Some thoughts on DPT foundational science coursework

When I finished writing this post I had this analogy come to mind: If you want the top of the building to go higher, you need the foundation to go deeper. It is this concept that I have in mind with these thoughts.

This post is about two thoughts regarding entry level DPT foundational sciences coursework, particularly those related to {physiology, exercise physiology, pathology} as a set and evidence based practice (which is where the Normative Model puts all things related to probability and statistics).

First thought - the set  {physiology, exercise physiology, pathology} should be sure to emphasize human adaptation on a broader basis then typically covered in this set of courses. As a profession we should look to the anthropologists, sometimes also called human biologists, and their hierarchy of human adaptation. The hierarchy of adaptation that is covered in a human biology context matches nicely with the multi-level stratification of the World Health Organizations (WHO) International Classification of Function (ICF), and is typically considered with a systems approach. Typical courses in that set  {physiology, exercise physiology, pathology} emphasize, as they should, the human physiological adaptations. But human biologists take a broader approach to adaptation. Harrison and Morphy in their book “Human Adaptation” emphasize a 4 level hierarchy - genetic, physiological, behavioral and cultural. Genetics alone may have more levels, and with epigenetic discoveries, and genetic regulatory control systems the genetic adaptations have proven more dynamic than anyone could have imagined - so whereas genetic adaptations were once thought to only occur within populations, we now understand that genetic adaptations can occur within a organism. Physiological adaptations are well covered. They are the focus of most physiology, exercise physiology and pathology courses. An understanding of behavioral adaptation would expand upon the current approach of simply interpreting response to illness, injury and loss as a psychological category and put it into the context of human adaptation to causal triggers (illness, injury and loss) in a much more dynamic process, and a process that must be addressed for rehabilitation success. Konrad Dias and I have just had a paper accepted on heart failure readmissions that will come out in September that addresses the physiology - behavior connection in heart failure. Cultural competence sometimes has the feeling of being all about being politically correct, respectful and inclusive in an effort to reduce social disparities in health - all important contributions of the dialogue on cultural competence. In addition, is the fact that cultural competence is integral to understanding the range of possible behavioral adaptation responses within a particular cultural context, and for deriving explanations for a patient’s current behavioral adaptive approach. Culture sets the conditions on the acceptable and unacceptable behaviors; culture educates us and frames our behavioral repertoire. If behavior is a component to adaptation, then cultural adaptation represents the meta-behavioral component. And believe me, adaptation is a critical concept for rehabilitation.

The next thought is about discrete mathematics. For an expansion from evidence based practice to knowledge based practice it will be necessary to teach the foundational concepts recommended for ”EBP” including topics typical of discrete mathematics. Discrete math  is typically an undergraduate course for students in computer science. Like statistics and probability typically taught in DPT programs, it has no pre-requisites beyond high school algebra. It’s emphasis is on discrete structures, it typically includes material on functions, set theory, logic, probability, combinatorics, information theory, algorithms, and graph theory. If you have been reading my blog at all these past few months, you already understand why I believe discrete mathematics should be introduced in a DPT program. Of course, it does not have to be offered as a full discrete mathematics course. But the concepts - at least of set theory, logic, probability, combinatorics, information theory, algorithms, and graph theory should be covered. They are primers for coverage of clinical reasoning.

My personal journey included finding out about discrete math from a friend of mine that is a computer scientist. I was explaining what I was trying to do in teaching about reasoning through complex cases with graphs and classification based on graph structure. He gave me a book to borrow and I found clear explanations of things I had been wrestling with for years. I subsequently worked through much of the book, but wanting a more formal introduction to the topic I took a discrete mathematics class. My suspicion that this was an important course for future PTs was solidified personally. But how to convince others - that was my concern.

Evidence based practice (and knowledge based practice) are built on logic, probability, and causal structure (which are nicely represented by, and reasoned through with,  graphical networks). An understanding based on discrete math provides this foundation. Such course content would allow a DPT program to jump right into using graphical models to teach concepts such as causation, confounding, bias, adjustment, and inference based on their foundations in functions, logic, set theory, combinatorics, information, algorithms and probability. These concepts (sets, causation, confounding, bias, adjustment, inference, models) are the bedrock of knowledge generation and clinical reasoning (knowledge use).

These foundations may eventually be able to move to the realm of pre-requisites, but until there is a clear use of the knowledge within the curriculum, I think it is best to consider them within the curricula itself. It is a bold proposition, but having more DPTs graduate with these foundations will provide a broader language for deeper dialogue about important topics within the profession as it moves to achieve it’s broad vision: “Transforming society by optimizing movement to improve the human experience” (APTA Vision Statement).

If you want the top of the building to go higher, you need the foundation to go deeper.

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