The Role of Instructional Design and Technology in Chinese Medicine Education

Originally written in 2005. Updated in 2020. Author’s note from 2024: The most recent update to this article was written before my first exposure to large language models like chatGPT. I believe the advent of these platforms brings us several orders of magnitude closer to the fruition of the vision expressed toward the end of this article.

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.

The ability to solve problems is innate to humans beings. So the question is not whether our highly intelligent 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 physicians throughout Chinese history. It is the right way and the way it should always remain. Or, is it.

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. 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. I would submit that the highest level of Chinese medical practitioner is not one who can quote every 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. This is not to say that when does not need to memorize a huge body of information to practice Chinese medicine effectively. While it is popular in certain academic circles to believe that all a person needs are critical thinking and problem-solving skills and then they can look everything else up when they need it, this is not supported by educational research. 

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, often 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.

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 off-topic). 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.

Information Overload

Research has repeatedly shown that decreased information density leads to increased long term retention:

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 information. 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.

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. There is abundant evidence that having many facts in one’s brain allows one to draw connections and gain insights that would never occur if the data was largely stored external to one’s brain. That the development of higher-order skills demands this.

However modern brain research also 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. 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 may have studied at some point but never used in practice. 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. 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.

Practitioners still need to have a strong working knowledge of everything they will regularly encounter in a typical general practice. That should form a sufficient foundation for any new information that needs to be accessed during the course of practice. Researchers like E.D. Hirsch have shown that a person needs to already understand around 90% of the facts and concepts in anything they read to fully grasp the new concepts and facts in the remaining 10%. The ideal approach to instructional design in TCM needs to strike a balance between what you absolutely need to learn as a foundation and the tools for finding and assessing new information.

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 over 2000 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 moderated, the following criteria were suggested by a veterinarian named Phil Rogers and modified slightly by me. As I’ve mentioned several times in this article, a tool like this is not a replacement for having committed a large body of knowledge to memory. It is very difficult to effectively use a tool like this for advanced purposes if one does not already have a strong foundation of knowledge in the subject domain.

  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
  6. Herb-Drug interactions and Cautions / Contraindications Database.
  7. 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

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.

The Critical Role of Standardized Terminology

This discussion of knowledge management encroaches into topics that I have written at length in the old CHA forums. As Bob Felt at Redwing pointed out to me long ago, computers are stupid. It is up to us to use a consistent language when querying them or we will get garbage out. At the time I originally wrote this article in 2005, it seemed clear to me that this whole exercise would be futile without single term standardization. Here’s my thought process at the time, with a big (new) caveat at the end.

I was preparing databases of herbs, formulas and patterns. 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. [Authors note: it is possible that this concern over denotative versus connotative translation has been mooted in the era of large language model AI] 

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 Practical Dictionary (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 term 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.

Here’s the big caveat. In the 15 years since I originally wrote this article, advances in machine learning and artificial intelligence may very well make this moot. This is an area I intend to explore further.

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 very 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 Wiseman’s PD). We can also expect rapid advances in translation technology over the next decade that will obviate most of this problem altogether. [Ed note: see caveat above]

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 effective instructional design and technology 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 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 prior 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 elites 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 practice one has in a given domain, 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 this approach is HerbalThink (HT) from the Rocky Mountain Herbal Institute. 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?

[Editors note in 2020: we’re not quite there yet, but we are a lot closer than we were 15 years ago.]

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.