Author: Michael Rowe / Submitted: 28 May 2018
Notes: The author of this paper is also the Editor of the journal. As such, all editorial decisions regarding peer-review and subsequent editorial processes around this submission are managed by others on the editorial board.
This article is currently under peer review.
About 200 years ago the invention of the steam engine triggered a wave of unprecedented development and growth in human social and economic systems, whereby human labour was supplanted by machines. The recent emergence of artificially intelligent machines has seen human cognitive capacity augmented by computational agents that are able to recognise previously hidden patterns within massive data sets. The characteristics of this technological advance are already influencing all aspects of society, creating the conditions for disruption to our social, economic, education, health, legal and moral systems, and which will likely to have a more significant impact on human progress than the steam engine. As AI-based technology becomes increasingly embedded within devices, people and systems, the fundamental nature of clinical practice will evolve, resulting in a healthcare system requiring profound changes to physiotherapy education. Clinicians in the near future will find themselves working with information networks on a scale well beyond the capacity of human beings to grasp, thereby necessitating the use of artificial intelligence to analyse and interpret the complex interactions of data, patients and the newly-constituted care teams that will emerge. This paper describes some of the possible influences of AI-based technologies on physiotherapy practice, and the subsequent ways in which physiotherapy education will need to change in order to graduate professionals who are fit for practice in a 21st-century health system.
For thousands of years the trajectory of human progress showed only a gradual increase over time with very little changing in the material aspects of ordinary peoples lives over the course of successive generations (Morris, 2011). But about 200 years ago there was a sharp increase in human social and economic development, which saw the curve of population growth and productivity veer sharply in an almost vertical direction (ibid.).
The invention of the steam engine started the Industrial Revolution and brought with it a range of technological advancements that enabled human beings to generate enormous quantities of energy, removing the biological bottleneck that limited the amount of work that could be done. The introduction of machine power significantly increased our capacity to shape our physical environment and created the conditions for the mass production of material goods, which improved quality of life across all levels of society (Brynjolfsson & McAfee, 2014). As the steam engine enhanced our ability to do physical work, so the rise of computing machines will create the conditions for cognitive enhancement that will enhance our capacity to do intellectual work. We are currently at an inflection point, beyond which we will see human cognition first augmented, and then surpassed, by artificially created intelligence, leading to a transformation of our social and economic conditions that are no less comprehensive than those that were introduced by the steam engine (ibid.).
To understand more clearly what is meant by artificial intelligence (AI), it may be useful to consider what we generally mean by intelligence, and by extension, what we do not mean. Intelligence is a general mental ability that involves reasoning, planning, problem solving, abstract thinking, comprehending complex ideas, and learning from experience. It reflects a broad and deep capacity for understanding our environment (Gottfredson, 1997). This definition of intelligence says nothing about self-awareness, consciousness, emotion or morality, nor that there anything essentially human about intelligent behaviour. In addition, there is nothing in this definition of intelligence suggesting that non-human intelligent behaviour should replicate human thinking processes. Indeed, “there are lots of ways of being smart that aren’t smart like us” (Winston, 1992). Today, AI is a cross-disciplinary field of research that attempts to understand, model and replicate intelligence and cognitive processes by invoking computational, mathematical, logical, mechanical and biological principles and devices (Frankish & Ramsey, 2017). More specifically, it is the study of the synthesis and analysis of computational agents that exhibit intelligent behaviour (Poole & Mackworth, 2010). In the field of AI research, an intelligent agent is something that acts in an environment where those actions are appropriate for its circumstances and its goals. In other words, the agent is able to adapt to changing environments and changing goals, learn from experience, and make appropriate choices given its perceptual and computational limitations (ibid.).
The field of AI research was first identified in the 1950s but until recently it has not lived up to the enthusiastic predictions of its supporters. However, there are three main characteristics of modern AI research that explain why this time is different. The first is the ubiquity of cheap computation. The second is the availability of truly massive data sets that are necessary for machine learning algorithms to be trained on. The third is the development of improved programming techniques and more sophisticated algorithms (Brynjolfsson & McAfee, 2014). The combination of these three characteristics have seen an increase in the accuracy and sensitivity of AI-based algorithms to reach conclusions in uncertain contexts that, in many ways, outperform what is possible by human beings. In addition, it is not only the computational power of machines that is noteworthy but the increased power and sensitivity of the associated hardware that making the AI of today qualitatively different than in the past. Better and cheaper sensors, GPS systems, networking, and gyroscopes enable systems to perceive their physical environment, locate themselves on earth, connect to and establish relationships with other connected devices, and understand their own position in space (ibid.). AI-based technologies are not only smarter than they were even five years ago, but are embodied and thus are able to move and learn in the real world. Intelligent machines are therefore no longer constrained to solving theoretical problems in academic research labs but are doing real work in the real world.
Despite the blithe dismissals of some, the AI revolution will not take place in the distant future. Today, AI-based research has led to the use of expert systems that guide clinical decision-making, computer vision algorithms that outperform human beings in the analysis of CT and MRI scans, better diagnostics and prediction of patient outcomes, and enhanced administration and planning in health systems (Harwich & Laycock, 2018). Research into AI technology is demonstrating important advances in the areas of information retrieval and retention, problem-solving and reasoning, image recognition, planning, and physical manipulation (Frankish & Ramsey, 2017). It is worth noting that, broadly speaking, these are also aspects of practice that are central to physiotherapy. In principle, it is difficult not to conclude that much of physiotherapy practice is vulnerable to automation by AI-based systems. The aim of this paper is therefore to explore the most likely practical impact of AI-based technologies in physiotherapy, and the subsequent ways in which physiotherapy education might change in order to graduate professionals who are fit for practice in a 21st century health system.
Artificial intelligence in clinical practice
Health and education systems are increasingly recognised as complex adaptive systems, characterised by high levels of uncertainty and constant change as a result of rich, non-linear interactions that cannot all be tracked (Fraser & Greenhalgh, 2001); Bleakley, 2010). This means that complex systems are inherently ambiguous and uncertain, and that they lack predictable outcomes or clear boundaries. As these systems become more complex it will not be possible for individuals or even single disciplines to work effectively within them (Frenk, et al., 2010). The emergence of AI-based technologies will play an essential role in augmenting our cognitive capacities so that we are able to function effectively in these complex systems. However, there are some important ways in which this will require future health professionals to change some of our more fundamental concepts around clinical practice (Wartman & Combs, 2017).
Firstly, patient management will be based on the interpretation of massive aggregates of data that are collected from multiple sources and applications, many of which will be patient-controlled. We can already see this with wearable – and soon, ingestible technology – that moves with patients, providing a continuous flow of information on a wide variety of health-related metrics at a scale that health professionals have never had to work with before (Susskind & Susskind, 2015). The exponential growth of these interconnected medical devices continuously generate a volume of data that simply cannot be analysed, interpreted, or even understood by human beings alone as they exceed the capacity of our cognitive ability (Obermeyer & Lee, 2017; Wartman & Combs, 2017; Claiborne, 2018). Clinicians will therefore need to incorporate AI-enhanced analysis of massive data sets into their clinical decision making, where the data resides in multiple locations and across a variety of service providers, all interacting in ways that are too complex for individuals or entire disciplines to track.
Following from this, a second characteristic of 21st century health systems is that care will be provided by newly-constituted teams where patients interact with providers across a wide range of professions, some of which are themselves only beginning to emerge. For example, patients may work directly with data scientists who will help them analyse and interpret the enormous amounts of personal and health-related data that they gather themselves (Topol, 2015). Thus, the role of the patient will change as they become true participants in clinical decision-making, possibly even becoming team-leaders as they delegate responsibility for various aspects of their care to different providers, as and when they deem it is necessary. Thus, the nature of the professional role will need to be reevaluated as specialised knowledge becomes increasingly available outside the discipline. This will lead to decision-making that is distributed across a variety of providers and services, some human and some machine, with the patient in control (Topol, 2015; Susskind & Susskind, 2017).
Finally, these interactions will take place in both physical and digital environments and will therefore be distributed in both time and space. As clinical encounters move into digital and online spaces, the vast number of interactions between patients, their data, and distributed care teams will need to be mediated by AI-based systems that manage and plan interactions based on the patients self-identified goals. Professional scopes of practice will need to be revised as cognitive and physical tasks, previously the explicit domain of discipline-based professionals, will be distributed between diverse care providers with differing levels of expertise. In these new health care teams clinicians will need to learn how to fluidly pass control of patient care between themselves, other team members (which may include data scientists and software developers, for example) and smart machines (Wartman & Combs, 2017). There will need to be a recognition of the collective intelligence of the system or network, rather than the privileging of a individuals or professions.
It seems clear that 21st century healthcare will be characterised by a move from producing information, to analysing and interpreting it on a massive scale and across distributed platforms. Clinical practice will therefore be enacted in data-rich systems that consist of information flows that consist of vast volumes of data that are generated from multiple sources of differing quality and validity (Wartman & Combs, 2017). It is in this context that the clinician must learn how to position themselves as they work alongside intelligent machines, not only because AI will augment our physical and cognitive abilities but because it will soon be impossible to function at all without them. As machines gain preeminence in the retention, access and analysis of information it has never been as important for physicians to recognise the human aspects of the profession, for example, those that are encapsulated in the art of caring (Claiborne, 2018). Future clinicians will need to focus their attention and efforts on a more patient-centered, higher quality of care (Panagiotis, 2017) and discard the paternalism that continues to characterise clinical practice today. We will need to come to terms with the fact that 21st century health systems will be patient-driven and that care teams will be loosely connected, cross-disciplinary, and will include smart machines imbued with artificial intelligence.
Preparing graduates for clinical practice in the 21st century will not come through iterative changes to our current clinical and educational paradigms but rather through fundamental reforms to how we think about professional practice (Susskind & Susskind, 2017). We would do well to think carefully about whether physiotherapy is an art practice or a technical craft remembering that, for much of our professional history, it has been viewed as the former (Nicholls, 2018). But if the nature of future practice is such that the technical components of the discipline are outsourced to intelligent machines, we may find ourselves in the position of being well-trained, competent, and irrelevant. We need to ask how to adapt physiotherapy education so as to deepen and strengthen the human-based components that are difficult for AI-based systems to replicate, as well as to integrate the technological and data literacies that are needed in order to understand and work with smart machines.
Physiotherapy education in the intelligence age
Education has always been one way for human beings to adapt to social and economic disruption; this is how we upgrade ourselves. But as machines get smarter – and the pace of change accelerates – the shelf life of a human education gets shorter. Accordingly, the ability to access professional education continuously throughout our working lives will become increasingly important. We should stop thinking of physiotherapy education as time-limited degree programme that people graduate from once in their lives, and reconsider it as a platform for lifelong learning that provides learners with customisable modules they can access when they need to (Aoun, 2016). This will be critical as more people return to higher education during their careers, driven by the need to stay ahead of technological change. In addition, it will not be enough to focus only on training future healthcare professionals, as the pace of AI implementation in health systems will rapidly outpace the retirement of practising clinicians. In other words, we face a situation in which current physiotherapists may find themselves unable to practice effectively as they struggle to communicate and collaborate with AI-based systems. Neglecting professional development may have been less serious in times of incremental change but in an era of profound transformation that requires the retraining of many thousands of clinicians, it will be problematic (Hodges, 2018). It is therefore essential that we develop improved systems for continuing professional development that not only aim to provide current practitioners with the knowledge and skills necessary for clinical practice in an intelligence age, but to cultivate a mindset of flexibility that enables them to adapt to a rapidly changing workplace (Susskind & Susskind, 2015). As a side note it is by no means self-evident that this curriculum will be housed within an accredited higher education institution. In fact, as specialised knowledge is democratised and available outside of discipline-specific programmes, it seems more likely that continuing education will be provided elsewhere (ibid.).
This is likely to present a significant problem for physiotherapy training. It should not be controversial to suggest that the profession is traditionally conservative and that undergraduate education continues to privilege the accumulation of knowledge and skills rather than the agency that students need to navigate uncertain and changing futures (Barradell, 2017). The current, largely memorisation-based programme must transition to one that integrates three fundamental literacies across the core physiotherapy curriculum; data literacy, technological literacy, and human literacy (Aoun, 2017). As clinicians become single nodes (and not even the most important nodes) within information networks, they will need data literacy to read, analyse, interpret and make use of vast data sets. As they find themselves having to work more collaboratively with AI-based systems, they will need the technological literacy that enables them to understand the vocabulary of computer science and engineering that enables them to communicate with machines. Failing that, we may find that clinicians will simply be messengers and technicians carrying out the instructions provided by algorithms. Finally, as machines take over the computation and reasoning tasks previously performed by human beings, clinicians will need the human literacy that are beyond the reach of machine learning algorithms, helping them to develop skills in empathy, teamwork, creativity, design, ethics, and entrepreneurship (ibid.).
The integration of these literacies within and across the core curriculum will help future therapists develop the creative mindset and mental flexibility to invent, discover and produce the original ideas that are necessary to supplement the computation and reasoning abilities of artificial intelligence (Aoun, 2017). A curriculum that is integrated in this way will help future clinicians learn to collaborate with high-performing algorithms while at the same time accentuating our uniquely human strengths. In contrast, a curriculum that is driven by content is oriented to the present and not the future, leaving little room for imagination, professional artistry and capability (Barradell, 2017). We will therefore need to reevaluate certain taken-for-granted assumptions about what we consider to be core to the curriculum. Will we continue teaching students to interpret X-rays when algorithms are already better at image recognition? Will students need to know about disease progression when expert systems have the sum total of all human knowledge embedded within them? Should students learn research skills when search, filtering, aggregation and synthesis algorithms do a better job of summarising a body of work? Or, will students need to know how to interpret algorithmic decisions, and more importantly, know when to ignore them? These are only a few examples of the kinds of questions that physiotherapy educators need to ask as we move into intelligence- and algorithmic based health systems.
Unfortunately, there is no evidence that any health professions programmes are even considering the incorporation of data science, deep learning, statistics, or behavioral science into the undergraduate curricula even though this is what is required to develop, evaluate, and apply algorithms in clinical practice (Obermeyer & Lee, 2017; Hodges, 2018). Without this integration we may find that we have generations of health professionals and educators who are simply unable to speak the language of 21st century healthcare. In addition, we must move away from the simple transfer of knowledge and skills that characterise many curricula, and instead aim to build students’ capacity for creative problem-solving and ideation. In short, we will need to develop creativity capacity and personal human connection instead of routine cognitive skills. Physiotherapy educators must strive to provide the things that smart machines cannot; depth of disciplinary expertise and practice wisdom, personal learning pathways, and an emotional connection to students as part of a relationship-centred approach to teaching and learning. While AI-based systems will take over the mundane tasks of managing the learning process, educators will help students identify meaningful goals, address the emotional aspects of learning, and develop closer relationships with students in order to better support and motivate them.
Artificially intelligent systems are driving changes in the health system that will have profound effects on how health care is enacted in the 21st century. These disruptive changes will force all healthcare professions to reevaluate how fit for purpose they are in an intelligence age that is characterised by smart machines, massive data sets of vast complexity, and fundamentally different relationships with patients and algorithms. We should probably take seriously the notion that the health professions of yesterday can – and maybe should – be at least partially replaced by more appropriate alternatives, including AI-based systems and cheaper alternatives. Intelligent algorithms are already smarter than us within certain narrow domains and successful clinical practice in the future will require that we understand how to interpret the advice of machines, when to hand over control to them, and when to ignore them.
The physiotherapy curriculum must be adapted in order to integrate data, technological and human literacy across all that is considered to be core to the profession, as clinicians who are unable to communicate with AI-base technology will become increasingly irrelevant. Educators must acknowledge that the curriculum must serve people for the duration of their careers, and not only offer time-limited undergraduate and postgraduate degrees. Clinicians will need to access the curriculum several times over the course of a career as they work to stay ahead of the changes in practice wrought by an increasingly competent variety of intelligent algorithms. We would do well to focus on adapting physiotherapy education and clinical practice for a radically different future, one in which we learn how to excel at the things that computers find difficult – or impossible – to replicate. Human connection will be key to success in an intelligence age and we must take every opportunity to use advanced technology – including artificially intelligent systems – to enhance our capacity to care for each other, to learn effectively over the course of our lives, and to develop creative solutions for the problems that matter to us.
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