Ladislaw AUTHOR (Xtown, USA)

Joseph V. Henderson M.D. IML (Interactive Media Lab), Dartmouth College Medical School Damasio asserts that Descartes’ error is symptomatic of a world view that [email protected] has come to dominate Western medicine, to its detriment. The “Cartesian- http://iml.dartmouth.edu based neglect of the mind” has impeded the effectiveness of diagnosis and treatment—and, I would add, prevention—of human disease. The "Virtual Practicum": Correcting “For the past three centuries, the aim of biological studies Descartes’ Error With Computers? and of medicine has been the understanding of the physiology and pathology of the body proper. The mind Summary was out, largely left as a concern for religion and This paper describes a virtual environment to improve clinical philosophy ... education by providing a more comprehensive view of The result of all this has been an amputation of the concept medical education and clinical practice. For the most part, of humanity with which medicine does its job. It should not Western medical education subscribes to a Cartesian world be surprising that, by and large, the consequences of view in which practice is viewed as technically rational and diseases of the body on the mind are a second thought, or mechanistic, addressable by the application of theory-based no thought at all. Medicine has been slow to realize that facts and rules. This restricted model of health care largely how people feel about their medical condition is a major factor in the outcome of treatment.” ignores the psychosocial dimensions of health and illness. It does not prepare students to deal effectively with the real For the most part, medical education subscribes to a Cartesian world view “swamp” of professional practice, particularly in the majority in which practice is viewed as technically rational and mechanistic, of cases where the variability of human behavior and human addressable by the application of theory-based facts and rules. This view situations plays a role. This “Cartesian error” may be partly neglects forms of knowledge that are less easily characterized, quantified, and “taught,” such as empathy, intuition, and what Donald Schön called addressable using emerging methods of technology-based “artistry,” an ability to deal effectively with situations not covered by learning, especially virtual environments that incorporate theory and rules (Schön, 1987). Damasio notes that there are exceptional these biopsychosocial aspects. practitioners who are “not only well versed in the hard-core physiopathology of their time, but are equally at ease, mostly through their own insight and accumulated wisdom, with the human heart in conflict.” These individuals, he asserts, are not so because of their professional Introduction training, but in spite of it. Antonio Damasio uses Descartes as “an emblem for a collection of ideas on body, brain, and mind that in one way or another remain influential in Schön (1987) has expressed similar concerns about professional education Western sciences and humanities.”(Damasio, 1994). Descartes’ error, he in general. He contrasted the high ground of "manageable problems [that] says, lies in separating mind and body, in allocating thought and emotion to lend themselves to solution through the application of research-based distinct domains. Rather, he says, the mind and body are inextricably theory and technique" with the swamp of "messy, confusing problems meshed. At lower levels the neuronal structures responsible for reason are [that] defy technical solution." also responsible for processing emotions and feelings and regulating vital body functions. These lower levels are in direct contact with nearly every “ The irony of this situation is that the problems of the body system, “thus placing the body directly within the chain of operations high ground tend to be relatively unimportant to that generate the highest reaches of reasoning, decision making, and, by individuals or society at large, while in the swamp lie the extension, social behavior and creativity.” problems of greatest human concern. The practitioner

1 must choose. Shall he remain on the high ground where professional artistry can be taught and that methods can be developed for he can solve relatively unimportant problems according to doing so. I also believe that technology, if applied well, can promote the prevailing standards of rigor, or shall he descend into the integration of intellect and emotion, to help bring up a generation of swamp of important problems and non rigorous inquiry? physicians whose judgments and actions, while still rational, are more humanistic. "The dilemma has two sources: first, the prevailing idea of rigorous professional knowledge, based on technical rationality, and second, awareness of indeterminate, A Model for Comprehensive, Technology- swampy zones of practice that lie beyond its canons.” based Clinical Education: The Virtual Outstanding practitioners, who deal well with the swamp, aren't generally Practicum said to have more knowledge than others (though technical knowledge is essential); instead, they're described as having more "wisdom," "talent," At Dartmouth we have developed a general model for clinical education "intuition," or "artistry." But these are commonly regarded as phenomena termed the "virtual practicum." The model has been applied in a series of interactive programs, one of which is currently available via broadband that are not amenable to "scientific" examination; as a result, professional 2 education tends to believe that it cannot adequately deal with them. Internet as well as on CD-ROM. The virtual practicum model intends expressly to remedy the Cartesian biases of medical education and provide Another way of expressing the impact of Descartes’ error is that medical for more comprehensive learning. The following presents the theoretical schools do not prepare physicians to deal effectively with the transactional 1 foundations for the model, then very briefly describes the model itself. This nature of medicine, i.e., the psychosocial areas of practice in which the discussion is presented more fully elsewhere, with a detailed description of highly variable nature of human behavior and human situations plays a the HIV program as an example (Henderson, 1998). significant role. Clinical management of individuals with HIV/AIDS is such an area. Scientific understanding of HIV disease is exceptional, and The virtual practicum model draws on Donald Schön's reflective practicum technical methods for its management are proliferating rapidly. However, (Schön, 1987), Max Boisot's Epistemological Space (Boisot, 1995) and care is often compromised by behavioral factors—ranging from prevention David Kolb's Learning Cycle and experiential learning theory (Kolb, of transmission to persistence in taking complicated drug regimens—that 1976). require knowledge and skills that “lie beyond the canons” of technical rationality. This reasoning applies to all clinical situations that are 2.1 Schön's Reflective Practicum transaction-oriented and thus highly dependent on the behaviors of patient Schön raises and addresses these complex educational questions: Can any and provider; and we should recognize that these comprise a majority of patient encounters. It is in these indeterminate zones of practice that we curriculum adequately deal with the "complex, unstable, uncertain, and conflictual worlds of practice?" Can "artistry" be taught? find well-developed technical knowledge, balanced with empathy, intuition, and artistry that mark the exceptional physician. Medical Schön operationalizes "artistry" with a concept he terms "reflection-in- education should strive to assist every physician in developing these qualities. action," which is distinct from another concept, knowing-in-action. Knowing-in-action applies our existing knowledge to expected situations. These issues can be addressed and are beginning to be addressed in a Reflection-in-action applies when a situation falls outside the boundaries of what we have learned to consider normal, i.e., we extend our expertise into variety of ways in many medical schools. With Schön, I believe that unfamiliar or unexpected domains. Encountering the unexpected leads to reflective thinking: we critically examine the situation, frame the problem, 1 Contrasted with more procedure-oriented practice. As Schön points out, gather on-the-spot information. The process may work, yielding expected modern medical schools, seeking respectability within the academy, have results, or it may lead to new surprises that incite additional cycles of chosen to emphasize rigor over relevance, and heavily emphasize the technical/scientific aspects of clinical care. 2 http://iml.dartmouth.edu/VPracticum/HIVPrimaryCare

2 reflection-in-action. Schön acknowledges that this is idealized and 2.2 Boisot's E-space and Kolb's Learning simplified; however, he feels that here lies a phenomenon that captures the essence of what he means by "artistry." Reflective practitioners exercise Cycle reflection-in-action to deal effectively with problems in the "indeterminate Max Boisot collates and systematizes an extremely broad body of research zones of the swamp." and thinking, linking scientific and philosophical theory to learning (Boisot, 1995). He provides a conceptual framework-the epistemology Schön proposes that reflective practice can be learned through exercising space (E-space)-that allows a deeper consideration of what constitutes reflection-in-action, and that professional education can and should provide comprehensive clinical education and how it may be facilitated using opportunities for doing so. To achieve this goal, he advocates the use of technology. Boisot begins with a connectionist view of thought and "reflective practicums:" memory, incorporates Bruner's concepts about perception and generalization, and then ties the E-space directly to learning methodologies ... a setting designed for the task of learning a practice. In a via superimposition of Kolb's learning cycle (Boisot, 1995). context that approximates a practice world, students learn by doing, although their doing usually falls short of real-world Theories form in individuals as a result of experience and reflection, or work. They learn by undertaking projects that simulate and they are received from others. However, there are no guarantees that the simplify practice ... The practicum is a virtual world, personal knowledge gained will be valid or comprehensive. A major intent relatively free of the pressures, distractions, and risks of the of the virtual practicum is that it provides, in addition to the articulate, real one, to which, nevertheless, it refers ... It is also a scientifically validated theories of technical rationality, experiences that collective world in its own right, with its own mix of stimulate the individual's development of valid personal theories. The latter materials, tools, languages, and appreciations. It embodies includes basic beliefs, and values that manifest themselves in such "skills" particular ways of seeing, thinking, and doing that tend, over as empathy, compassion, and an ability to communicate. time ... to assert themselves with increasing authority... The E-space (Fig. 1) summarizes a great deal of learning theory in a Students practice in a double sense. In simulated, partial, or simple, schematic way. The vertical axis considers the attributes of the protected form, they engage in the practice they wish to sensory stimuli perceived by an individual; this perceptual categorization learn. But they also practice, as one practices the piano, the ranges from uncoded (stimuli perceived in more or less raw state, because analogues in their fields of the pianist's scales and arpeggios. they cannot be adequately perceived in coded form or because the They do these things under the guidance of a senior combination of stimuli is novel) to highly coded (stimuli are perceived as practitioner... From time to time, these individuals may teach pre-processed "chunks"- often represented as words or symbols-as a result in the conventional sense, communicating information, of familiarity and learning). The horizontal axis portrays conceptual advocating theories, describing examples of practice. categorization as ranging from concrete (here and now, specific case) to Mainly, however, they function as coaches whose main abstract (universal and timeless, general principles). Edelman notes that an activities are demonstrating, advising, questioning, and important difference between perceptual and conceptual categorizations is criticizing.” that the former originate in local stimuli involving the five senses and the latter depend mainly on non-local stimuli originating in memory and The virtual practicum takes this description literally, using technology to experience. These categories provide quite different methods of dealing create a computer-generated, immersive environment that has all of these with the world, but they interact constantly, with concepts shaping and elements. These elements are listed in Section 3, below. filtering the perceived world.

For present purposes we will consider the E-space in terms of the knowledge artifacts one encounters in its different regions (Fig. 1). In the upper regions of the E-space we find knowledge that derives from technical rationality. The northeast region contains highly coded, logically

3 formulated, more systematically studied and reviewed, scientific 'enskilment' that comes not from mechanistically internalizing a stock of knowledge. We find this type of information in journals and textbooks, knowledge, but from being actively engaged with a practice environment. expressed almost exclusively as symbols, words, formulas, and tables, with figures and occasional images such as x-rays and photomicrographs that Knowledge in the southeast region contains uncoded abstractions which, themselves require highly coded, abstract knowledge to interpret. This is while they cannot be handled with precision, may nevertheless contain the the region of intellectual thought and action, isolated to a great extent from most powerful influences on behavior. It is here that core beliefs and values the variability and idiosyncrasies of the real world. That which is difficult lie, influencing our thinking and behavior in fundamental ways, often at an to quantify tends to get ignored. The northwest region has technical unconscious level. Some argue that one cannot abstract without coding, but knowledge, which provides for direct applicability of abstract scientific Boisot distinguishes between codes that one merely names (e.g., knowledge to concrete situations. This knowledge is often manifested in "professional ethics," "compassion," or "truth"-or even empathy and physical devices, such as an ultrasound machine, IV delivery set, or artistry) and having an uncoded, personal knowledge of what they mean. medication. That philosophers and ethicists debate the meaning of these sorts of abstract concepts attests to their instability as quantifiable, codeable knowledge. One can find language to discuss such concepts in abstract ways, but it is mainly through the richer contexts of concrete experience that one learns about and practices them.

Fig. 1. Boisot’s Epistemological Space and knowledge artifacts within it.

It is in the lower regions of the E-space that we find the knowledge essential to Schön's artistry. The southwest region contains esthetic Fig. 3. Artifacts within the E-space, an example from HIV antiretroviral knowledge, which can be interpreted as an ability to sense, understand, and therapy. act at a non-verbal level, to grasp meaning in a situation without necessarily being able to account for the process used. The ability rapidly A great deal of scientific and technical information bears on management and accurately to determine which features of a complex set of stimuli are of this patient's situation. In Fig. 3, the northeast, Scientific Knowledge salient is a mark of the expert practitioner, learned through a process of region contains knowledge of the HIV life cycle, viral mutation, and development of drug resistance (and basic science supporting that

4 knowledge, e.g., genetics, biochemistry, pharmacology) and, perhaps, data conscious manipulation of well-coded data complexions" and we think of about compliance among different patient populations. The northwest, reflective observation as "a detached, non-committal search for patterns, Technical Knowledge region contains a set of objects that manifest our operating either internally or externally, at a lower level of coding. The first scientific and technical knowledge: medications in the form of pills that takes place in the world of the given, of things with hard edges that can be interrupt the life cycle, perhaps a brochure or videotape on why and how to moved about without dissolving; the second takes place in the world of the take the drugs. possible, one in which things shade into one another to yield new configurations." This modification maps the learning cycle into the E- If the northern regions contain the more biological aspects of management, space. Further, since the active experimentation stage becomes a source of to the south are the more psychosocial aspects. Having applied scientific analytic activities, then the cycle, still starting from concrete experience, knowledge and elected a technical method of treatment, success now can run in both directions. depends entirely on our patient's persistence in following a difficult drug regimen. Our ability to understand her emotional and intellectual state, to communicate and influence behavior, to have appropriate models of patient-provider interaction and to exercise them, in short to participate effectively in the transactional aspects of patient care, will be important determinants of success. In the southwest region lies particular knowledge of this patient and her qualities, of her gestures and facial expressions, recognizing patterns that are combinations of more- and less-coded cues and responding to the concrete circumstances she presents us with. To the southeast lie broad, unarticulated knowledge of communication, especially non-verbal; values about the importance of communication and education; beliefs about patient-provider interaction; and attitudes about patients with HIV and the various life styles that can accompany that condition. Again, these can be named, but they are developed, incorporated, and applied at a more uncoded, contextually rich level, in which reason and behavior derive jointly from intellect and emotion.

To make a direct connection with learning, Boisot modifies Kolb's learning cycle and maps it onto the E-space, as shown in Fig. 4. In Kolb's experiential learning model, experiences are translated into concepts, in turn channeling new experiences. There are four stages: 1) immediate, concrete experience is seen as forming a basis for 2) observation and Fig. 4. Kolb’s Learning Cycle reflection; this, in turn, leads to 3) a process of abstraction and assimilation into models and theories; in a fourth stage, these models are applied as actions in new situations. The cycle can then repeat itself indefinitely, with Kolb derives four statistically definable learning styles, each of which can "successful" iterations persisting as knowledge in the learner's E-space. be viewed as the "quadrant" of the E-space for which an individual learner has a predilection. However, to become fully mature, the individual must In its original form, the arrows of Kolb's cycle moved only counter- integrate the four styles. From an educational viewpoint, this necessarily clockwise. Further, Kolb viewed concrete experience and active involves providing learning experiences that promote such integration. experimentation as dealing only with the concrete world and its events. Experiences that concentrate attention only on one region of the E-space Boisot argues that Kolb's distinctions between "real," external activities and ultimately limit growth. In most formal clinical education, the cycle is internal, concept-building activities are limiting. The cycle can be shifted to the northeast, occupying mainly those areas of the E-space that strengthened if we view active experimentation as "the deliberate and

5 are more highly coded and abstract. And opportunities for learning-and  It provides a technology-based "Virtual Clinic" or "Virtual Mini- growth-are restricted, not by the limitations of the learner, but by the design fellowship" that approximates the world of clinical practice, of learning experiences. represented as media elements (graphics, video, sound, text) within which the learner can move, work, and learn. Viewing Descartes' error in terms of the E-space, when learning is dominated by the highly coded, more intellectual northern regions, reason  Students learn through simulated clinical practice, particularly can be impaired; conversely, when reasoning is dominated by the uncoded, simulated teaching cases which compress time and space, giving the more emotional southern regions, it can also be impaired. The virtual experience of evaluating, managing, and counseling a patient over a practicum model seeks to eliminate the Cartesian Mason-Dixon line that virtual time span ranging from days to years. There are documentary- divides the E-space, to reinforce a natural approach to judgment and style "interviews" with genuine patients, providing narrative impetus decision-making that appropriately integrates thought and emotion. and context for considering health and illness from the patient's perspective. The Virtual Practicum Model  It provides a virtual world sufficiently immersive and intrinsically The Virtual Practicum model seeks more fully to exploit the E-space and to enjoyable to allow even busy professionals to ignore, for a time, the achieve, simultaneously, increased educational efficiency and pressures and distractions of the real world. The virtual practicum may effectiveness. It incorporates all elements of Schön's reflective practicum also reduce the risks to real patients as students develop and apply new model in an automated, electronic, replicable, and disseminable form. A knowledge and skills, since these are done in a technology-generated key to both the reflective and virtual practicums is simulation of the environment before applying them in the real world. practice world with sufficient complexity and realism and, at the same time, to provide access to the less-coded stimuli of the southern E-space.  It is a collective world in its own right, providing an inviting, strong Multichannel communication can help achieve these qualities by greatly sense of place that one can visit repeatedly to learn, containing expanding the repertoire of stimuli that can be conveyed to a learner. As language, materials, and tools which have analogs in the real world of Boisot notes, "Multichannel communication is communication in a natural practice and which borrow from the esthetics of best-practices in mode; it is the deployment of coordinated gesture, speech, tone, clothes, computer game design; a key feature is use of narrative and case-based movement, in the service of messages whose complexity would overwhelm reasoning to increase engagement, enhance reflection, and improve the single channel." While we cannot be complete in depicting all features learning. of clinical practice, video and sound can convey many of the less coded, essential features of that environment. In fact, key features may be  It embodies particular ways of seeing, thinking, and doing via cycles dramatically emphasized, as our common experience of television and film of experience, reflection, abstraction, and experimentation in the attests. Digital multimedia technologies, including motion video, can be tradition of Dewey, Schön, and Kolb; "story-telling" used in the case delivered today via CD-ROM and tomorrow via a broadband Internet; presentations provides an underlying structure and context for these technologies can be used to provide for multichannel communication, discussions and reflection that "assert themselves with increasing to deliver complex, intellectually and emotionally rich sets of learning authority" and intensity. experiences to a global audience.  Activities include clinically realistic patient encounters, documentary- Schön's reflective practicum can be used to define the elements of the style interviews with real patients and practitioners, and computer- Virtual Practicum. Kolb's learning cycle can be used to consider the generated exercises that allow for heuristic learning of facts and rules deployment of these objects more fully to exploit the E-space. (Schön's "scales and arpeggios"). Using Schön's description of the reflective practicum (cited above) as a  All this is done under the guidance of senior practitioner (in the best template, we derive the elements of the virtual practicum: case a master teacher and master clinician) who may

6 stimuli, responses, and feedbacks can be difficult to construct and optimize but,  teach in a conventional sense, "communicating information, when successful, can result in powerfully engaging and effective learning advocating theories, describing practice examples" via mini-lectures experiences. and case discussions

 function as a coach, "demonstrating, advising, questioning, and Conclusions criticizing" via case discussions and guided (with feedback) reflection and experimentation. Peter Senge laments the “dilemma of learning through experience” in the complex, real world of practice (Senge, 1990). Learning by doing, he says, only works when feedback on the decisions we make is rapid and unambiguous. In the complex, real world, feedback is often ambigious, and delayed or not present at all. “How, then, can we learn?” Reminiscent of Schön’s reflective practicum, he advocates use of computer-generated “microworlds” that recreate essential characteristics of a practice environment and “compress time and space so that it becomes possible to experiment and to learn when the consequences of our decisions are in the future and in distant parts of the organization.” The argument applies to clinical education. A comprehensive educational experience, as outlined above, is achievable in real life: synchronicity prevails and the master practitioner, the great patient, and the motivated student actually come together. More often than not, however, the conditions for optimal learning do not occur. Typically, clinical experiences are hit-or-miss; teaching is relegated to providers who are neither good educators nor master practitioners; and feedback on decisions made is delayed (or non-existent) and ambiguous.3 A result is wasted time and lost opportunities for learning. Virtual practicums can be viewed as microworlds providing the necessary conditions for efficient and effective learning. Add to that an increased awareness of a need to encompass more of Boisot’s E-space and we have created the conditions for very comprehensive learning. Virtual Practicums, Figure 5. Virtual Practicum Elements in the Learning if executed well, can at least supplement, and perhaps greatly improve on, Cycle and (implicit) E-Space. real life clinical education.

However, there are dangers. Virtual practicums are difficult and costly to The virtual practicum ties Schön's ideas directly to Boisot's E-space and Kolb's design and produce and there is, so far, no community of educational learning cycle. Fig. 5 shows how practicum elements are associated with technology practitioners to develop them. Even when extremely well done, different stages of the learning cycle; the underlying E-space is omitted for their novelty may delay their adoption, since it is difficult to convey the clarity and it is understood that the learning cycle fully occupies the E-space as quality of the experiences they provide when “marketing” them. There is in Fig. 2. Importantly, the figure fails to show the interplay among the various also a danger that we will, like Pygmalions, become too deeply enraptured elements nor the fact that each element plays some role in all of the learning with our Virtual Galateas, blinding us to the fact that the realities created strategies. Again, space does not permit more than cursory descriptions of the elements, which are fully described elsewhere (Henderson, 1998). Note also that we can have learning cycles within learning cycles, generated by a 3 Particularly in ambulatory care, where conditions are less controlled than blending of stimuli that play out at different rates. This choreography of with hospitalized patients.

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