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photo montage of herbal medicine

The Role of Instructional Design and Technology
in the Education and Practice of TCM

by Todd Luger

2005

 The Perpetual Problem

It is hard to teach Chinese medicine in 2-4 years. Not only must we contend with a culturally different mode of thinking, but also a huge amount of data and the skills necessary to process that data in a clinical setting. Arguably, it all comes down to the latter. If our students cannot effectively practice, none of the rest really matters. As time goes on, these issues pose mounting challenges. Freshman students are often quite young these days, with little significant exposure to Chinese culture or philosophy. Remarkable as it may seem to some of us “veterans”, quite a few students have never had acupuncture or taken a tai ji class before matriculating. In addition, neither memorization nor critical thinking have been emphasized in the modern academic curriculum. Passing tests and learning job skills is pretty much the limit of public school education these days. We can bemoan this fact or try and do something about it. I would even suggest that we have an ethical obligation in our institutions of higher learning to insure that our graduates leave with the ability to manipulate large quantities of clinical data in an effective manner regardless of their prior ability in this area.

The ability to solve problems is innate to humans beings. So the question is not whether our highly educated students can learn to practice Chinese medicine, but rather how to effectively accomplish the goal. A certain percentage of the ancient Chinese were able to memorize the classical texts and discern deep meaning from them. This number was always quite small, yet this was most definitely the gold standard of medical scholarship. Most physicians did not attain this level. Quite a few could not read or could read only simplified material. Even in ancient times, it had already become necessary to produce primers for the rank and file physicians. The teachers of that era took advantage of several amazing new technologies (paper, stable ink and the printing press) to disseminate songs by which to learn the medicine. Thus, they used an old technique rooted in the oral tradition and used the form of written verse to reinforce it. Students would both recite and transcribe the materials, thus obtaining visual, auditory and kinesthetic inputs. This enabled a much wider range of the Chinese population to practice some semblance of medicine and indeed many great physicians arose from the popular tradition. Training would also typically include a rather lengthy apprenticeship in which to one got to solve hundreds of real clinical problems under supervision.

Even if translators and teachers were to focus their efforts on creating a sufficient body of English language verses to accomplishing the same task, we must ask ourselves whether this is sensible. Keeping in mind that the ancient Chinese were drawing upon the cutting edge of instructional design and technology in their era, we should consider if there are any new ideas or technologies that might yield some insight in the problem of effective education in Chinese medicine. On one hand, there could be a call to return to the classics. Require that all students learn Chinese, immerse themselves in Chinese philosophy, devote sufficient time to memorization and apprenticeship in the old-fashioned way. Then, it is claimed, after enough time had passed, such students (now longtime licensees) would finally live and breathe the medicine. That was the way it was for most of us and most physicians throughout Chinese history. It is the right way and the way it should always remain. Yet Volker Scheid reports that the modern Chinese experiment along these lines was a dreadful failure. That the modern textbooks were actually written because the students were not learning to practice effectively just by studying the classics, even under direct tutelage. So modern primers were created. The model used this time was a very linear rote memorization model popularized in German medical schools and adopted in premaoist China in their western medical schools. This same system was adopted in TCM schools, in part to make them look more “western, modern and scientific”.

Given enough time and external discipline, this method has worked adequately in modern China. The typical TCM physician from the PRC is a walking encyclopedia. But whether due to the rigidities of this type of education or the maoist regime or both, many PRC trained physicians seem disinclined towards questioning of textbook dogma upon arrival in the US. Many, such as Scheid and Fruehauf, have commented that the system of education in China tends to produce a product that goes by the book rather than thinks outside the box. Luckily, it doesn't take long in America before even the most indoctrinated begin to speak freely. I would submit that the highest level of Chinese medical practitioner is not one who can quote chapter and verse, but one who knows how to use the knowledge base to solve novel clinical problems. All of my best teachers, Chinese or otherwise, embraced flexibility as the key to clinical success. Not an anything goes flexibility, mind you. A flexibility rooted in the firmness of certain fixed principles. Like a reed bending in the wind, not a tumbleweed rolling along the prairie.

A New Model

So what should be our model for TCM education in the US and what technologies can aid us in education or practice? Before just speculating and experimenting, it might behoove us to consider the large body of literature that has accumulated in past decades on learning theory, instructional design, effective use of technology in the classroom and clinic. This formal body of knowledge, most typically called Instructional Design and Technology, has been used to develop effective teaching models and tools in many fields, including others that focus on clinical practice. But before dispensing with the prevailing educational model, lets consider an important an oft-heard defense of the status quo. Students lack discipline and motivation, we are told. For whatever reason. The “dumbing down of our educational system” is one phrase you hear bandied about. If one doesn't have a certain attitude and aptitude, then we should not adapt the mode of education to cater to this supposedly inherently unsuited student. That ends up being incredibly defeatist in practice as most of the students in acupuncture schools are not scholars and the laws of statistics suggest that this will always be the case. It is the case in almost other profession, so why not ours?

It is not surprising to hear this debate within our own centers of learning. This is an ongoing debate in academia. Which is whether education should be learner centered vs subject centered. Extreme advocates of subject centered education argue for study of the classics, conventional lectures and writing assignments, no use of any innovation beyond pen and paper. The attitude is that if this method was good enough for the smartest to learn the material in days past, it should still be the standard. Purely learner centered education can distort or dispense with established bodies of knowledge as well as the value of experts in these fields. Ideally there must be a way to convey established bodies of knowledge (like Chinese medicine), yet do so in a way that is accessible to learners whose modes of thinking may be different than the typical scholar-physician of old.

Traditional apprenticeship often involved memorization of certain classics and/or primers, the latter often written in verse. It also involved lots of observation and practice. This was the method in which one of my teachers learned TCM. She memorized books by morning, copying key passages by hand. Then she recited passages from memory in the afternoon. She followed her father, feeling pulses and looking at tongues from the age of ten, beginning to treat her own patients at about 14. By 18, she was ready to practice (and then the story gets complicated and offtopic). While this style of learning involved huge volumes of memorization, it also involved lots of problem-based learning in clinic all along the way to reinforce the data.

Problem-Based Learning: Combining Old with New

Apprenticeship is actually similar in some ways to the current model in western medical schools where students are assigned clinical problems in class, but still have some demand put upon them to memorize data outside of class (they still need to pass licensing exams). While these students don't do quite as well on first year standardized exams as their rote educated peers, they are far happier with their education and perform better on tests of clinical applications as well as long term knowledge retention. And one can't help but wonder whether some of the exciting new advances in western medicine after what had seemed like decades of just more of the same may be in part a reflection of the coming of age of leading researchers who were part of the first wave of problem based learning in WM.

I recently examined a thorough metanalysis of all the controlled research on PBL style education [Gijbels, D., Dochy F., Van den Bossche P., and Segers, M. (2005). Effects of problem-based learning: a meta-analysis from the angle of assessment. Review of Educational Research, 75(1), 27-61.]

This article take a comprehensive look at the existing research literature on problem based learning (PBL). The authors note that research on PBL has been contradictory and equivocal at times. With a well documented literature review, they demonstrate that PBL has been studied using many different instruments of assessment and that the method of assessment has had a significant impact on the outcome of the studies. They also consider whether there is any net gain by learning PBL style other than increased student satisfaction.

The problem studied by these authors is a significant one for several reasons. PBL has been widely adopted in medical schools. Due to its apparent success, it is being adapted, perhaps prematurely to other domains. However it is expensive and difficult to implement and the authors report there have been some calls to reconsider the use of PBL in medical schools. This paper is quite recent (this spring) and is a meta-analysis. So it begins by reviewing essentially all the prior research on the subject. By identifying a key variable between these studies, the instrument of assessment used, the authors provide insights that should help clarify some of the seeming contradictions in the published research on PBL.

Immediately upon immersing oneself in this article, one is impressed with the depth and breadth of the authors” literature review. Being a meta-analysis, the whole purpose of the paper is a rigorous critique and statistical analysis of the existing literature. The studies chosen for inclusion are all critically evaluated. Through this process, the authors were able to identify key differences in study methodologies. The premise of their analysis is that these differences can be rationally explained by comparing the instruments of assessment used. The need for this meta-analysis is amply supported in the literature due to the many seemingly divergent results obtained by different researchers over several decades.

The authors are very clear about their intent in this study. If their hypothesis is correct, then we will be able to more accurately assess past literature on PBL as well as design new research that answers the questions we really need to ask. The key point made in this regard is that the purpose of PBL teaching is to improve the ability to practice one’s discipline in authentic situations. Yet much of the assessment done comparing PBL with conventional teaching has focused on assessing skills other than problem solving. By analyzing data as a whole and comparing it to data subcategorized according to assessment method, the authors reach some interesting conclusions that will likely please neither camp in this debate.

The amount of data that is meta-analyzed is more than sufficient from which to draw conclusions that may be generalized. One can immediately see ramifications from the findings that would be applicable to any medical education setting. While the authors caution against applying this data outside the medical field, the basic concepts of PBL education suggest wider applicability than any given field. However, they are correct that there is no empirical data to support wider implementation at this time.

The authors used a standard statistical software product, Metastat, to analyze their data. They also offer some qualitative interpretation of their findings. The findings are both sensible and plausible. The idea that the assessment one uses will affect the outcomes is almost intuitive. The final analysis demonstrates unequivocally that when one assesses PBL students for PBL learning objectives, they perform significantly better than their conventional peers. This would be the expected outcome if the theories underlying PBL are correct. While admitting there could be limitations in their methodology, such as selection bias in the studies they chose, the authors carefully address all such concerns. Their main one remain the interapplicability of their model between different educational domains.

The one well documented finding that medical students who learn using the PBL style find their education more enjoyable and satisfying is reiterated here. Where the authors break new ground is when they insightfully explore the corollary weakness often attributed to PBL students, which is that their knowledge acquisition is deficient compared to their conventionally trained peers. I excerpt a few passages from the study's conclusions here:

More studies report negative effects of PBL when assessing the understanding of concepts. However, when the weighted average effect sizes are taken into account, a different picture emerges. PBL has a small positive effect size (weighted average ES = 0.068), meaning that when the understanding of concepts is the subject of the assessment, students in PBL perform at least as well as students in conventional learning environments…. First, students in PBL seem to posses a highly structured network of concepts and principles (Level 2). Second, students in PBL are equally competent at recalling specific items of information, as compared with students in more conventional learning environments.…The question is to what extent students' year of study is a moderating variable…Their results suggest that the advantage of the conventional education method in knowledge acquisition disappears after the second year.

It is in this last item that realized their most important finding. If PBL is truly more enjoyable, more effective at conveying clinical skills and equal in the longterm at knowledge retention, then implications for research and practice are obvious.

Information Overload

Problem based learning (PBL) is in part a revival of certain important aspects of apprenticeship based learning. Modern rote memorization of linear facts is quite artificial by contrast. And while effective at achieving certain short term goals such as improved test-taking performance, it is a poor way to train professionals whose jobs depend on problem solving. Especially in an area as critical as healthcare. Yet whenever the question of changes to the educational system in TCM are raised, there are always those who insist the solution is just to increase the information density and penalize severely for lapse of knowledge (in other words, you better know anything I ask you in clinic off the top of your head). This is despite the fact that controlled research has reliably shown that decreased information density leads to increased long term retention, as the following abstract shows:

Russell. I.J., Hendricson, W.D., & Herbert, R.J. (November, 1984). Effects of lecture information density on medical student achievement. Journal of Medical Education, 59, 881-889.

Concerned about the explosion of information available in medical texts and the perceived need by lecturers that they must cover even more material in the limited time available, the authors studied the effect of information density on student retention. They prepared three different lectures on the same subject. Ninety percent of the sentences in the high-density lecture disseminated new information. By comparison, only 70 percent of the medium and 50 percent of the low-density lecture presented new information. During the remaining time, the lecturer reinforced material by restating key ideas, highlighting the material's significance, providing illustrative examples, and relating the material to the student's prior experience. The lectures were presented to a total of 123 students randomly distributed into three groups, which showed no significant difference in cumulative GPA's. Finally students were given a pretest that showed no significant difference in their knowledge base, a posttest (1) immediately after the lecture, and an unannounced posttest (2) 15 days later.

The implication is that the amount of new information that students can learn in a given time is limited and that we defeat our purposes when we exceed that limit. [Who among us has not gone over the allotted class time by a minute or two to provide "just one more thing"?] This study suggests, however, that we would be better off presenting only the basic material necessary to achieve our learning objectives: approximately only 50 percent of the material presented in any lecture should be new. The rest of class time should be devoted to material or activities designed to reinforce the material in students' minds.

This study is significant since one of the chief barriers always presented by faculty to the acceptance of active learning is that "there is simply too much content to cover." Apparently less new content and more time reinforcing the facts and concepts presented [which could include active learning] will lead to greater student learning.

This means that if I teach you 10 things and you remember 1 versus teaching you 5 things and you remember 2, you are better off with being taught less data. This supports a well established principle in modern instructional design, which is that no class should devote more than half of its allotted time to introducing new data. The other half should be spent doing exercises, discussion, drawing relationships, taking questions, reviewing and summarizing. It is a more enjoyable experience for all involved and the outcome is superior. Win-win. The issue of data memorization raises another topic, which is knowledge management. With the speed of modern computers and effectiveness of modern search engines, it is now possible to easily organize all the clinically relevant data one would ever need at their fingertips into a highly functional tool. This changes the terms of the debate over more or less memorization.

The ancient Chinese had no choice but to commit all they could to memory. Not only were there no digital databases available to them, but the nature of their language did not even allow as convenient searching of textual data as alphabetical languages do. Since we do not have to commit the same volume of data to memory due to the existence of modern databases, we then have to consider what we may have lost or gained in this process. Some would argue that having all the data in one's head allows one to draw connections and gain insights that would never occur if the data was largely stored external to one's own brain. That the development of intuition demands this.

However modern brain research suggests knowledge is only useful if it is used. Knowledge stored and never used again may be accessible by certain memory techniques. But if the knowledge is not regularly accessed in the course of higher order thinking, it has little impact on one's problem solving abilities. For example, I once knew how to perform differential equations in calculus, but the details of that matter are not immediately accessible to my conscious mind and the fact that I once had this data at my fingertips on exam day is meaningless to anything I currently do. Just as is the entering channel of an herb I have never used in practice. On the other hand, the information I use daily will develop a life of its own and grow and change as part of my experience. But, as we all know, that is the data we never forget anyway.

Knowledge Management

So I don't think anything is lost by using external databases (also known as Electronic Performance Support systems or EPSS) to store and retrieve information one has not yet used. As I said, it will be remembered after it is used in practice, so the matter is really whether and what one needs to memorize before being able to use it in practice. In the purest conception of problem based learning, one needs to understand the process, but any data necessary can be acquired in the course of solving the problem at hand. While this is not how most of you were taught in school, you will immediately recognize it as they way you actually learn things for good in real life. All of us had done lots of research on a case once only to use what we internalized many times over the years. This is the way the best practitioners function. So why shouldn't our educational system be geared to produce thinkers who know where the data is instead of test-takers with certain trade skills (insert this needle here, turn this knob to this level, etc.).

Now perhaps something is actually gained by freeing the brain from the inefficient burden of rote memorization so that it may focus on creating the much more complex and flexible neural connections necessary to be an effective problem solver. In other words, memorizing less data may not be any sort of sacrifice or compromise at all. Not some sellout to the Google generation, but a dramatic shift of resources to something new and better. Some have assumed that modernity is a certain path to ruin and that includes the changes in they way people think, learn, remember and act. Yet evidence in other quarters suggest many of these newfangled ideas and devices actually can be used to support the development of problem solving and even critical thinking when properly applied. Consider knowledge or information management as one example.

Knowledge management is a catch-all term that refers to a variety of ways of storing and retrieving useful data. Chinese medicine has existed for thousands of years and there are literally thousands of books on the subject. No person has ever known the properties of all 5,767 herbs in the zhong yao da ci dian from memory. It is just not possible. And say there was some intricate way to store all this data in one's brain, it would be far slower to access it than if it was stored on a fully searchable database. Say you had remembered the 6000 or so songs for each herb, but you had to sing them all to yourself in realtime to access the data. It is exactly this type of task at which that computers already far exceed the capacity of humans. Whether computers will someday also exceed the critical thinking skills of the human brain is an open question. We know for sure at this point that humans are still the gold standard in this area. We are comfortable with machines doing our heavy physical lifting, why not the heavy mental lifting as well. Sifting through data is gruntwork. It is the perfect job for a machine.

A TCM Database

In order for a knowledge management tool to actually provide a quantum leap over conventional texts, it must have certain features. In discussion in an online forum I moderate, the following criteria were suggested by a veterinarian named Phil Rogers and modified slightly by me. These criteria are already embodied in part by three program already on the market (acuvusion, shen, and HT - see more below):

1. THESAURUS + DICTIONARY: A searchable list of all terms and synonyms used in the database. Where possible, the language in the main databases [(2) to (5), below].should be "standardized" to the most commonly used term for each concept.

2. SYNDROMES: All the main Syndromes listed in the classical texts and in modern commentaries and clinical articles should be included. Each essential characteristic of the Syndrome should be listed. Occasional (non-essential) characteristics and variants should be listed also. The listings should include S&Ss, Pulse, Tongue and other diagnostically useful info.

3. SINGLES Database: with all relevant data, including dosage, indications, contraindications, pharmacological actions etc

4. FORMULAS Database: with all relevant data, including dosage, indications, contraindications, etc

5. DISEASES database

5. Herb-Drug interactions and Cautions / Contraindications Database.

6. A powerful DATA ENTRY Page, with extensive Drop Down Menus to guide users through the relevant questions on present and past S&Ss, likes & dislikes, psychological/mental profile, etc, from WM AND TCM viewpoints

Use of buttons and tick-boxes would obviate the need for unnecessary typing (and spelling errors).

7. Finally, the software would need a powerful Boolean Search Engine to enable data entry that might not be covered adequately in the drop-down menus (6, above). This would include all Chinese and western categories of disease

The Engine would pick up spelling errors and prompt alternatives automatically. It would then pick up the synonyms from the Thesaurus. Then it would display the DATA from (6) and (7) for tweaking before doing its search of databases (2 to 5), above.

The HITS for Syndromes, Singles and Formulas, respectively, would be scored (1-100), where 1 = 1% fit and 100=100% fit.

Now creating exactly the database that Phil has outlined is not likely to be taken on as a corporate project. The number of potential sales would be too small. It would have to be undertaken by a college or consortium of colleges, perhaps as a library project. In the mean time, there may be a shortcut that accomplishes the most important goal. The most important goal is the access to the material. If one could merely enter a term or two and search for all the entries that included those terms, the amount of data produced would be enormous and not that helpful. However if one could enter unlimited search terms using a Boolean tool, then the results could be refined to the most relevant. This would be similar to searching medline abstracts, but the data would be herbs, patterns, formulas etc. While it would be ideal to have dropdown menus for all the data fields, this would take a lot of programming. On the other hand, if one knew the term set used in the database, then search parameters should be intuitive. This is one of many reasons to use a single standardized terminology for such projects and not cater to any arguments for diversity of terms.

Desktop Search Engines: Do It Yourself

For those who are not familiar with the term Boolean and also do not use medline, a more familiar experience may be with Google. Google is a Boolean search tool, though this is largely hidden from the lay user. But click on the link for advanced search and you will be able to enter a range of different variables. Enter multiple terms in each of the fields present and then hit search. Now look at the top of the results page and you will see the actual Boolean operators google used. These will include things like pluses and minuses (+/-), ORs, quotation marks, etc. This allows you to require terms or to exclude terms, etc. So how does this help us manage information. We won't find what we are looking on the web. Well, Apple has introduced something called Spotlight with their latest operating system. This application can search your personal hard drive using very powerful search parameters. It is just being released as I write and the code is opensourced for developers. It is likely by the time of this printing that that there will be plugin modules that greatly ease the use of complex search queries.

So imagine you had a folder. And in that folder were individual files, each one being the complete text of a section from an internal medicine text, let's say. This would include disease name, pattern, indications, formula, ingredients, modifications. These would be set up in chart form and saved in html format. The portions of the text that included formula names, herb names and perhaps patterns could then be hyperlinked to more detailed entries on this data. Once Spotlight had indexed this folder, you could enter a comprehensive Boolean search for multiple disease names and multiple patterns, etc.. The results window would identify those files that fit your parameters. So say you were looking for all entries that included any of the following terms - “lower abdominal pain”, “lesser abdominal pain” “liver depression” diarrhea, spleen qi vacuity, dampheat, fatigue, wiry, greasy, “blood in stool”. This is far more efficient than paging through textbooks and far more powerful than simple database programs like filemaker pro can muster. We can bring the same power to the desktop that google brings to the web and now anyone can do it. Options that work similarly and may be equally powerful for PC systems are the Blinkx, Google and Yahoo Desktop search applications.

The Critical Role of Standardized Terminology

This discussion of knowledge management encroaches into topics about which I have written at length in my online forum. One is the issue of terminology, to which I allude above. As Bob Felt at Redwing pointed out long ago, computers are stupid. It is up to us to use a consistent language when querying them or we will get out garbage out. I have had quite a few resentful students over the years complaining about how much money they wasted on the supposedly comprehensive practical dictionary by Wiseman. And yet they are rarely able to find most of the terms they are looking for in the text. Why? Because the authors of the leading board exam texts do not provide a comprehensive glossary for their translation terms, arguing that those terms not glossed are self apparent in meaning (though they are not to me and isn't the reader the final arbiter of this matter). In any event, students often look for definitions of various terms in the PD as they are not in the glossary of the text they are reading. However, since the terms are not standardized, they don't even know what term to look for. This whole exercise would be futile without single term standardization.

Over the past few weeks, I have been preparing databases of herbs, formulas and patterns to take advantage of the built-in spotlight search technology in the new Apple OS. When you are creating such a database, one thing becomes readily apparent. The debate over denotative versus connotative translation collapses in the midst of the overwhelming pragmatics of programming search engines. Denotative translations assigns one English word to every Chinese word. Chinese words may be one or two characters, but in TCM, they are usually just one. Connotative translation allows the use of different English words in different contexts even when translating the same Chinese word. The argument for this approach to translation is that the writer is free to convey meaning through word choice.

As has been argued elsewhere exhaustively by Wiseman, et. al., this has never been the standard in technical translation where technical dictionaries derived from exhaustive sources are the basis for determining meaning, not personal connotations. Nowhere is the validity of Wiseman's argument more apparent then when one goes to search existing files and has to search for various permutations of deficiency, excess, vacuity, repletion, wiry, bowstring, taut, wetness, dampness, chill, cold, exterior, external, restlessness, irritability, vexation, to name just a few of the most common of the thousands of terms glossed in Wiseman's PD. The result is fruitless. Keep in mind this is not a debate about term choice. Any reasonable term works for me. It is about term standardization. The only way to reliably find the term(s) one is looking is if the translation term used is the same in every case.

A Chinese physician searching a similar database in Chinese characters would certainly be entering the same characters into his search engine, regardless of the context in which they were being used. The primary argument in favor Wiseman's database is not his choice of terms (that debate is really over my head), but rather that it is extremely comprehensive and already exists in digitized format. This does not prevent others from being less comprehensive if they so choose. One could easily cross-reference the 300 or so glossed terms used by other translators. But searching their works for finer details would be inherently limited due to the impossibility of guessing what unglossed terms actually refer to or remembering every idiosyncratic terms that is used in a given text. As in many other areas of life, technology often ends longstanding debates. If the profession is interesting in maximizing the potential of modern information storage and retrieval systems, then term standardization is an absolute necessity.

A related issue is that most of the Chinese medical literature remains untranslated. A proposed solution is that everyone must learn to learn to read Chinese. While this seems reasonable on its face, it is an undertaking beyond the ability of most clinicians. Yet this is not a sufficient excuse to explain away complete ignorance of the language and the plethora of modern and ancient essays not accessible as a result. It thus would behoove practitioners to acquire some way to access some of this material. Translation tools like the wenlin software provide one option. Wenlin substitutes for a stroke order dictionary. It does not tell you what a text means, but it eliminates the most tedious part for a new learner. Which is the looking up of every new word one comes across in a very laborious fashion. While wenlin is not perfect, the database can easily be modified to include standardized Chinese medical terms and at the every least, one will be able to identify the pinyin and tone for any character and then easily find the standardized term in an alphabetical pinyin TCM dictionary (such as the Wiseman CD). We can also expect rapid advances in translation technology over the next decade that will obviate most of this problem altogether. One could spend ten years trying to achieve a reasonable level of fluency only to be suddenly eclipsed by computers.

Virtual Communities

While knowledge management is perhaps the most obviously practical topic to both the student and the clinician, there are several other key issues that must be addressed as part of comprehensive strategy for implementing IDT in TCM education. These center around writing skills, collaboration and clinical training experiences. One of the keys to the first two issues are online class forums. Now common in all departments of mainstream academia, they are the centerpiece of online educational programs. In the past, students have often asked tutors for help with the weekly study questions, papers and other written assignments. But what if students posted their questions, answers and comments directly to an online forum instead. The tutor/TA could handle a dozen similar questions online at once instead of 12 times in person, so it would be more efficient. This would serve other purposes as well. The instructor would be able to monitor the activity of the tutor. This would prevent them giving out wrong information and help hone their teaching skills for the future. It would also establish a more obvious mentoring relationship between upper and lower level students. All students could remain in the forum during their entire year of material medica studies so they may continue to benefit from the discussion and help those that follow them with whatever tricks they pick up.

This will cultivate writing skills and encourage respectful professional collaboration as well as aid in the development of teachers. Nothing is better for critical thinking than regular reading and writing. Such forums will create a virtual community of herb students at each college with a complete record of all past problems and solutions encountered in the study of materia medica. The online forums for each class could easily include a searchable archive of all past Q&A. This would be an invaluable resource. I know if I need to troubleshoot my computer, the first thing I do is search for an existing solution online before asking a human for help. The efficiencies this would create over time would be dramatic. However the posts would have to be moderated by a trustworthy TA and/or the professor in order to avoid archiving incorrect information. Archived solutions could include links to other web resources plus downloads of charts, photos, etc.

Example: What does a geographic tongue look like? Search the Diagnosis class forum archive and find the link to a downloadable photo of the tongue in question. And so on.

Virtual Experiences

If we accept the premise that case based learning is the ideal, then the learning must limited largely largely by the quantity and diversity of the cases one is able to see in the educational environment. You can certainly can't expect to see everything in your internship, but there are differing amounts of experience necessary in order to demonstrate competence for different students. And basic competence in standard medical matters is a reasonable expectation pruior to graduation. For some, they do some things right the first time. For others, they do some things easily (like deep motor point needling perhaps) and others with more difficulty (writing herbal prescriptions). So you can set an objective standard of competence and then insure there are a minimum number of experiences available to educate even the slowest learners that will graduate from your institution. One other thing we have learned in the past decade or so is that many students who learn slowly or only with endless repetition can still learn quite well and practice quite effectively.

The problem is how many experiences one could possibly expect to have prior to graduation from a TCM college? Let's do the math. Let's say one needs to see about 250 patients over about 500 hours of internship. Now if most of your patients came 5-15 times, then you might manage 50 (or less) separate cases during your year of internship. However, some portion of those will involve co-treatments with other interns due to cancellations, no-shows, etc. There will also be a decent share of one timers, walk-ins, fellow students. So over the year of internship, at best you get to manage about 35-40 cases on your own for a month or more per case (which is not much for internal medicine). Now 60% of those cases will be musculoskeletal cases due to injuries and overuse, with some arthritis thrown in. So if you are lucky, you get to manage 16 internal medicine cases over the year, or about 5 per semester.

Let's take it a step further. Say you evenly divide up your education with five element shifts, orthopedic shifts, TCM shifts, and Japanese shifts. That would mean you get to personally manage about 4 internal medicine cases during your internship using each different methodology. It is hard for me to imagine that one learns much about any particular style after only 4 cases. I think it is hard to believe one would feel confident with even 20 cases under one's belt. This is not meant to outline a failing of the schools. There is certainly no way to have more clinical experience in the allotted time without having interns doing 36 hour rotations in clinics that offer free 24/7 service (like a teaching hospital for MDs). The point is merely that there is a clear need for more opportunity to practice supervised clinical problem solving than can be accomplished in the current system. This obvious gap has led to calls in California to implement a mandatory residency prior to practice. As Jack Miller has argued in a letter to the legislature, this is not necessary for public safety and would just be a hurdle to practice leading to increased healthcare costs. Indeed, the state has no reason (or right) to mandate this, but the schools do have good reason to do something to address this deficit anyway. Technology may provide an option.

In the past I have argued that the best solution to this inherent learning problem is to limit one's studies to a narrow domain. Even to the extent of working closely with a single supervisor to the exclusion of most or all others. I gained much from my long tenure with a single teacher and there is something quite traditional about that approach. I was also quite limited in the amount of English language CM literature that was available at that time (1990-1996). The only gems to be found for a long time were those that emerged from my teacher's mouth. That is no longer the case. Even so, others have argued that in most cases, you will not have many years to work closely with the teacher of your choice and would thus benefit more from a broader exposure to the different applications of medical problem solving techniques. Since you will not master any style during your limited internship, why not sample the fare, so to speak? I think there are merits to both positions, but the latter one is certainly considered standard in western medical training. Narrow exposure is a sure route to uncritical thinking.

But unbounded exposure is equally perilous and also likely to lead to uncritical thinking. The solution is the same. Set an objective standard of competency and then allow the student to accomplish the required tasks at their own rate in a range of different settings. Now this does raise the issue of how eclectic a single program can be before it is unable to meet its core educational objectives. For example, it is quite reasonable that a student could demonstrate competency in all aspects of TCM style practice (herbology, acupuncture, moxa, cupping, gua- sha, e-stim, tui na) as well as certain amounts of WM such as reasonable physical exam, lab tests, orthopedics, etc. However in order to accomplish this, they might need to work with a number of supervisors who have varying skills in these areas. That might better serve the educational goals than working with a single supervisor getting all you can in their area of strength and sacrificing other important exposures.

But is it reasonable to accomplish all of this and also expect to develop high competency in 5 phase or channel based acupuncture? With the bulk of an accredited program being directed towards TCM and Western Medicine, one would have to devote an inordinate amount of study and clinical internship to one of these other styles in order to have any chance at competency. This would likely necessitate a large diversion of time and energy away from core studies. At this point, the styles of problem solving might be too dissimilar to lead to any result other than confusion for all but the most gifted. So while a certain degree of eclecticism and broad clinical exposure is clearly desirable, there are also limits to this enterprise. There is definitely a case to be made that certain styles of practice might best be reserved for postgraduate, continuing education studies or freestanding accredited non TCM program that can do full justice to their concepts and methods. For those who see the value of broad exposure during internship but also see the value of sufficient reinforcement of certain lines of thought, technology may offer us some options once again.

Video Games and the Smarting Up of America

So what technology am I referring to? One of the most interesting trends of the early 21st century is interactive video game sales now top hollywood box office receipts. 18-34 year olds apparently spend more time playing games than watching TV in any other form (cable, DVD, etc.). This was reported on the Wired magazine website. Bloggers all over the web are touting this statistic as a harbinger of the inevitable demise of what novelist Neal Stephenson dubs “passives”. Many trendwatchers agree. Interactive media will be the dominant mode of entertainment in the future. And it will be the expected mode of education as well. Again, the first thought of those who have no experience in the world of games and simulations is that this is just one more more example of the dumbing down mentioned earlier. But while books and text based databases still serve a vital role in education and practice, there is a role for games and video based simulations as well.

A recent essay by Stephen Johnson in the New York Times magazine makes the radical proposition (and produces evidence to back it up) that there are elements of modern entertainment that have dramatically increased the problem solving abilities and IQs over the past 20 years. IQ scores are configured to always place the average score at 100, but the actual raw scores themselves are far higher today than in the past. Johnson argues that the complexity of modern video games and many of the most popular television shows actually enhances the ability to rapidly process many parallel stems of thought. These shows and even moreso the games require detailed recollection of past knowledge to either apply in the new situations of role playing and strategizing or to keep up with intricately woven plots of series like 24 and CSI. Many liberal educators who still like to brag about not owning a TV or the demise of culture since the advent of video games have fallen way behind the science that lends strong credence to Johnson's suppositions.

The more one works with the problem solving method, the more effective one will be at it. And with regard to processing and analyzing data it does not matter whether the process is real or simulated as long as the simulation is sufficiently valid. While a casual player might object that a given game does not accurately mimic reality, it has been shown that perfect mimicry is neither possible nor necessary in games in order to convey the desired skills. Simulations are used in western medical education with great success. They fill a vital experiential gap in training that is far more pronounced in American TCM colleges. We can make use of case based simulations to strengthen one's abilities in certain areas, from herbal prescribing to otoscopic examination. An example of an innovative series of games/simulations for TCM comes with a program called the Herbal Tutor (HT). In addition to the fully searchable tables in the HT software, the progammers have developed the most innovative games to challenge, test and hone ones knowledge and diagnostic skills.

While there are several games related to herbs, formulas and syndromes, I found the syndrome games most interesting. One receives a single random clue from the computer and can view a screen of about 25 syndrome choices that include the one sign or symptom listed. From the given symptom, one considers the possibilities from amongst the syndromes and then chooses from a variety of options. One is another random clue - this could be anything. Another is an optimal clue, which usually points strongly in one direction. I usually choose a specific clue from a category such as speech, behavior, respiration, etc. This is allows one to apply the hypothetico-deductive process advocated by Bob Flaws in his master's diagnosis class. This is the process whereby the answer to any one question should immediately lead one to ask other questions that can quickly allow one to deduce the correctness of their working hypothesis (i.e. rule in or rule out the diagnosis). For example, if one suspects spleen qi vacuity, there are different questions one needs to ask than if one suspects liver qi depression.

This game promotes the skills of efficient questioning, often lacking in even experienced practitioners. It also reveals ruts and weaknesses in one's thinking. They can also lead to unexpected revelations. When Dan Bensky spoke at the Chinese Herb Academy conference in 2003, he answered the question, Why Study the Shang Han Lun? Because if you don't know what's in the SHL, you will never see the patterns in your patients. This occurred to me as I peeked at the answer to the syndrome game on my desktop one time and saw that the solution was shaoyin stage deficiency cold. I had been staring at the screen for some time, trying to think what zang-fu disorder this might be and it never occurred to me to consider the Shang han lun patterns even though the shaoyin option was listed on the same screen right in front of me. Even a seasoned practitioner can benefit from such a game. But you wouldn't know until you tried.

The Future?

The last technology I want to mention is still quite a few years away. Referred to as Language User Interface (LUI) by pioneers in the field such as John Smart of Acceleration Watch, this change in the way one searches databases will be another major leap in computing similar to but far greater in magnitude than he advent of the graphic user interface (GUI) introduced by Apple in 1984. LUI will allow the user to ask in natural speech for any data they want. A patient could conceivably report their case verbally in layman's terms to a holographic image, which could then input the data into a searchable knowledge tool which would generate a range of possible solutions for the doctor to evaluate before choosing a course of therapy. The LUI would literally be able to have a conversation with the user to narrow the search parameters. And while today, text is still prized by the ease of finding stored data, it will become more and more feasible to search audio and video files for their specific content with the same precision we now search text. Combine this accessibility with simple natural language verbal commands to sort the data and the possibilities are literally beyond our current comprehension. Those of us who enjoy it can always dream of the future, but there is plenty we can already do today.

Todd Luger, the founder of the Chinese Herb Academy, has been designing courses for face to face and online instruction for over 18 years. He pioneered the use of the threaded discussion forum in TCM continuing education in 1999, an approach to online teaching that has since become the standard in all mainstream online programs. Todd was an instructor at Pacific College of Oriental Medicine from 2000-2005, working with professional educators in the areas of course development, classroom instruction and clinical supervision. He completed his Master's of Science Degree in Instructional Design and Technology at Emporia State University in 2009.

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