The healthy curriculum (Part 2)

Photo by Brett Jordan on Unsplash

Last week I suggested that 21st century education should not only be about healthcare, but should also be healthy for the student (last week’s post here).

My argument was that rather than being focused on some unseen subject, the curriculum should begin and end with you. You should leave your training knowing yourself better, equipped with all manner of physical, cultural, spiritual, psychological, political, and social skills to take into your new professional life.

But wouldn’t a curriculum shaped entirely around the students make the person self-centred? Wouldn’t they forget that healthcare is always about other people? I think not. In fact, I think the opposite might actually be true. Especially when you consider how we currently think we help students to become person-centred.

My guess is that your training was rather like mine. Never once did one of the tutors ask us about ours personal values and beliefs and, accordingly, change what was going to be taught. It was all set up in advance, and we were just the latest cohort of empty vessels waiting to be filled up with physiotherapy tools and techniques.

And still today, almost every physiotherapy curriculum I know is a set, standard, linear, invariable, technical training, designed to fit students, whoever they are, wherever they are from, into a standard mould.

Ask yourself, how well does that prepare people to be patient-centred?

Look at the work of Nick Sullivan, Clair Hebron and Pirjo Vuoskoski, Ian Cowell, or Caroline Cupit. They have all shown that physiotherapists and other health professionals regularly ‘overrule patients’ concerns and uncertainties … such that some patients feel unable to openly discuss their health needs in preventative consultations’ (Cupit, 2019).

We are trained to see patient’s concerns as barriers to be overcome, and to ‘sell’ the standard physiotherapy view of health and illness to patients. Consequently, we become uncomfortable when patients express their own narratives. Our treatments become paternalistic power-plays because the therapists feel ill equipped to manage even the most basic communication skills like rapport-building (Cowell, 2019; Sullivan, Hebron & Vuoskoski, 2019).

Part of this comes from our belief that physiotherapists should be objective experts. And this shapes everything in our education system.

Ask yourself, for instance, how many students in your class had a declared disability? How many looked like the clients/patients they were going on to serve? Your class, like mine, was probably full of seemingly able-bodied, young, fit, and strong people, and the argument was always that you had to be physically able just to do the work. Even the myriad blind physiotherapists brought into physiotherapy training through the years were ‘allowed’ to enter training because it was felt their disability would not interfere with their dispassionate objectivity. Not so others.

There might have been some justification for this in the past, when there was more emphasis on manually handling people, but for years now people have had mechanical beds, hoists, therapy assistants, and a distrust of too much hands-on therapy, to lighten the physical load. And people’s attitudes to inclusivity have also changed, at a societal level at least, meaning that this kind of discrimination should not still be happening today.

But the real reason why physiotherapy students were always fit and strong was not because of the physicality of the job, and it was not fundamentally against diversity. Rather, it was because we wanted physiotherapy students to be set apart from their clients/patients.

We didn’t want people to focus on their individual beliefs, and develop self-aware, holistic practitioners. We wanted objective, detached, dispassionate, and value-neutral clinicians, who could perform technical assessments and treatments in an objective, detached, dispassionate, value-neutral way. We wanted scientists trained in the image of medicine, who could focus on the body-as-machine without any hint of subjectivity.

The evidence-based era has only enhanced this. And even though EBP asks the clinician to consider patient experience in determining best practice, the patient is still seen as the object of our deliberations: as different to the clinician; as “not like me”.

So, how would a healthy curriculum be different?

Well, rather than focusing on developing practitioners who are trained to be detached from their clients/patients, a healthy curriculum would constantly reinforce the obvious point that healthcare is a personal and community experience, and that to be good at your job means building your therapy around your clients/patients, in the same way as your training curriculum was built around you.

We would look to recruit people into courses because they were from all sections of the community. Curricula would be different all over the world because the people on the course were different. Methods of assessment and therapeutic strategies would adapt to the needs of the people being served.

But would this narrow a student’s training? Would it be too ‘local’ to be useful in another context? No. Because what the student is learning is how to adapt to the community they find themselves in. To become embedded, rather than the current approach, which emphasises an almost ‘colonialist’ logic, where patients are subject to the therapist’s expertise, and ‘the doctor knows best’.

Traditional health professional training emphasised the importance of the clinician being distant from their client/patient. We were meant to be objective experts, and we were given enourmous power to manipulate people (in every sense). A healthy curriculum takes the opposite view. You start by learning about yourself and you frame your practice around the things that make you healthy.

A healthy curriculum follows the adage that “I’ll make the first coffee for you. You make the second coffee for yourself. Then we’ll make the third coffee for someone else”.

Next week I’ll talk about some of the ways this can work in practice, and how some curricula have already taken this approach.

References

Cupit, C. et al. (2019) Overruling uncertainty about preventative medications: The social organisation of healthcare professionals’ knowledge and practices. Sociology of Health & Illness. https://doi.org/10.1111/1467-9566.12998

Cowell, I., McGregor, A., O’Sullivan, P., O’Sullivan, K., Poyton, R., Schoeb, V., & Murtagh, G. (2019). How do physiotherapists solicit and explore patients’ concerns in back pain consultations: a conversation analytic approach. Physiotherapy Theory & Practice, 1-17. https://doi.org/10.1080/09593985.2019.1641864

Sullivan, N., Hebron, C., & Vuoskoski, P. (2019). “Selling” chronic pain: physiotherapists’ lived experiences of communicating the diagnosis of chronic nonspecific lower back pain to their patients. Physiotherapy Theory & Practice, 1-20. https://doi.org/10.1080/09593985.2019.1672227