by Paul Karsten

reprinted from the

European Journal of Oriental Medicine

At present in the United States there is an ongoing discussion within the ranks of the schools and profession about what courses should be included in masters degree level and doctoral degree level programs in Oriental medicine and how these relate to licensure and scope of practice. The consensus of these discussions has sometimes become the framework for criteria for accreditation of school programs and certification of individual practitioners. But though value and importance is given in these discussions to numbers of hours of study and topics of courses, little has been said about the method of instruction to be used in training practitioners of Oriental medicine. This is because despite differences in content of existing programs, there is a single educational philosophy underpinning the majority of the schools' educational structures. This paper is written to critically consider this educational approach, explore its historical and philosophical roots and to compare it to an alternative educational approach, now called problem-based learning, which is regaining prominence after close to a century of hibernation. The case of a small institute in Seattle will be used to illustrate the possibilities for this "new" form of instruction in Oriental medicine.

The standard thinking in medical education is that a student must first go through extensive academic coursework in the relevant fundamentals of the health science being studied before spending significant time in clinical settings. Coursework is set up to systematically instruct students in the explanations of pathology, diagnosis and treatment used by the particular medical paradigm. These "basic clinical science" courses are considered an academic necessity in the first year or two of medical programs and generally their successful completion is required before any extensive clinical work is begun. Any clinic observation done by students is a separate affair and not academically connected with the systematic presentation in the didactic courses. Following this study students move into a clinical phase where they treat patients with supervision. Coursework continues but with a more clinically relevant perspective though often the topics have little instructional interaction with what is occurring in clinic.

In the last decade several medical schools and educators in medicine have questioned this approach to medical education. [1] There have been several concerns expressed in the literature with the outcome of the standard approach. The most prominent of these are:

-lack of student satisfaction and involvement with the program

-lack of clinical relevance of academic coursework

-deficiency in development of clinical reasoning and interpersonal skills

-poor development of networking and teamwork approach to patient care

-poor record of continuing education and professional development after graduation

To counter these observed deficiencies several schools have taken a page from adult learning research and developed programs which utilize what is called in instructional theory a problem-based approach.[2] The underlying belief is that from the beginning students learn by doing and they especially learn by tackling problems similar to those they will face in their work setting. Therefore in medicine from the very start of the educational program the instructional tool becomes the patient. For instance, a case presented on asthma will spur student research into anatomy and physiology, pathology, diagnosis, and therapeutics. The learning of these disciplines is acquired through investigation into how to care for the person. Through multiple cases students learn the skills and theory necessary for clinical practice. The model emphasizes both group efforts and independent research. It downplays the traditional lecture and systematized approach to course material. Books are viewed more as references in coming up with solutions then as textbooks to be followed.

This clinically-based and patient-centered style of medical education has now been adopted in all or in part by over sixty medical schools worldwide, including those at Harvard, Johns Hopkins, Michigan State, McMaster and New Mexico.[3] And yet it has not migrated into the alternative medicine field to any great extent. Even though schools of acupuncture and Oriental medicine profess an alternative approach to health, disease and medicine, they maintain the conventional approach to learning and continue to mirror traditional western perspectives of medical education, medical research, peer relationships and physician/patient interactions. Why is this so? Sometimes it helps to have a historical perspective to understand the origins of certain practices. In this case, the roots of the "standard" approach to medical education takes us back to the mid and late 1800's.

Up until the 1880's American doctors, like their Chinese counterparts, received their training primarily at the bedside observing and working with mentor physicians. Whether it was the apprenticeship approach or the medical school setting, instruction occurred in clinical settings and it was the expertise of the doctor/instructor in caring for patients that was the primary content of the study. Books and classes supplemented this study of patient care. To be sure there were troubles with these programs. Poor instruction, "quickie" programs, laxity in admissions, narrowness of therapeutic perspectives and all the other problems that can haunt any educational endeavor plagued medical education. But it was generally believed that you learned by being with patients.

This all began to change in the 1880's. American medicine was in a philosophical and therapeutic crisis. The observational data of the Paris School in France in the 1840's had demonstrated through some of the earliest uses of biostatistics that most of the therapeutic approaches being used by European and American physicians were ineffective. This research demolished American doctors confidence in the standard therapies of the time; bleeding, emesis, purgatives and calomel (a mercury compound). The generation of physicians that grew up with these revelations practiced a more conservative medicine and in many cases despaired of finding any useful medical therapies. Many believed the future of medicine would be in preventative medicine, public health, or hygiene; that is proper exercise, diet and lifestyle. A form of therapeutic nihilism struck many of the medical providers in Europe and America.[4]

But many in America resisted this direction. There was a strong movement to find therapies and a philosophy of medicine which would retain the conventional patient/physician relationship and effective medical therapies to answer the health concerns of the public. The public and professional discussion about the future of medicine included several perspectives. The most prominent positions taken at the time were:

* focus funds and personnel on public health, not private physicians.

* train physicians to be lifestyle counselors emphasizing diet, exercise and preventative measures.

* return to the old purgative methods but with a more conservative attitude.

* continue a trial and error approach to finding new therapies based on careful bedside observation and biostatistics

* consider the new scientific approach from Germany which moved the focus of diagnostics and therapeutics into the laboratory and utilized recent findings in pathophysiology and biochemistry.

For a variety of political, economic and professional reasons the approach which gained most support within the American medical school community was the new laboratory medicine from Germany. This direction rode the positivistic wave of the science of the day. It ensured the continuation of physician's authority in health care and opened up new hope for certainty in medicine and cures of the diseases of the time. The discoveries of the pathogens responsible for cholera, tuberculosis, syphilis and other dreaded conditions bolstered public support for the laboratory approach to diagnosis and treatment.

In education this meant that physicians had to be trained as scientists as well as patient care providers. The German model required four years of college prior to medical school and that the first two years of medical school be spent in learning the biological sciences necessary for laboratory research. It also promoted animal research as a prerequisite for learning about human pathophysiology and for developing therapeutic interventions. The shifting of the student's study from the clinic to the lecture class and laboratory brought on probably the most fierce debate ever experienced in medical education in America. It split faculties in medical institutions into warring camps. It pitted school against school and region against region in the debate over teaching methods as well as the underlying philosophies of therapy and research. What is medicine? What is medical education? What is the source of knowledge and philosophy underlying medical thought? Many doctors and teachers vigorously opposed the basic science curriculum saying it would not train good clinicians. On the other side many supported the basic sciences as core knowledge for physicians in order to further medicine and, perhaps as importantly, the profession. As the dust settled the larger institutions like Harvard and Johns Hopkins adopted the German approach and by the 1920's the politics of funding, licensing and certification transformed the American medical education scene into the model which is prevalent today.[5] A new era of physician authority based on respect for science and its truth-telling capability was born.

The power of the model was phenomenal in the early 1900's. It either swept other medical approaches under the rug or inspired them to adopt a similar educational approach. Osteopathic, Chiropractic and Naturopathic institutions adopted the framework in order to gain public and governmental respect. In China where western medicine became the official government standard in the 1920's, the imprint formed the basis for traditional Chinese medical education of the private schools of that era and the official schools founded in the 1950's.[6] TCM colleges created programs which emphasized basic sciences followed by clinical practice. When acupuncture training began occurring in academic settings in America it also adopted the ghost of the German scientific approach to education.

But things have a way of coming full circle. Now the very institutions, Harvard and Johns Hopkins, that a hundred years ago led the way to the basic sciences curriculum, are now leading the way to returning to a more clinically-oriented curriculum.[7] Their programs have been completely revamped so that students work with patients from the beginning of their education and the discussions about those patients' welfare help form the educational goals of the curriculum.

What does all this imply for developing education in Oriental medicine? It is useful to be aware of the cultural forces that drive our sometimes unconscious assumptions. I believe many of us as educators have just assumed we have to develop curricula and instructional methods in a particular way because that is what we see being done around us. This issue is also important in adapting research methodologies for Oriental medicine (another topic).

It is not that we are not aware of the deficiencies of the standard format. All of us have heard the complaints of students and alumni about the relevance of academic classwork to the realities of clinical practice. We have justified (though poorly) the teaching of pulse qualities, tongue observations, point functions, diagnostic patterns and other clinical skills in classroom settings divorced from the reality of real patients. We have all seen the difficulty many students have in the transition from the academic to the clinical phase of acupuncture programs. We bemoan the proliferation of simplistic routines in diagnosis, recipes in treatment and rigid protocols, yet that is the likely outcome of education which begins instruction through a rational systematized approach rather than the fluidity and uncertainty of actual patient care. It is clear that academic skills like being effective at taking a multiple-choice exams are very different from the skills and experience needed in a clinic setting. Still we proceed with a mode of instruction that few of us would want to personally participate in if we could choose how to go back to learn Oriental medicine.

There are many reasons for preserving this academic approach; most administrative, political and financial. But from the point of view of an educator, as a faculty person, we must responsibly consider how to best train graduates to go beyond us, to give them a deeper opportunity to learn the art of medicine. I suggest that to do this we need to have more confidence in the healing relationship as an instructional tool.

To demonstrate this, one year ago Dan Bensky and I started the Seattle Institute of Oriental Medicine. The goal was to see if a clinically-based program would work. In this program students would learn about points, herbs, diagnostic skills and treatment approaches through direct patient contact. The focus of the first year of student education has been in observing and assisting experienced practitioners. By working in small groups with a practitioner in a structured clinical setting students participate in patient care as their primary learning experience. Careful note-taking on each patient's condition and treatment leads to the creation of personal reference journals which record uses and functions of acupuncture points and herbs. Pulse taking, interview skills, diagnosis, treatment plans, point functions, and herbal remedies are all learned through clinical practice. Class time is spent in discussions and labs to augment and deepen the experience from clinic. Clinical practitioner/instructors are chosen because they represent different schools of thought in Oriental medicine yet share a respect for other approaches. Thus students have lengthy clinical experiences with Chinese, Japanese and eclectic practitioners each of whom have developed a personal style and philosophy in their practice.

The exchange of ideas and perspectives on particular conditions becomes the focus of diagnostic seminars. Students bring to these discussions their experience with different practitioners and patients as well as the research in journals and texts. The format is designed to promote discovery in each student of a personal practice style as well as encourage consultative relationships with peers.

The school encourages seeking information from a variety of traditions and sources. Students learn medical Chinese to be able to access Chinese medical journals for additional ideas on herbal and acupuncture treatment. These courses also give a vantage point for understanding Chinese medical theory which is unreachable without some knowledge of the language. Use of Medline and the University of Washington Health Sciences library is expected in researching English articles on conditions being studied. Clinical opportunities in public health and specialty settings are provided. Students receive credit and subsidy for attending seminars at other acupuncture institutions to encourage dialogue and sharing of clinical perspectives. These activities are designed to break down communication barriers within the profession and between health professions. They are also to develop skill in critiquing and evaluating approaches to practice and research. In this way they learn to ascertain what methods may be most appropriate for a particular practitioner and problem.

What have we learned from this experiment so far? Some things are clear. The students are already quite clinically experienced. By this we mean that they can handle conversations about patients with complex diagnoses, recommend appropriate herbal formulas and modifications, palpate and assess meridian and point conditions and localize points for treatment. The Chinese language component has enhanced all of this by often taking the discussions to another level based on student understanding of the Chinese words relevant to the clinical situations. At this point they are therefore much more clinically astute than the average first year acupuncture student. But will this difference still be measurable at the end of three years? We believe it will be so, but it will be necessary to develop some mode of evaluating outcomes to ascertain how the students are doing at the time of graduation and later on in their careers. For now, our experience with this group compared to a decade of experience teaching students in the standard system indicates that this approach is a clear improvement for most students.

There are some cautions that need to be expressed. Though it is a relatively simple idea to prepare future practitioners by having them work closely with experienced practitioners in the clinic, there are some important differences in learning and teaching styles that need to be remembered. First, for students, because the learning is almost all hands-on, there is a stronger responsibility to do the "book-learning" at home and come prepared to clinic and classes for practical applications. There is still a great deal of memorization that must go on in acupuncture and herbs. The difference is that it is expected that the students will do this without the benefit of also hearing it in lectures in a class. There is also an increased need for comfort with uncertainty. Problem-based learning engenders an atmosphere where students have to foray out into their personal unknowns to seek answers for clinical problems. There are often no clear answers; furthermore the faculty responsibility is not to provide explicit answers, but to facilitate the learning process. This can lead to some anxiety.

Also, interestingly enough, the dynamics of student interactions with each other become more potent. For students, the small group settings require heightened communication skills, respect for others and a sense of professional conduct which is not necessary to such a degree in a large class lecture setting. Administratively, careful attention must be given to admissions, student morale and individual student needs.

For instructors, the shift is from being prepared for a particular focus which is presented in lecture, to being open to a free-ranging discussion about a clinical condition in which there needs to be an openness to critique and disclosure of limits of clinical knowledge. Part of the vitality of this program is the comparing and contrasting of practice approaches and the discerning of the limitations and benefits of each. This can only be done harmoniously when faculty are willing to be honest and self-critical about their own knowledge and practice. Given the emphasis on discussions, labs and clinical settings there are risks involved for instructors in regards to class management and control. These must be considered carefully before a school adopts this approach to education.

But on the whole, we believe there is already sufficient evidence that a problem-based, patient-centered approach to education is more in harmony with practicing traditional Oriental medicine than the conventional educational model used by most acupuncture schools in the United States. Ironically, it may turn out that the effort by western medical schools to create educational structures more attentive to student and patient needs may just be the lesson acupuncture schools need to be more effective in training Oriental medical practitioners.

For discussion or additional references contact Paul Karsten at the Seattle Institute of Oriental Medicine, 7106 Woodlawn Avenue NE, Seattle, WA 98107. (206) 517-4541.