Meditation on the New Media and Professional Education

Joseph V. Henderson, MD
Interactive Media Laboratory
Dartmouth Medical School
Hanover, NH 03755

Marshall McLuhan said a great deal in his life, some of it overblown rhetoric, much of it profound. In talking about "new media" he emphasized that we need to be careful about using them, that we urgently need to understand them and how they work. The problem is that new media can be so powerful and all-encompassing that they overwhelm. Every new medium creates its own environment, which can affect our perceptions in a "total and ruthless" fashion. The new medium does not just add itself to what already exists; it transforms it. The computer, for example, has to be viewed in the context of the data networks, the methods of communicating and viewing information, the reduction of the world to that which can be conveniently represented in binary form — the all-encompassing changed habits and situations it has brought with it.

McLuhan was not speaking of The New Media as in this book, but any extension of ourselves that is novel and is adopted, the automobile as much as the telephone and television. However, he foresaw a good deal of what we can include in our current discussions of New Media, in particular world-spanning communications networks (firmly establishing his "global village") and personal, portable computers that help us mesh our personal experience with the experience of that "great wired brain of the outer world."

Today we can add what many are calling interactive multimedia, combining computers and media (text, still and moving images, sound), yielding tools that can focus our perception and facilitate understanding. And further along the same continuum, but with the same purpose, lies virtual reality, providing a visual (ultimately audible and tactile) sense of immersion in a three-dimensional environment that is completely computer-generated.

This chapter discusses the New Media and how they might be used in the education of health professionals, written from the dual perspectives of an educator who designs, produces, and uses New Media programs and of an epidemiologist who has wrestled with the issues of building a large, multimedia data base. The chapter contains views that are more personal and philosophical, and less technical or research-based. McLuhan pointed out that the effects of a new medium are powerful, but they are usually so pervasive that they are insensible. The effects of the New Media are already powerful and pervasive, and they will grow much more so. My goal is to help make them a bit more sensible.

First, a prιcis will establish a broad context for considering New Media in health education. Following this, a brief critique will summarize some current thinking on medical education as it relates to health care reform; there is an emphasis on the education of generalist care providers. Finally, a more specific discussion, with brief diatribe, will consider the two predominant — and countervailing — approaches to using New Media in education: "drill and practice" for rote memorization of facts on the one hand and, on the other, unguided, unstructured "exploration and discovery" meanderings through collections of multimedia information. A third alternative will be proposed, based on the ideas of Dewey and Schön; I advocate use of New Media to provide guided experiences and reflective practicums that can help professionals integrate theory-based "facts" with clinical practice, to help them learn the "art" of providing care, and that can help prepare them for the real, "swampy" world of professional practice.

Context: The Information (Knowledge) Age

As you've undoubtedly heard, we're entering what many call the Information Age. Evidence for this abounds: headlines, speeches, and no small amount of hype declare the imminent arrival of Information Superhighways; 500-channel, video-on-demand, interactive TV set-top boxes; Interactive Multimedia, etc. A national information infrastructure, capable of transferring data at rates in the gigabits per second range is starting really to be built, funded through an amalgam of public and private sources. CD-ROM-based interactive computer entertainment, educational, and informational programs are starting to roll off the presses, sales of CD-ROM players are soaring and publishers are scrambling to define and take advantage of the immediate market for these new electronic media — and, more long range, to develop programming and publishing paradigms to be ready for this Superhighway they've been hearing about.

Business leaders and pundits are more and more talking about a new world economy based on information as a main product (even when hard goods are involved), accompanied by major reorganization and relocation of workers; telecommuting will become the norm, they predict, with central offices more a club-like setting for social contact; workers will leave cities and move in increasing numbers to rural communities. Leaders in health care are starting to regard health information as a useful and marketable product of the care system, and to advocate the use of New Media to support decisions made by recipients of care as well as providers.

So, we're leaving the Industrial Age and entering the Information Age or, as some prefer it, the Knowledge Age (assuming that information is only of benefit if you know something useful after you've had a chance to mull things over). In fact some think in terms of a hierarchy with data at the bottom, somehow being processed into information, then into knowledge. Given current and emerging technologies, data can be put together in fairly automatic ways, with bits of data correlated and packaged for viewing. To get to knowledge, people usually have to get involved and start thinking about what these correlated bits mean, and various technologies can assist that, from statistics and simple tables and graphs to complex, multi-dimensional, "scientific visualization," computer displays. Others say that the knowing comes in the application of information, usually in actual practice. but more and more in computer-based simulations.

Which leads to another step in this hierarchy, moving from having knowledge to achieving wisdom. A more difficult step. I think that wisdom involves bringing the perspective of personal experience, applying knowledge — not in an arms-length and abstract way — but with a deeper understanding of how that application can affect our world and the people in it (however we define that world — our practice, our region, our nation, etc.). Technology might be used to help us bridge the gap between having information and having a personal experience of it, for example by providing simulations that can actually improve on the experiences that real life allows. But this must be carefully done and failure adequately to simulate important aspects of the practice world is a danger — and a likelihood — given our current understanding of how to apply these technologies (for more on this see Education, below). On the other hand, technology has already widened that gap, promoting a population that prefers to experience the world vicariously via the orthicon tube, a world filtered, by and large, to emphasize the sordid and the sensational. And, again, we're on the threshold of that new "information infrastructure." The impact of so much information, so much programming seeking to claim our attention and our dollars, so much life-forming experience (however vicarious) will be multiplied by sheer numbers — and by the very nature of the interaction; and the impact will be enormous.

But I digress.

Three Elements of the New Media: Desiderata and Dangers

The New Media can be viewed as a convergence of — and synergy among — three technologies: computers, electronic media, and communication networks. Here are some of the salutary uses — and dangers — that might be found in these.

Computers

Computer technologies can assist us in gathering, storing, retrieving, displaying, analyzing data, to get some information, perhaps some knowledge. Those data can be more than simply text. For example, x-rays and scans, microscope slides, even recordings of surgical procedures (many of which are already performed in a video environment) could be accessed. New methods of visualizing data, including interactive statistical graphics and "scientific visualization" techniques, could be applied to help navigate, explore, and analyze complex, multimedia data sets. Further, much of this work could be automated, with intelligent "agents" — software routines with a persona — acting on behalf of an analyst or policy-maker to ferret out salient features of a data set, cases worthy of audit, deriving outcomes-related knowledge to feed back into the care system in an efficient and very timely way. Educational interventions can be planned, even constructed, based on the raw and reduced data and information that have been gathered and analyzed. And these interventions can employ computer-generated interfaces to information AND experiences using multiple media. A result can be an effective and efficient, tight feedback loop connecting clinical practice, research into the outcomes of care, and devising outcomes-specific educational interventions that are targeted to the individual care provider to positively affect performance.

On the other hand, there are problems in adequately formulating questions and sampling the world of clinical experience in ways that include important phenomena, particularly subjective ones; in ensuring that those data we do gather are sufficiently complete and accurate, that the analyses are appropriate and well-understood; that the information and its application are well-considered. . . and tempered with human caring and judgment. There is great danger in not keeping these requirements — and the limitations on being able to satisfy them — firmly in mind.

"In a culture in which the machine, with its impersonal and endlessly repeatable operations, is a controlling metaphor and considered to be an instrument of progress, subjectivity becomes profoundly unacceptable. Diversity, complexity, and ambiguity of human judgment are enemies of technique."
"[B]ecause the computer [is treated as if it] "thinks" rather than works, its power to energize mechanistic metaphors is unparalleled. . . We have devalued the singular human capacity to see things in whole in all their psychic, emotional, and moral dimensions, and we have replaced this with faith in the powers of technical calculation"(Postman, 1992).

The hazards are amplified by the rapidity and efficiency with which such a mechanized system can "turn around" data, qualities that we generally value and wish to augment. A tendency to automate without due regard to quality and meaning, combined with the tightness of the feedback loop, can result in a system that goes rapidly out of control.

Media

In the world of entertainment, and to a lesser extent in education and training, the craft of creating impactful, engaging presentations has been honed to a very fine edge. Sounds, video, computer animations can make for very memorable experiences. We now have a mature art and method of recording, or creating, human stories that can — in the best cases — convey meaning and insight, even engender wisdom. Combined with sound pedagogy and married to computers, the art and technology of media can provide interactive learning that is memorable, that combines the best that education and media have to offer, to help make complex concepts clear and to bring the complexities of real human experience more immediately to the discussion than usually happens in the typical medical or nursing school lecture hall.

On the other hand, these powerful tools have often been used inappropriately to persuade rather than to educate; subtle or blatant, biased information and propaganda of various shades — commercial, political, or for the "public good" — are widely used to shape public and private decision-making. Health care, subject to powerful economic forces and vested interests, is no stranger to these kinds of bias. Consumer health information services are likely to become a lucrative market, and network capacity will initially create a programming vacuum that many commercial interests will seek to exploit. And with interactive technologies the presentation can be even more powerful. Great care must be taken to assure that information provided to decision makers, be they clinicians or patients, is as free of content and framing bias as possible; it's unlikely that this will happen without vigilance on the part of public-interest agencies.

Use of media tends to require special talent and expertise. A very close collaboration among educators, health care experts, and media experts is required, a need that intensifies when large issues of content accuracy, framing, presentation, and balance must be dealt with, as commonly occurs in health education. Unfortunately, this close collaboration is a rare event, usually due to a lack of common experience and vocabulary among the development team, exacerbated by the frequent unavailability and competing priorities of busy clinician content experts. Finally, it is frequently difficult or impossible even to view, much less evaluate, complex, computer-based, multiple media programs; fully exploring numerous pathways that can branch in numerous ways and reviewing numerous optional segments is a labor that few, if any, outside reviewers or students will endure or do well.

Communication Networks

As we've heard, there is an inexorable push to establish high-bandwidth digital networks capable of conveying information existing in multiple media, including motion video and sound. Moreover, these networks will be interactive, so that passage of information is no longer passive and one-way. The possibilities for health care are enormous, particularly for citizens and practitioners in underserved areas (e.g., rural and inner city). Important applications include those that will help ease the administrative burden of the rural practitioner; those that will assure completeness, accuracy, and ready availability of an individual's health record; those that will provide consultative services at a distance to avoid unnecessary travel and hardship to the rural citizen and his family, and to support our rural practitioners; and those that will help the rural practitioner feel part of the larger health care community in our region; and to provide educational services tailored to the performance and needs of the practitioner.

However, there is a fair likelihood that certain populations — such as rural citizens — will not have this service any time soon. The cost of putting up satellites, and their limited bandwidth, combine to require physical links to rural communities; this is likely to be left to the carriers who have few incentives to expend resources for what they consider a limited market. New regulatory environments will obviously play a role, but there is reason to fear that there will be fewer, rather than more, incentives for rural "datafication." Universal access, something we've taken for granted with telephony and electrification, may not be there. Many may only have a dirt road, or no road, leading to the information superhighway. Though a longer-term trend to dispersion of the workforce into rural America may eventually lead to rural services, the short-term outlook is very unsettled. This is very much a topic for discussion and activism.

And Finally. . . Education

Why Health Education Reform?

Here are two of many reasons to consider dramatic change in the way we train our health care providers. The focus is on medicine, but these concerns are generally applicable to education in the health professions.

As discussed elsewhere in this volume, health care reform is impossible absent an expanding role for — and increased numbers of — generalist physicians and primary care alternatives such as nurse-practitioners. The technology, techniques, and venue of medical care are changing rapidly as our society is changing, and the exercise of reform will undoubtedly accelerate the rates of change. There is concern that the current model of medical education is not able to accommodate — much less assist — these changes (Gastel and Rogers, 1989).

These criticisms and concerns stem in large part from an historic and current domination of medical education by acute care hospitals, which focus on the 5% of patients with the most acute pathology, at the expense of the 95% of patient care that occurs outside the hospital. The current, heavy emphasis on inpatient and sub-specialty care in clinical medical education is inappropriate today and likely to be so in the future (Boufford, 1989).

"Just as the health care delivery system in the United States has been dominated by acute care hospitals, so, at least since the 1920's, has organized medical education. . . Most of clinical medical education and of basic science preparation for it have focused on the 5% of medical practice handling patients with the most acute pathology. The inpatient enterprise has been a relatively well-oiled machine, with an intense sense of urgency, considerable dominance of subspecialists applying their substantial expertise to narrow patient problems for which the student sees the effectiveness of a high-technology intervention.
"Meanwhile, the student's exposure to the other 95% of medical practice has been less than satisfactory. The occasional rotation in an ambulatory care setting is often in an overcrowded, high-volume block-appointment clinic (a relatively chaotic environment for the first-time visitor) or in a private doctor's office (where student participation typically is rather restricted).
"Applying the model used for training in inpatient medicine — block rotations — to the ambulatory setting leaves the student with a marginal role to play in a series of first encounters that involve lengthy interviews, physical examinations, and problem formulations, and for which the student sees no outcome, since he or she leaves the rotation before the patient returns. The alternative is a series of acute walk-in encounters where a focal complaint is quickly treated and the student has no knowledge of the patient's past or future. In this setting, the student has a low sense of mastery and may not perceive the efficacy of medical care. Finally, many students find the ambulatory setting less attractive than the inpatient services because physicians are less dominant, other health professionals play important roles, and patients have considerable autonomy. The primary care physician focusing on transaction-oriented medicine greatly dependent on patient participation certainly can compare unfavorably with the procedure-oriented inpatient specialist whose action appears to be the sole reason for patient improvement.
Shouldn't we shift clinical preparation to better reflect, and prepare the physician for, the 95% instead of the 5% of medical practice?"

There is also a disintegration of medical teaching and learning, with basic science subjects (e.g., anatomy, physiology, biochemistry) usually taught as isolated facts and with little effort to make them clinically relevant. This is typified by the coming practice of separating the learning of basic, factual knowledge from acquiring clinical knowledge and skills, and spending two "preclinical" years to accomplish the former (Barrows, 1989).

"'Preclinical,' is, nevertheless, an appropriate term for the first two years, as the student is in a classroom listening to a series of lecturers from isolated disciplines disgorge voluminous information, facts and factlets, that the student knows will have to be disgorged on written examinations that challenge mostly the cognitive process of rote memorization, not the process we would like to see all that valuable information hooked up with [clinically applicable problem-solving and decision-making]. Analysis, synthesis, and application of principles to patient-related issues are rarely assessed. The half-life of information learned through memorization is so short that cramming and review are essential before each examination -- yet somehow the examination score is felt to indicate that the student has learned. . .
"Integrated courses do not integrate information in the student's mind, as they still treat each discipline in a separate compartment; the integration is only in the calendar. . . No wonder the student arrives in the clinical years remembering little from the basic sciences, and that the information left in long-term memory is not enmeshed with the clinical reasoning process or recalled in association with patient encounters."

To address these two problems, health care educational reform must include a restructuring of health education to decrease dependence on hospitals and to increase opportunities to gain experience in providing comprehensive and longitudinal care. And, not incidentally, it should assist in recruiting more generalist practitioners by providing experiences and role models for students that will make the generalist "specialties" more appealing. In the best of worlds, students would have highly meaningful educational experiences that are available to all on demand, that are engaging and intellectually stimulating, and that teach more than "facts." In the best of worlds, the experiences would help the student develop not only knowledge, but the wisdom and the "artistry" that is seen in the best practitioners.

Tall orders. I believe that these are goals which can, at least partially, be addressed by applying the New Media. But they must be applied well — with artistry and wisdom.

The Need for Reform in the Use of New Media

Sitting in on a discussion among New Media technologists — be they in computing, media, communications, or education — can be a heady experience. Visions of global interconnectedness, on-line societies and virtual spaces for work and learning, interactive interface designs for knowledge exploration and navigation, virtual human bodies on which to practice surgical technique, virtual data and virtual reality spaces that can lead to more immediate understanding, these concepts are among many that excite and strain our ability to imagine. There appears to be no dearth of technological ideas about developing and applying the New Media.

What we do lack, however, is a solid core of educational ideas about how to use the New Media to help people learn. This is not unique to New Media, of course, but the application of these technologies — and the large sums of money often spent on doing that — accentuates the issues. I don't presume to offer a comprehensive discussion of these issues, nor to be prescriptive. I do wish to emphasize what I see as the greatest potential strengths of the New Media: to provide educational experiences that are optimally suited to the individual; experiences that promote reflective thinking and practice, and the development of professional "artistry;" experiences that emulate — and deliver on demand — the best that great teachers have to offer. In doing this, I will draw on the work of two educational theorists: John Dewey and Donald Schön.

Experience and Education

At a recent educational technology meeting, a woman who controls a substantial training budget viewed an interactive video program that was heavy on "exploration" and "hypermedia." She was appalled at the lack of pedagogical structure and about the apparent lack of intent toward established instructional goals and objectives.

At another meeting, the dinner speaker gave a talk on technology in education, culminating with the notion, "We should do less teaching and allow more learning." The student should be encouraged to learn mainly through exploration and discovery. Provide an interesting collection of information presented in a variety of media, provide a means for exploring the information, and stand back. Other than as a "coach" or facilitator, the teacher should have little or no direct role in the process.

Both individuals had strong views about what constitutes New Media and how they should be used. Both views have some validity. Together, these views guide most New Media educational programs now being produced. Both views are limiting.

They are limiting because they are primarily concerned with ideology and not as much on what is accomplished in the mind and spirit of the individual. And they are mired on opposite sides of the same ideology. By and large, one group is intent on retaining a traditional, assembly-line, goal-based model of education, while the other is intent on avoiding it.

A result of these limiting views is educational New Media programs that are mis-educative. Many of these programs perpetuate a "drill and practice," rote approach to education. Others have students "constructing" knowledge without providing a sequence of concepts that can lay a foundation and create a framework for understanding. Either type may help a student in special circumstances. Neither is generally useful or effective.

There are other ways of approaching this question, setting aside labels and ideology (one hopes). The question is appropriately framed in terms of teaching and learning, and how New Media might help individuals and groups to learn about meaningful things — in ways that matter to them. There are two important aspects to doing this, both derived from the work of John Dewey. The first is the role of multimedia in providing experiences for learning; the second is broadly concerned with using multimedia to promote "reflective thinking."

John Dewey is arguably the most influential of American philosophers and perhaps the greatest educational theorist of our time. A hallmark of his thinking is "the organic connection between education and personal experience" (Dewey, 1963, p.25).

Experiences can have profound effect on what is learned and how learning occurs. Further, experiences occur regardless of the pedagogical approach taken. With traditional approaches, the experiences can be mis-educative (Dewey, 1963, p. 26).

"It is a great mistake to suppose, even tacitly, that the traditional classroom is not a place in which pupils had experiences,. . . [but these] were largely of the wrong kind. How many students, for example, were rendered callous to ideas, and how many lost the impetus to learn because of the way in which learning was experienced by them? How many acquired special skills by means of automatic drill so that their power of judgment and capacity to act intelligently in new situations was limited? How many came to associate the learning process with ennui and boredom? How many found what they did learn so foreign to the situations of life outside the school as to give them no power of control over the latter?"

Dewey is equally critical, however, of so-called "progressive education" as it is widely practiced. He has been falsely accused of advocating that educators not be overly concerned with teaching and structure, and that they promote "experiential" learning by providing experiences that are largely random and informal. On the contrary, he views lack of a teacher's guidance and lack of deliberate structuring of content as "really stupid. For it attempts the impossible, which is always stupid; and it misconceives the conditions of independent thinking" (Dewey, 1926). He counsels against the development of new educational approaches mainly in reaction to the perceived ills of earlier ones (Dewey, 1963, pp. 20-21).

"The general philosophy of the new education may be sound. . . There is always the danger in a new movement that in rejecting the aims and methods of that which it would supplant, it may develop its principles negatively rather than positively and constructively. . .
"Take, for example, the question of organized subject-matter . . . The problem for progressive education is: What is the place and meaning of subject-matter and of organization within experience? How does subject matter function? . . . A philosophy which proceeds on the basis of rejection, of sheer opposition, will neglect these questions. It will tend to suppose that because the old education was based on ready-made organization, therefore it suffices to reject the principle of organization in toto, instead of striving to discover what it means and how it is to be attained on the basis of experience."

Providing experiences of high quality is key to success in education. Quality has two aspects: an immediate, apparent one of how accessible, enjoyable, and engaging the experience is, and the less easily determined one of the effect the experience has on the learner. Effective education lays a foundation for understanding and builds upon it. The resulting structure supports later consideration of information by the student. There are clear, appropriate and impactful examples, so that the student can become involved with concepts viscerally, as well as intellectually. The student is challenged to inquire, to manipulate and build ideas. "Inquiry-oriented learning theorists from Dewey to Bruner and the modern cognitivists view instruction as a way of encouraging students to become active constructors of knowledge, of knowledge as open and evolving, of academic learning as exciting and vital, and of teaching as a stimulus to curiosity and a model of inquiry. . ." (Seal-Wanner, 1988).

This brings us to Dewey's idea of an experiential continuum possessed by each individual, defined by his or her unique set of experiences and associated learning -- in all aspects of life, not just the school. That continuum uniquely determines what further experiences encourage an individual's intellectual growth. It defines the opportunities for learning for that individual at that moment. At best, an educational experience promotes worthwhile future experiences: "Wholly independent of desire or intent, every experience lives on in further experiences" (Dewey, 1963, p. 90). As Dewey quotes the poet,

. . . all experience is an arch wherethro'
Gleams that untraveled world, whose margin fades
For ever and forever when I move.

If each student is different, and each is changing over time, it is clear that traditional, "lock-step" approaches to education cannot provide experiences that are well- suited to learning. On the other hand, simply providing access to experiences without providing guidance is also to be avoided. The best course is one taking the individual characteristics of the student into account, while structuring his or her environment and contexts for learning in ways that build positively on past experiences. It is precisely that course that allows us to escape the limitations outlined at the outset.

Dewey acknowledges that this is more easily said than done, and that one barrier to adoption of these principles is the difficulty in planning, developing, and implementing methods to apply them (Dewey, 1963, pp. 89, 90).

"The educational system must move one way or the other, either backward to the intellectual and moral standards of a pre-scientific age or forward to ever greater utilization of scientific method in the development of the possibilities of growing, expanding experience. . .
"The only ground for anticipating failure in taking [the latter] path resides to my mind in the danger that experience and the experimental method will not be adequately conceived. There is no discipline in the world so severe as the discipline of experience subjected to the tests of intelligent development and direction."

And here lies a major sticking point. We haven't yet established methods for developing sequences of educational experiences that educate and move, that make learning meaningful and memorable. There are, of course, great teachers and they've been around for a very long time; but we don't really know what makes them so effective. And there are theorists, but few who actually apply these theories. Some educators, and some New Media developers, appear to have a natural ability to make progress toward Dewey's ideal. They're the exception.

As with education in general, this is the key issue in the application of New Media in professional education: whether an ability to craft life-forming "experiences subjected to the tests of intelligent development and direction" will remain the province of a few developers and great teachers, or whether we will we be able to devise proven, replicable, and learnable methods more generally to develop educational experiences that meet Dewey's ideal. (An alternative, related question is whether the New Media might be applied as a way of "channeling" the best that great teachers have to offer, but this begs the same issue: how best to do it.)

Nevertheless, with New Media it is today possible to construct experiences that are engaging (even gripping), realistic, and comprehensive in dealing with complex issues (Henderson, 1990, 1991). Students can have vicarious experiences of a wide variety, limited primarily by the imagination and budgets of the developers. Moreover, having expended the effort in their construction, these programs are readily available at any time and nearly any place, with the quality of the experience known and, ideally, of high quality. If carefully prepared to be accessible to the average teacher and student, these approaches may provide a means to bring Dewey's ideals to the average student in a widespread way. If properly applied, New Media could serve as a medium for students and teachers alike to gain access to a world of appropriately structured, vital, growth-enhancing experiences.

Reflective Thinking, Reflective Practice, and Professional Artistry

"The artistry of painters, sculptors, musicians, dancers, and designers bears a strong family resemblance to the artistry of extraordinary lawyers, physicians, managers, and teachers. It is no accident that professionals often refer to an "art" of teaching or management and use the term artist to refer to practitioners unusually adept at handling situations of uncertainty, uniqueness, and conflict." (Schön, 1987, p. 15)

Most of education today places great emphasis on memorization of facts and theories, justified to large extent on preparation for standardized "tests of knowledge." The "recitation" (orally or through multiple choices) of abstract, theory based "knowledge" is part and parcel of formal education in most of the world today, whether in grades 4, 12, or 18.

This situation goes directly to habits of thinking, learning, and acting and to how these habits limit opportunities for growth and real-world problem solving. By and large, in education we approach the world as modern, "scientific" thinkers, believing it to be amenable to abstraction — and containing deterministic problems with clear, textbook solutions. There is little, if any, regard paid to the particular case, nor to the "artistry," if you will, of framing problems, formulating and implementing solutions, estimating and improvising while dealing with real-world, indeterminate situations.

And students mostly buy into this abstract, deterministic view of the world and how to deal with it. They're rewarded or penalized according to their ability to produce answers, either through recall of memorized facts or through solving problems that almost invariably have clear answers. Some students are "successful" and move up the academic ladder; others aren't and drop out, mentally if not physically. As a result of this "recitation" approach to learning and thinking, many — perhaps especially those climbing higher on the academic ladder — can be ill-prepared for the real world of human experience. This extends to education for the professions; we don't do a very good job teaching the "art" of professional endeavor.

Reflective Practice and Professional Artistry : Donald Schön writes about education from the viewpoint of practice in professions such as medicine, law, business, engineering, teaching. Schön (1987, p.3) contrasts the high ground of "manageable problems [that] lend themselves to solution through the application of research-based theory and technique" with the swamp of "messy, confusing problems [that] defy technical solution."

"The irony of this situation is that the problems of the high ground tend to be relatively unimportant to individuals or society at large, while in the swamp lie the problems of greatest human concern. The practitioner must choose. Shall he remain on the high ground where he can solve relatively unimportant problems according to prevailing standards of rigor, or shall he descend into the swamp of important problems and non rigorous inquiry?
"The dilemma has two sources: first, the prevailing idea of rigorous professional knowledge, based on technical rationality, and second, awareness of indeterminate, swampy zones of practice that lie beyond its canons."

Schön goes on to point out that outstanding professional practitioners, those who deal well with the swamp, aren't generally said to have more knowledge than others; instead, they're described as having more "wisdom," "talent," "intuition," or "artistry." But, he says, these are commonly regarded as junk categories, as phenomena that aren't amenable to "scientific" tests of rigor or relevance; as a result, professional education believes it cannot adequately deal with them. He disagrees.

"On the basis of an underlying and largely unexamined epistemology of practice, we distance ourselves from the kinds of performance we need most to understand. . .
"The question of the relationship between practice competence and professional knowledge needs to be turned upside down. We should start not by asking how to make better use of research-based knowledge but by asking what we can learn from a careful examination of artistry, that is, the competence by which practitioners actually handle indeterminate zones of practice. . ."(Schön, 1987, pp. 13-14)

Schön describes "artistry" as a kind of intelligence that is inherently different from, but essential to the exercise of, standard professional knowledge.

"In the terrain of professional practice, applied science and research-based technique occupy a critically important though limited territory, bounded on several sides by artistry. There are an art of problem framing, an art of implementation, and an art of improvisation — all necessary to mediate the use in practice of applied science and technique. . ."(Schön, 1987, p. 13)

Schön raises and addresses these deeper educational questions: Can any curriculum adequately deal with the "complex, unstable, uncertain, and conflictual worlds of practice?" Can anyone, having studied and described it, teach "artistry" by any means?

Several educational theorists from Dewey to Schön have emphasized the importance of reflective thinking in education. Dewey (1933, p. 3) describes reflective thinking as "the kind of thinking that consists in turning a subject over in the mind and giving it serious and consecutive consideration." He elaborates:

". . . reflective thinking, in distinction from other operations to which we apply the name of thought, involves (1) a state of doubt, hesitation, perplexity, mental difficulty, in which thinking originates, and (2) an act of searching, hunting, inquiring, to find material that will resolve the doubt, settle and dispose of the perplexity." (Dewey 1933, p. 12)

Reflective thinking, in other words, is the best approach to indeterminate questions and problems, problems that are complex and messy.

Extending this idea, Schön develops a concept of reflection-in-action, which is distinct from another concept, knowing-in-action. Knowing-in-action applies our existing knowledge to expected situations. Reflection-in-action comes into play when a situation that develops falls outside the boundaries of what we've learned to consider normal. That is, we're surprised by a development in the situation. Surprise leads to reflective thinking as Dewey has outlined; we embark on a process of critical examination of the situation, framing of the problem, on-the-spot information-gathering (experimentation) to explore the new phenomena. The experimentation may work, yielding expected results, or it may lead to surprises that call forth additional cycles of reflection-in-action. Schön acknowledges that this is idealized; however, he feels that here lies a phenomenon that sums up the elusive "artistry" discussed above. Reflective practice is professional practice that uses reflection-in-action to deal with problems "in the swamp." The phenomenon is subject to study. Moreover, Schön proposes that reflective practice can be learned through exercising reflection-in-action, and that professional education can and should provide opportunities for doing so. (Dewey, of course, advocated doing this throughout the course of learning and growth, from the earliest years.)

Reflective Practicums and the New Media: Schön argues eloquently for the use of "reflective practicums" to promote development of reflection-in-action. He describes the reflective practicum as

". . . a setting designed for the task of learning a practice. In a context that approximates a practice world, students learn by doing, although their doing usually falls short of real-world work. They learn by undertaking projects that simulate and simplify practice. . . The practicum is a virtual world, relatively free of the pressures, distractions, and risks of the real one, to which, nevertheless, it
refers. . . It is also a collective world in its own right, with its own mix of materials, tools, languages, and appreciations. It embodies particular ways of seeing, thinking, and doing that tend, over time. . . to assert themselves with increasing authority." (Schön , 1987, p. 37)

New Media can be used to create effective reflective practicum experiences. Carefully constructed, replicable, readily available, interactive systems can provide complex and highly involving simulations of real-world situations. An example is a program produced for the Navy, Regimental Surgeon.

New Media and Reflective Practicums for Health Education - an Example:

As noted previously, much of medical education takes the high ground, and avoids the indeterminate problems of the swamp, particularly the 95% of clinical practice outside the hospital. This is not to say that theory-based knowledge has no value. It clearly does. However, the knowledge must be applied in the real practice world if its relevance is to be seen.

An example "in spades" of this problem, one that highlights these issues (and one that, conveniently, has been addressed using New Media) is the plight of the military physician. He is educated in one profession (medicine) and must, on demand, work in another profession (the military) with little or no preparation. This can be an enormously disorienting experience, involving very complex interactions among many factors about which he has little knowledge, and over which he has little control. There are conflicts of values between the respective professions, with military values nearly always prevailing. In this environment the military physician is expected to know his main profession and perform at the level of an expert; in reality he is simply not prepared to deal with operational medical issues that, almost without exception, fall into the swamp category.

Regimental Surgeon (Henderson, 1990) is an interactive multimedia program that strives to provide a reflective practicum experience according to these criteria. The program is intended to foster facility in applying reflection-in-action in the professional activities of the student, and to promote the development of new knowledge and attitudes through an exercise of reflective practice in a multimedia "virtual world." It teaches through experience by putting the learner "on the job," in this case as Regimental Surgeon responsible for the health of 3,000+ men in a combat zone. The learner exercises "knowing-in-action" in more routine medical matters, but is frequently challenged by a series of surprises designed to throw him into "reflection-in-action." The user can enter, explore, discover facts, and formulate rules and principals; this, much as one would in real life. The program is intentionally entertaining as well, placing the learner within the context of a story whose evolution and outcome depend on the decisions made by the learner. Numerous themes are developed simultaneously, any of which can be developed and emphasized in discussions outside the context of the program itself.

The program has the following objective: given a hypothetical combat scenario involving U. S. Marine Forces, to provide, through simulation, experiences which will allow the learner to develop knowledge and skills needed to function as a staff medical officer. In the process, the learner is challenged to

  1. evaluate and define the medical threat (malaria) confronting Marine Forces in his unit.
  2. identify, plan, and implement the preventive medicine countermeasures which can reduce risk.
  3. communicate the urgency of those countermeasures to key commanders.

There are ten other facilitating objectives dealing with basic organizational, interpersonal, and medical aspects of functioning as a staff medical officer.

The program is organized somewhat as an 'Adventure' computer game, where various locations can be visited. In such a game, the locations can contain treasures and/or characters with which limited interactions can occur. In "Regimental Surgeon" the locations are various elements and units of the Regiment (Headquarters and the three Battalions), Division Headquarters, and medical support units (hospitals); the "treasures" are facts which can be obtained from a variety of sources in a variety of ways: epidemiologic surveys, reading documents, questioning individuals, looking at blood smears. The learner is required to assemble the facts he's acquired, draw conclusions, and, based on these, inform and make recommendations. Characters can facilitate or obstruct this process, or act as mentors, depending on the learner's actions as he transverses the program.

The program begins with an Opening Sequence which sets the scenario, introduces most of the main characters, and establishes principal rules of the game. It is also intended to engage the learner and motivate him to continue and complete the simulation.

Midgame contains the body of the program. There are 40 scenes of two types: Initial and Developmental. Initial scenes are those seen by the learner on his first visit, while developmental scenes further plot development and reflect learner's progress to that point. During development there are up to three encounters with each of eight main characters (of a total of 32 speaking parts). For seven of these characters there are different versions of the encounters, encouraging/friendly or distracted/distant or unfriendly, depending on how the learner has handled his job so far. Each character, representing main teaching points, has a different view on the learner's job and how he should be doing it. Response of the other principal character (the chaplain) is constant for each of the encounters, though his dialogue depends on the learner's previous choices.

Epilogue is a coda to wrap things up. If the learner has managed to keep Division out of things and has delivered his briefing, he gets a chance to back up his assertions with evidence; feedback depends on completeness of investigation and plan. If Division did get involved, then a different ending is seen.

Since there are many ways to transverse the program, the learner can gather information in ways and to an extent that is variable (the role of chance is minimized by placing critical information redundantly). For example, the learner may choose to play a very active role, traveling personally throughout the command, gathering needed information and completing the program in a very comprehensive (perhaps too comprehensive) and successful way; or he may delegate some of the work and play a less active role, and still be successful; or, he could choose to stay in his tent, or sleep, with an unsuccessful outcome. In each case the learner experiences the consequences of his actions, and learns whatever he decides is the knowledge contained therein. Thus, instructional content is variable in two ways: it depends on the path chosen by the student and it depends on his interpretation of the events encountered on the path.

Finally, representing contained information is an interface design issue addressed by what some call a "concept map." Concept maps in "Regimental Surgeon" are literally a series of nine animated maps to provide a means of navigating through the physical, temporal, and concept elements of this reality. Upon reaching a location, the user is presented a "talk" menu allowing him to ask questions or read documents, blood smears, or tactical maps. A design goal that the interface be intuitive, i.e., its use not requiring additional instruction, was met in two ways: 1) by using logical design, in the sense that graphics and content are consistent and integrated with the reality portrayed; and 2) by incrementally increasing the complexity of the interface, starting with simple menus and adding features.

Unfortunately, we don't know if these educational goals have been realized, since there has been no study of the program in this regard. (This gets into another tangle of issues regarding evaluation that we will side-step here, thus perpetuating a very unfortunate practice to neglect this important issue.) The program has been widely disseminated and there are anecdotal reports that it was helpful in preparing some medical officers for duty in the Persian Gulf War. It is an early example of the use of New Media and virtual environments to promote reflective practice and the "art" of dealing with the swamp of professional endeavors.

Another Example: HIV/AIDS

Our laboratory has just completed a project titled HIV & AIDS: an Interactive Curriculum for Students in the Health Professions. This interactive multimedia program combines theory-based education concerned with factual knowledge with a series of reflective practicums consisting of simulated patient encounters. The goal is to cover all major aspects of HIV and AIDS, from the molecular level to the complex psychosocial, integrating the presentation of factual information with clinical application.

HIV & AIDS pays great attention to esthetics and the quality of media production and programming. Graphics interfaces are easy to use and responsive, 2- and 3-D animated graphics are used to help make complex concepts, such as HIV binding to CD4+ T-cells, clear and memorable. There are very moving — even riveting — interviews with real individuals, four with HIV and six care providers. Of the former group, two are married, one is a gay nurse, and one is a mother who lost her child to HIV. The program has approximately two hours of full-motion video and an additional two hours of audio to support voice-over text and graphics. There are numerous exercises and activities in which the student interacts with video, text, and graphics; the goal is to have students participate actively as they progress through the program.

The reflective practicum consists of a series of four encounters with a simulated patient, Laurie Matthews. Ms. Matthews is a young woman whom we manage from her initial, pre-test counseling visit, over a period of four years, to a final visit when she is diagnosed as having AIDS and is admitted for Pneumocystis carinii pneumonia. Learners are told that the patient is an actress. However, it is remarkable that most become very emotionally involved in her story, which unfolds in a series of disclosures; these, to some extend, are governed by the choices of the learner.

Each encounter consists of gathering clinical information from the patient, followed by a series of questions posed by Ms. Matthews to the learner. Interaction is via menus with varying numbers of choices. For each of these questions, the learner can obtain feedback and discussion of issues; this "mentor" function can be activated by the learner as desired. Though some questions require mostly factual explanations, all are concerned with the "art" of patient counseling and most involve complex issues in the "swampy" world of HIV practice: fears of death and rejection, guilt, relationships and marriage, pregnancy, non-compliance in medication and safer sex practices, ethical issues for the practitioner (framing, paternalism, patient autonomy).

New Media for Great Teaching?

There are, of course, data and information bases from which to learn; these will proliferate, become richer in content and media used, and become — electronically and conceptually — more accessible. And they will play an increasingly important role in health education. However, it is important to distinguish between these systems and New Media programs that are specifically designed to be educational, that do more than simply provide the information. In these programs, experiences are crafted — in the Deweyan sense — specifically to help people learn; in other words, they teach.

This view of a New Media program that "teaches" is somewhat out of favor; many prefer the data base, explore and discover model, as discussed previously. But this philosophy avoids or ignores the challenge and flat-out excitement that a great teacher and a wonderful sequence of ideas can bring to a child or adult who must learn about something.

The best teaching programs can accomplish much of what a great teacher can do. They can excite interest; explain clearly with great, even stunning examples; allow learners to manipulate, play with, and develop ownership of concepts; and provoke reflective consideration of them. For a majority of students, these don't happen simply by letting students "have at" a large, hypermedia data/information set, no more than letting them "have at" a library or museum.

This kind of New Media program, to be complete, should have two more things. First, they must have what Dewey calls "a career;" that is, they should give a strong sense of participating in a reality that has a past and present, and is going somewhere. In other words, it exists in time and space, if only in our imaginations. Second, the program should in some way enter and occupy a place in our hearts; there should be an emotional richness that speaks to our human caring. These can provide a unifying framework for a program's concepts and, at the same time, provide "information" that can't be codified, quantified, or computerized. That is, the human, rich, "swampy," non-deterministic stories of people and their situations can reveal the consequences of decisions made and actions taken, not simply their process.

There's nothing magical about doing this; we've been telling stories to pass on information, knowledge, and even wisdom for centuries. As we bring to bear increasingly sophisticated and complex technologies, we've been doing it with increasing levels of sophistication, complexity and — for good or ill — effectiveness. The danger lies in not exercising sufficient care in the application of these technologies, resulting in further fragmentation and sterilization of information, and isolation of the practitioner from those he or she would help. The promise is in providing educational experiences that transform our understanding of our world, of ourselves and others, and of the consequences of our actions. There's some wisdom in that.

References

Barrows, H. S., commenting on Wilson, M. P. The Clinical Teacher and the Learning Process: Toward a New Paradigm for Clinical Education. In Gastel, B. and Rogers, D. E. (Eds.) (1989). Clinical Education and the Doctor of Tomorrow (pp. 33-46). New York: The New York Academy of Medicine.

Boufford, J. I. Changing Paths and Places for Training Tomorrow's Generalists. In Gastel, B. and Rogers, D. E. (Eds.) (1989). Clinical Education and the Doctor of Tomorrow (pp. 67-80). New York: The New York Academy of Medicine.

Dewey, J. (1926) "Individuality and Experience." Journal of the Barnes Foundation, II, p. 4.

Dewey, John (1933). How We Think: a Restatement of the Relation of Reflective Thinking to the Educative Process, Heath: New York.

Dewey, J. (1963, orig. 1938). Experience and Education. New York: Macmillan.

Gastel, B. and Rogers, D. E. (Eds.) (1989). Clinical Education and the Doctor of Tomorrow.New York: The New York Academy of Medicine.

Henderson, J. V. (1990) "Designing Realities: Interactive media, Virtual Realities, and Cyberspace." Multimedia Review, (pp. 47-51).

Henderson, J. V. (1991) "Virtual Realities as Instructional Technology , Journal of Interactive Instructional Development," (pp. 24-30).

Postman, Neil (1992). Technopoly (pp. 118, 158)New York: Knopf.

Schön, D. A. (1987) Educating the Reflective Practitioner: Toward a New Design for Teaching and Learning in the Professions. San Francisco: Jossey-Bass.

Seal-Wanner, C. Interactive Video Systems: Their Promise and Their Potential. In McClintock, R. O. (Ed.) (1988),Computing and Education: The Second Frontier. (p. 23). New York: Teachers College Press.