This is such an incredible honor. I want to thank all of my colleagues who were involved in the nomination process, with a special thank you to Dr David Morris, who coordinated the nomination packet. I also want to thank the Education Section Awards Committee for selecting me for this honor, and Pauline Cerasoli's family members, who were instrumental in designating funds for this lecture. Finally, I want to recognize all of the previous Cerasoli lecturers for their inspiring thoughts about physical therapy education.
Although I didn't know Polly well, I had the honor of interacting with her on 2 occasions. We were first introduced by a mutual acquaintance at a reception at a conference in the late 1980s. A year or so later, on a connecting flight on the way to yet another conference, I happened to be seated across the aisle from Polly. We recognized each other and chatted off and on throughout the flight. My perceptions of Polly, based on these interactions, were that she was warm, greeting me with a bright smile and a gracious manner even though we had only met once before; witty, displaying a wry sense of humor that I could relate to; and wise, with insightful observations about professional issues we discussed. As a tribute to Polly, I will do my best to try to reflect those qualities—warmth, wit, and wisdom—in my remarks today.
This is an exciting time for the profession of physical therapy. There has been lively dialogue about the future of physical therapy practice and education, beginning with the Physical Therapy and Society Summit (PASS)1 and continuing with an Innovation Summit on Collaborative Care Models,2 the networking conference, Preparing the Next Generation of Physical Therapists for Innovative Practice,3 and a Clinical Education Summit4 in 2014. In addition, the American Physical Therapy Association (APTA) adopted a far-reaching vision statement in 2013: Transforming society by optimizing movement to improve the human experience.5
As a result of these initiatives, a picture of the physical therapist of the future is emerging. We envision movement system experts who are leaders, innovators, collaborators, and entrepreneurs who can synthesize rapidly changing information, integrate advances in technology into practice, and have the flexibility to thrive in an evolving health care environment. That vision creates an exciting but challenging opportunity for educators, as we develop academic and clinical learning experiences to prepare future physical therapists. As I considered the vision for the future of physical therapy and reflected on a topic for this lecture, I decided that the timing was right to begin some dialogue about future curricular models for physical therapist education.
My objectives for this presentation are that learners will be able to identify factors affecting the need for revision of current curricular models, describe principles of concept-based curricular models, and analyze potential opportunities and challenges for implementation of a concept-based curriculum model.
My overarching goal is to stimulate thought and discussion about the type of curricular models that will be a good fit for the future needs of the profession and of society.
The Spiral of Learning
It will come as no surprise to anyone who has worked with me or taken a course with me that I am beginning this session with the spiral of learning (Figure 1). Constructivist Learning Theory holds that we each have a unique spiral of learning in which our previous knowledge, beliefs, bias, and experiences are swirling around.6 When new knowledge enters the spiral, 1 of 2 things can happen. The new knowledge can either be integrated with previous knowledge or experiences or it can squirt out the sides of the spiral of learning. The key to minimizing “squirtage,” if you will, is relevance. The more relevant the information, the more likely it is to be assimilated into the spiral of learning.
I would like to spend a few minutes describing some of the experiences that have stuck to my spiral of learning over the years and have helped to frame the conceptual lens with which I view physical therapist curriculum issues. This also gives me an opportunity to recognize some of my mentors. I will start with my first experience in the field of physical therapy, which occurred when I was an impossibly young looking physical therapist student at the University of Texas Medical Branch in Galveston. The physical therapist curriculum in those days resulted in a bachelor's degree, and the professional phase was only 15 months in length (12 months of academic education and 3 months of clinical education). Although admittedly more interested in parties on the beach than the course work at times, I was amazed at how much I learned in that short time frame. As I reflect back on the curriculum, I realized that the emphasis on thinking and problem-solving stuck with me much more than any information that I tried to memorize.
After working in the clinical setting for 6 years, I moved to Atlanta to pursue a Master of Medical Science degree at Emory University. There, I was fortunate to be mentored by Dr Pam Catlin. I credit Pam for sparking my passion for the teaching and learning process. There was a strong emphasis on process at Emory and that process orientation has stuck with me over the years. As an aside, those of you who know Pam will appreciate the fact that she also did her best to instill a sense of discipline in me by making me meet with her at 7 o'clock in the morning, which is not the time of day when my brain functions best.
A few years later, back in Texas, I pursued my doctoral degree in adult education with an emphasis in learning theory. My dissertation, in which I explored conceptual learning processes used by physical therapist students, was a qualitative study that provided me the opportunity to delve into the literature on learning theory and student learning processes.7 This experience helped shape my views on teaching/learning processes and curriculum structure. It was a major “ah-ha” moment when I realized that Constructivist Learning Theory provided a foundation for the teaching methods that had worked best for me in my early years in academia.
Later, I became director of the Physical Therapist Education Program right here at the University of Indianapolis and had the honor of being mentored by Dr Beth Domholdt. Beth taught me many things, including the importance of being bold in your ideas and that it is sometimes better to ask for forgiveness than for permission. We also had many philosophical conversations about curriculum and administrative issues that have guided me over the years.
Finally, my experience with the Commission on Accreditation in Physical Therapy Education (CAPTE) has helped to shape my thoughts about the relationship between curricular structure and assessment in the accreditation process. My perspectives are based on my experiences as a physical therapist education program onsite reviewer and team leader, various roles on the institutional side of the accreditation process, and more recently as a consultant to educational programs.
The writings of 2 visionaries in our field have also had a strong influence in shaping my views about physical therapist curricula. These statements by Dr Helen Hislop,8 published in 1985, resonate with me and I believe they are still quite relevant to our discussions 30 years later:
The clinician's scope becomes broader and broader, so curricula are added to and added to, and added to, until the force-feeding of facts becomes counterproductive.
Where does it stop? One way to stop it is to identify what is and what is not physical therapy. Input of knowledge, just because it is available, when time is so precious, does not enhance our goal of excellence in physical therapy.
Those things about which we are expected to make decisions must have ascendancy in curriculum content.
It is bad enough to become obsolete in practice, but it is worse to be the recipient of an obsolete education.
In her 1985 McMillan lecture, my wise and wonderful friend Dr Geneva Johnson9 made these visionary statements about physical therapist curricula:
Because our students in the future will be older, self-directed learners, I expect them to have a major responsibility for their own advancement.
Consequently, in a short time, we will find that our traditional lock-step curriculum will be neither appropriate nor adequate. Creative and immediate curriculum change must be in our parade. I expect the faculty for our new and different curricula to serve as facilitators, guides, mentors, and enablers of learning.
Again, I believe these statements are pertinent for our discussions today. I am thrilled that Geanie is able to be here today and I would love to have us recognize her many contributions with a round of applause.
Clearly, these experiences and influential mentors have had a strong impact on my thoughts about teaching and learning processes and curricular issues. As we begin exploring issues affecting the need for curricular change, I would like for each of you to take a minute to think about your spiral of learning in regard to teaching and learning and physical therapist curricula. Think back to your experience as a student. What aspects of your education stuck with you the most? What aspects squirted out of your spiral of learning? Think about your experience as an academic or clinical educator and/or your experience with patient/client education. What made some experiences more meaningful than others? What mentors influenced your thoughts about education? Keep those thoughts in mind as we discuss some ideas about curricular models.
The Curriculum Puzzle
As I considered factors affecting the need for revision of current curricular models, the image of a puzzle came to mind (Figure 2). Some pieces of the puzzle that should be considered as we explore curricular models that are consistent with future needs are: content saturation, student learning strategies, the information explosion, advances in science and technology, the evolving health care environment, and the clinical education model. In the spirit of appreciative inquiry,10 I will discuss these areas as opportunities rather than problems.
Content saturation. Are PT curricula “a mile wide and an inch deep?” This phrase was coined by the Third International Mathematics and Science Study and refers to the tendency to superficially address a wide range of content or topics in a curriculum rather than to address fewer topics or concepts in more depth.11 This term has been applied to curricula at all levels of education for all types of content. Although we have added many areas to physical therapist curricula over the years, I can't think of many topics that have been omitted. And for every topic in the curriculum, many of us feel compelled to address every aspect of each topic, even when there are close similarities among topics. This results in a relatively superficial coverage of many topics rather than in-depth coverage of key ideas or concepts, and results in a class schedule that is filled to the brim. One wonders when the students have time to think! As we consider that future physical therapists will need to have an understanding of fields of study such as genomics, regenerative medicine, and robotics, the issue of content saturation becomes even more of a concern. Our opportunity here is to develop a dynamic curricular model that focuses on broad principles that can be applied to topics that may change over time.
Student strategies. It is no wonder that students feel overwhelmed by the amount of information presented to them, particularly in the first year of the physical therapist curriculum. I have heard phrases like these from students over the years:
It seems like slide after slide of unrelated information, so I just try to memorize as much as I can.
I have always been successful on tests by memorizing information. I just don't know how to do this (think critically).
My spiral of learning was full on the first day of the program!
Our students are academically talented, but may not have been challenged to think critically in previous educational experiences and struggle when they reach a point in the curriculum where memorization strategies are no longer successful. Memorization may also lead to lack of retention of information. It is always disconcerting to me to ask if the students remember what we talked about last week, or even worse, yesterday, and to be greeted with a room full of blank stares! This creates an opportunity to integrate a focus on learning how to learn and provide opportunities to develop critical thinking skills throughout the curriculum.
The tendency for memorization may lead to a superficial understanding of concepts. To illustrate this point, I present the case of albumin. Finding the most effective way to teach concepts related to the role of albumin has plagued me for years in our pathology course sequence. For those who may need a brief review, albumin is a protein that maintains colloid osmotic pressure in the blood vessels and has several other functions.12 Although my colleague, Dr Diane Clark, and I feel like we go to great lengths to explain concepts related to the role of albumin in an entertaining way, these concepts do not always stick to the students’ spirals of learning. While most students perform well on multiple-choice questions where recognition of key words may be helpful, we start to see some creative writing on structured white space questions where the students are asked to explain relationships between albumin and clinical signs and symptoms. After much reflection on why this occurs, I came to the conclusion that memorization strategies and lack of a deep understanding of the physiologic principles that underlie the function of albumin are the primary reasons that this proves to be a challenging concept for students. The opportunity here is to focus on promoting a deep understanding of the fundamental basic science concepts and reinforcing those concepts throughout the curriculum.
Information explosion. As was pointed out by Leslie Portney13 in the 17th Cerasoli Lecture, medical knowledge is exploding at an exponential rate. At the same time, social media and other electronic communications provide us instant access to an overwhelming amount of information every minute of the day, as depicted in an infographic from Domo, Inc. entitled, “Data Never Sleeps 2.0”14 (Figure 3). This instant access to information has direct implications for our curricula. If students can access facts in an instant, we need to consider whether it is necessary for faculty to deliver those facts. This reminds me of an interaction I had with a student who, in class one day, found a definition in about 5 seconds by “Googling it.” He then asked this question: “Dr Graham, what did students do before there was Google?” I responded that students used to rely on textbooks and went to the library to look things up. His response was a befuddled, “Oh.” I believe that the opportunity here is to integrate skills in processing and synthesizing information and critical analysis of credibility of information into our curricula and to funnel student enthusiasm for technology into meaningful learning experiences.
Advances in science and technology. This quote from the proceedings of the PASS1 meeting illustrates how advances in science and technology will influence a shift in the curricular emphasis in the future.
The use of virtual environments and robotics have shown increased functional return when combined with more traditional care to the individual who has experienced traumatic brain injury or stroke. Meeting this challenge will require spending far less time learning activities such as range of motion and muscle testing and more time assimilating advances in genomics, molecular science, and technologies.
The opportunity here is to partner with colleagues in the biomedical sciences, engineering, and other disciplines to provide students with a foundation in these areas.
Evolving health care environment. We have all become aware of the reality that the only constant in the health care is change (Figure 4). Health care environments, practice and payment models, and modes of access to health care are all changing and will likely continue to change in the future. I see the opportunity here to integrate health care policy and leadership concepts throughout the curriculum rather than relegate these topics to separate courses, which tend to occur toward the end of the curriculum.
Clinical education model. The 2014 Clinical Education Summit4 generated exciting dialogue about the future of physical therapist clinical education and resulted in recommendations and action steps in the areas of student readiness, curricular experiences, partnerships, and the culture of teaching and learning. The timing of these clinical education initiatives provides an opportunity for academic and clinical educators to work together to create an integrated curriculum that meets the needs of all stakeholders.
A Concept-Based Curriculum Model
Considering all of the factors I have discussed and my interest in conceptual learning, I was intrigued when I came across the idea of a concept-based curriculum. Much of the literature about concept-based curriculum models comes from 3 fields. Lynn Erickson15 is a leading author in concept-based curricula in K-12 education and the title of her book, Stirring the Head, Heart, and Soul: Redefining Curriculum, Instruction, and Concept-Based Learning, stuck to my spiral of learning immediately. Jean Giddens16 is a leader in development of concept-based curricula and learning platforms in nursing. Joel Michael and Jenny McFarland17 are among several authors who have taken leadership roles in defining major concepts or “big ideas” in physiology.
A concept-based curricular approach is based on the following principles:15,16
- The curriculum is organized around concepts or “big ideas” rather than topics.
- The focus is on deep understanding of the concepts.
- Selected exemplars represented by the concept are chosen.
- Learners explore connections between the concepts and exemplars and among exemplars.
- The emphasis is on active learning in authentic contexts, using a variety of methods.
To provide a brief overview of conceptbased learning, I am going to use a conceptbased approach by explaining the theoretical basis, then providing 3 exemplars.
The Structure of Knowledge
Erickson's15 depiction of the structure of knowledge provides the theoretical basis of concept-based learning (Figure 5). Starting from the bottom of the diagram, Erickson describes facts as specific information about people, places, situations, or things. Topics organize a set of facts. Concepts are mental constructs that umbrella topics. Concepts are typically broad and abstract, represented by 1 or 2 words, universal in application, and timeless. Generalizations are 2 or more concepts stated in a relationship. Generalizations are also known as enduring or essential understandings for a discipline. In a traditional model, the curriculum and individual courses are organized by topics and teaching methods and focus on conveying facts about a condition, region of the body, or procedure. Subsequently, an effort is made to then overlay a concept on the topics and facts. In a conceptbased curriculum, the primary focus is on the concepts and selected exemplars that are used to illustrate the concepts. In other words, the concepts drive the topics and facts instead of the other way around.
Figure 6 provides an example of the structure of knowledge with oxygenation as a concept and anemia as a sample exemplar. Starting from the bottom of the diagram, you can see that a fact about anemia is that it is associated with a lack of hemoglobin. Anemia is the topic, oxygenation is the concept, and the generalization is that oxygen is needed for tissue viability.
Exemplar 1. Continuing with the oxygenation concept, an example adapted from Giddens16 illustrates the concept and selected exemplars (Figure 7). The focus is first on attaining a deep understanding of the oxygenation concept, then on comparing and contrasting exemplars. The exemplars represent different mechanisms that impair oxygenation (cellular, restrictive, etc), but do not include all conditions that involve oxygenation. So, the exemplars are representative, not exhaustive. Depending on the placement in the curriculum, the exemplars could be built out to include lifespan elements, comorbidities, psychosocial issues, cultural competence, and death. The ultimate goal is to be able to transfer the concept when the student encounters a different condition that involves oxygenation.
Exemplar 2. Figure 8 depicts the concept of inflammation. We developed this example at the University of Alabama at Birmingham after a class session in which we asked thirdyear physical therapist students to reflect back on the previous coursework and describe the underlying mechanisms of inflammation, then to think across the systems and provide examples of conditions that involve inflammation. We then asked the students to describe similarities and differences between the conditions and to compare and contrast medical and physical therapist management of the conditions. So, this was kind of a retrospective concept-based assignment, but it demonstrates ways that concepts can be integrated across systems. This example can also be used to illustrate the importance of flexibility in learning as medical knowledge evolves. There is emerging evidence that Parkinson's disease is thought to involve an inflammatory component, but the mechanism is not clear at this point.18 If the student has a deep understanding of inflammation, he or she should be able to apply that understanding and potentially adapt interventions as new information emerges.
Exemplar 3. Figure 9 illustrates the interplay of several interrelated concepts to address the overarching concept of health promotion. In this diagram, Giddens16 depicts 3 concept categories used by some nursing programs. Concepts of health and illness (nutrition and mobility) are represented to the right, concepts of professional nursing (patient education, health policy, health care economics, and evidence-based practice) are represented at the bottom left, and concepts of patient attributes (culture, motivation, development, and adherence) are listed at the top. Exemplars used with these interrelated concepts would depict a variety of attributes across the concepts. Exemplars might include case studies of a child with obesity from a low socioeconomic background, an adult who smokes and has pulmonary comorbidities, and a generally healthy individual who has risk factors for chronic diseases and wishes to improve his or her fitness level.
From a learning theory perspective, a concept-based curricular approach combines aspects of several theories. Scaffolding refers to provision of support via structured interaction during the learning process.19 In concept-based learning, the concept or conceptual lens provides a support or platform on which the learner can “hang the facts.” Collaboration with peers provides another form of scaffolding, consistent with Vygotsky's20 theory of the zone of proximal development. Schema theory holds that an organized pattern of thought or cognitive framework or concept helps to organize and interpret information.21 This is evident in the concept-based approach to learning, in that the concept serves as an organizing framework for topics and facts. Finally, Constructivist Learning Theory holds that learning is an active, social process, and that learners construct knowledge based on interactions between experiences and ideas. Constructivists also hold that learning proceeds from whole to part to whole, which parallels introducing the whole concept or big picture first, then exploring details through exemplars, then returning to the whole picture through application in authentic contexts.6
Many instructional methods are consistent with the principles of a concept-based curriculum. There are 2 common themes among these teaching methods. First, instructor support occurs during the activities that require the highest cognitive load and not during low cognitive load activities, such as learning facts. This theme is consistent with the idea of flipping the classroom, in which students acquire factual information in a online format and problem-solving and clinical decisionmaking activities occur in the classroom.22 The second theme is that the teaching methods involve authentic contexts, meaning that the learning context is as similar to a “real life” experience as possible, which promotes application and retention of the information.6
The Neighborhood 2.0 is an example of a virtual online community.23 This learning platform was developed by Jean Giddens for use by nursing programs in conjunction with Pearson Higher Education. It includes stories, activities, and case studies on more than 40 characters in 11 families. The characters come from diverse cultural and socioeconomic backgrounds, as well as family structures. It also includes nurse characters that work in a variety of settings to illustrate leadership and management roles. The platform is designed to complement specific courses or can be integrated throughout the entire curriculum. This type of learning format is ideal for engaging learners in authentic contexts, providing a holistic view of patient care, and taking advantage of technological advances in teaching resources.
Team-based learning (TBL) is a systematic teaching/learning process in which students are held accountable for class preparation through individual readiness assessments, followed by group readiness assessments, mini-lectures by the instructor to address difficult concepts, and group application activities.24 TBL emphasizes accountability and collaboration, as well as application of concepts in authentic contexts.
Problem-based learning (PBL)25 is another method that fits well with a concept-based curricular approach. Students learn in small groups with a faculty tutor and all learning occurs in the context of authentic cases, thus facilitating self-directed learning and collaboration.
Simulation26 also provides an opportunity for students to apply concepts in an authentic context while taking advantage of advanced technology. This teaching/learning method also provides an opportunity for students to obtain feedback on application of clinical skills and to function in a collaborative environment.
Finally, my belief is that a conceptbased curricular approach provides an ideal platform for interprofessional education. Consider the examples I provided today: oxygenation, inflammation, and health promotion. Since those concepts are universal for health care professionals, interprofessional activities, including case discussion, simulations, and other methods, would be an excellent way for students from a variety of disciplines to discuss both the foundational concepts and the role of each health care provider.
Benefits, Challenges, and Outcomes
Benefits of a concept-based curricular model noted in the literature include: (1) alleviates content saturation by focusing on concepts, which provide a lens through which students can view factual information; (2) an emphasis on information management through use of technology and promotion of flexibility in applying information; (3) a focus on application of the latest evidence; (4) an emphasis on student learning and engagement with a focus on learning in authentic contexts; and (5) provision of a platform for collaboration.15,16 Some challenges noted in the literature include difficulty in determining and defining major concepts and the ideal way to build a curriculum around those concepts, and potential faculty and student resistance to changes in teaching methodology.16
There is limited information available regarding outcomes of concept-based curricular models, but the data does point to positive trends in licensure exam scores, learning strategies, and retention of the concepts.16,27,28 I look forward to future outcome studies, as I agree with Dr Geneva Johnson's assertion in the 2008 Cerasoli lecture that we should practice evidence-based curricular decision-making.29
Imagine the Possibilities
I would like to conclude with some “big picture” considerations as we move forward in our discussions about physical therapist curricula of the future. I invite you to imagine the possibilities in 4 areas.
First and foremost, there is a need for continued dialogue about curricular models. If we consider a concept-based approach, we need to establish our “big ideas” in physical therapy. While resources, such as the Guide to Physical Therapist Practice and the Normative Model for Physical Therapist Education, help to define our scope of practice and provide some conceptual frameworks for patient/client management, these documents don't emphasize the type of “big ideas” or concepts that are typically used as the foundation for concept-based curricula. Imagine the lively dialogue that would occur at a consensus conference as stakeholders debate the big ideas in physical therapy! This type of discussion would be a perfect fit with ongoing APTA initiatives to refine the identity of the profession.
In terms of curricular structure, I believe that we can reduce the length of the didactic component of our educational programs by alleviating content saturation and including blended learning models and other online platforms, thereby reducing seat time in the classroom. For the psychomotor skills component of our curricula, I envision a competency-based model in which learners could demonstrate basic competency in these skills at their own pace. Competency in application of these skills in authentic contexts could occur using simulation activities or assessments such as the Objective Structured Clinical Examination.30
I have long been an advocate for a more conceptual approach for curricular accreditation standards, and adoption of a conceptbased curriculum model would provide an ideal opportunity to move in that direction. While I appreciate the more streamlined version of the new CAPTE standards31 and the hard work that went in to the revision process, I believe that the time has come for us to move away from a discrete list of content areas and skills toward a more conceptual way to assess our curricular outcomes and processes. Imagine the opportunity to succinctly demonstrate to CAPTE how your program addresses perhaps 15 or 20 broad curricular concepts and assures competence in clinical skills!
In considering a clinical education model that would best complement a concept-based curriculum, 2 elements come to mind: integrated experiences in the early phase of the curriculum and partnerships to reduce the need for each program to affiliate with a large number of clinical facilities. Imagine a clinical model that includes early integrated interactions with patients and clients to reinforce concepts being learned. These early experiences could take place in a variety of formats including grand rounds, virtual grand rounds, targeted visits to clinical sites, faculty practices, telehealth visits, and pro bono clinics, to name a few possibilities. For long-term clinical experiences, imagine regional partnerships with fewer clinical sites, perhaps 30 instead of 300, which would allow for more oversight and specific clinical faculty development opportunities so that the concepts addressed in the didactic component of the curriculum could be reinforced through structured clinical experiences.
I sincerely hope that some of the ideas I have discussed will stick to your spiral of learning and will stimulate continued dialogue as we begin to explore curricular models to prepare the physical therapists of the future. In closing, I believe the time has come for change, and the risks of not changing likely outweigh the challenges that may come as a result of adopting a new model for physical therapist curricula, as is eloquently stated in this quote from Anais Nin: “And the day came when the risk to remain tight in a bud was more painful than the risk it took to blossom.”
I want to thank to my colleagues at UAB who have provided support, encouragement, and lots of laughs over the years. I also want to thank the group of friends who served as my sounding board as I was developing my ideas for this lecture: Marty Hinman, Claire Peel, Diane Clark, Brenda Greene, and Suzanne Peloquin. I also want to thank Amanda Sherman for her assistance with the PowerPoint presentation. And finally, I want to thank all of the students I have had the pleasure to work with and learn from over the years.