Ms Lonka says. But when it comes to real life, our brain is not sliced into disciplines in that way; we are thinking in a very holistic way. And when you think about the problems in the world - global crises, migration, the economy, the post-truth era - we really haven't given our children the tools to deal with this inter-cultural world. I think it is a major mistake if we lead children to believe the world is simple and that if they learn certain facts they are ready to go. So learning to think, learning to understand, these are important skills - and it also makes learning fun, which we think promotes wellbeing." (Kirsti Lonka, a professor of educational psychology at Helsinki University, link)[/su_pullquote].

So the challenge to identify our threshold concepts lies in front of us.  But what complicates things even more is the fact that we are now experiencing perhaps the most radical transformation in the way people think about healthcare, health knowledge and health technology that we have ever seen.  Health professional roles that were designed to function in a 20th century - where many physiotherapists had their salaries paid by the taxpayer, and had access to subsidised training, patients lying in wait, abundant social capital and legislative protection - are disappearing fast.

The BBC is reporting today that a school in Finland has stopped teaching 'subjects' to its students.  The report states that, 'In August 2016 it became compulsory for every Finnish school to teach in a more collaborative way; to allow students to choose a topic relevant to them and base subjects around it. Making innovative use of technology and sources outside the school, such as experts and museums, is a key part of it' (link).

And this is the world that future physiotherapy students, practitioners and consumers of healthcare will increasingly demand.

So, not only do we need to do work to find the threshold concepts that really matter to physiotherapy, we also have to imagine what they are in the context of the new economy of healthcare that we increasingly find ourselves operating within.

Picking up on the spirit of Emma Stokes' Tweets yesterday, creating a space in which there is a superabundance of 'judgement' would seem to be in order.  To do that, we need to learn to critique with decency and respect, but to not be afraid of taking even the most sacred threshold concepts and asking naive questions about its future value.

There is an old maxim that says that if something worked yesterday, it should work again today as long as nothing has changed.

Things have changed, and so should we.