Joseph V. Henderson M.D.
IML (Interactive Media Lab), Dartmouth College Medical School
joe.henderson@dartmouth.edu
http://iml.dartmouth.edu
The "Virtual Practicum": Correcting
Descartes’ Error With Computers?
Summary
This paper describes a virtual environment to improve clinical
education by providing a more comprehensive view of
medical education and clinical practice. For the most part,
Western medical education subscribes to a Cartesian world
view in which practice is viewed as technically rational and
mechanistic, addressable by the application of theory-based
facts and rules. This restricted model of health care largely
ignores the psychosocial dimensions of health and illness. It
does not prepare students to deal effectively with the real
“swamp” of professional practice, particularly in the majority
of cases where the variability of human behavior and human
situations plays a role. This “Cartesian error” may be partly
addressable using emerging methods of technology-based
learning, especially virtual environments that incorporate
these biopsychosocial aspects.
1
Introduction
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
Western sciences and humanities.”(Damasio, 1994). Descartes’ error, he
says, lies in separating mind and body, in allocating thought and emotion to
distinct domains. Rather, he says, the mind and body are inextricably
meshed. At lower levels the neuronal structures responsible for reason are
also responsible for processing emotions and feelings and regulating vital
body functions. These lower levels are in direct contact with nearly every
body system, “thus placing the body directly within the chain of operations
that generate the highest reaches of reasoning, decision making, and, by
extension, social behavior and creativity.”
Damasio asserts that Descartes’ error is symptomatic of a world view that
has come to dominate Western medicine, to its detriment. The “Cartesianbased neglect of the mind” has impeded the effectiveness of diagnosis and
treatment—and, I would add, prevention—of human disease.
“For the past three centuries, the aim of biological studies
and of medicine has been the understanding of the
physiology and pathology of the body proper. The mind
was out, largely left as a concern for religion and
philosophy ...
The result of all this has been an amputation of the concept
of humanity with which medicine does its job. It should not
be surprising that, by and large, the consequences of
diseases of the body on the mind are a second thought, or
no thought at all. Medicine has been slow to realize that
how people feel about their medical condition is a major
factor in the outcome of treatment.”
For the most part, medical education subscribes to a Cartesian world view
in which practice is viewed as technically rational and mechanistic,
addressable by the application of theory-based facts and rules. This view
neglects forms of knowledge that are less easily characterized, quantified,
and “taught,” such as empathy, intuition, and what Donald Schön called
“artistry,” an ability to deal effectively with situations not covered by
theory and rules (Schön, 1987). Damasio notes that there are exceptional
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
training, but in spite of it.
Schön (1987) has expressed similar concerns about professional education
in general. He contrasted 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
1
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.”
Outstanding practitioners, who deal well with the swamp, aren't generally
said to have more knowledge than others (though technical knowledge is
essential); instead, they're described as having more "wisdom," "talent,"
"intuition," or "artistry." But these are commonly regarded as phenomena
that are not amenable to "scientific" examination; as a result, professional
education tends to believe that it cannot adequately deal with them.
Another way of expressing the impact of Descartes’ error is that medical
schools do not prepare physicians to deal effectively with the transactional 1
nature of medicine, i.e., the psychosocial areas of practice in which the
highly variable nature of human behavior and human situations plays a
significant role. Clinical management of individuals with HIV/AIDS is
such an area. Scientific understanding of HIV disease is exceptional, and
technical methods for its management are proliferating rapidly. However,
care is often compromised by behavioral factors—ranging from prevention
of transmission to persistence in taking complicated drug regimens—that
require knowledge and skills that “lie beyond the canons” of technical
rationality. This reasoning applies to all clinical situations that are
transaction-oriented and thus highly dependent on the behaviors of patient
and provider; and we should recognize that these comprise a majority of
patient encounters. It is in these indeterminate zones of practice that we
find well-developed technical knowledge, balanced with empathy,
intuition, and artistry that mark the exceptional physician. Medical
education should strive to assist every physician in developing these
qualities.
These issues can be addressed and are beginning to be addressed in a
variety of ways in many medical schools. With Schön, I believe that
1
Contrasted with more procedure-oriented practice. As Schön points out,
modern medical schools, seeking respectability within the academy, have
chosen to emphasize rigor over relevance, and heavily emphasize the
technical/scientific aspects of clinical care.
professional artistry can be taught and that methods can be developed for
doing so. I also believe that technology, if applied well, can promote the
integration of intellect and emotion, to help bring up a generation of
physicians whose judgments and actions, while still rational, are more
humanistic.
2
A Model for Comprehensive,
Technology-based Clinical Education:
The Virtual Practicum
At Dartmouth we have developed a general model for clinical education
termed the "virtual practicum." The model has been applied in a series of
interactive programs, one of which is currently available via broadband
Internet as well as on CD-ROM.2 The virtual practicum model intends
expressly to remedy the Cartesian biases of medical education and provide
for more comprehensive learning. The following presents the theoretical
foundations for the model, then very briefly describes the model itself. This
discussion is presented more fully elsewhere, with a detailed description of
the HIV program as an example (Henderson, 1998).
The virtual practicum model draws on Donald Schön's reflective practicum
(Schön, 1987), Max Boisot's Epistemological Space (Boisot, 1995) and
David Kolb's Learning Cycle and experiential learning theory (Kolb,
1976).
2.1
Schön's Reflective Practicum
Schön raises and addresses these complex educational questions: Can any
curriculum adequately deal with the "complex, unstable, uncertain, and
conflictual worlds of practice?" Can "artistry" be taught?
Schön operationalizes "artistry" with a concept he terms "reflection-inaction," which is distinct from another concept, knowing-in-action.
Knowing-in-action applies our existing knowledge to expected situations.
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
unfamiliar or unexpected domains. Encountering the unexpected leads to
reflective thinking: we critically examine the situation, frame the problem,
gather on-the-spot information. The process may work, yielding expected
2
http://iml.dartmouth.edu/VPracticum/HIVPrimaryCare
2
results, or it may lead to new surprises that incite additional cycles of
reflection-in-action. Schön acknowledges that this is idealized and
simplified; however, he feels that here lies a phenomenon that captures the
essence of what he means by "artistry." Reflective practitioners exercise
reflection-in-action to deal effectively with problems in the "indeterminate
zones of the swamp."
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. To achieve this goal, he advocates the use of
"reflective practicums:"
... 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...
Students practice in a double sense. In simulated, partial, or
protected form, they engage in the practice they wish to
learn. But they also practice, as one practices the piano, the
analogues in their fields of the pianist's scales and arpeggios.
They do these things under the guidance of a senior
practitioner... From time to time, these individuals may teach
in the conventional sense, communicating information,
advocating theories, describing examples of practice.
Mainly, however, they function as coaches whose main
activities are demonstrating, advising, questioning, and
criticizing.”
The virtual practicum takes this description literally, using technology to
create a computer-generated, immersive environment that has all of these
elements. These elements are listed in Section 3, below.
2.2 Boisot's E-space and Kolb's Learning Cycle
Max Boisot collates and systematizes an extremely broad body of research
and thinking, linking scientific and philosophical theory to learning
(Boisot, 1995). He provides a conceptual framework-the epistemology
space (E-space)-that allows a deeper consideration of what constitutes
comprehensive clinical education and how it may be facilitated using
technology. Boisot begins with a connectionist view of thought and
memory, incorporates Bruner's concepts about perception and
generalization, and then ties the E-space directly to learning methodologies
via superimposition of Kolb's learning cycle (Boisot, 1995).
Theories form in individuals as a result of experience and reflection, or
they are received from others. However, there are no guarantees that the
personal knowledge gained will be valid or comprehensive. A major intent
of the virtual practicum is that it provides, in addition to the articulate,
scientifically validated theories of technical rationality, experiences that
stimulate the individual's development of valid personal theories. The latter
includes basic beliefs, and values that manifest themselves in such "skills"
as empathy, compassion, and an ability to communicate.
The E-space (Fig. 1) summarizes a great deal of learning theory in a
simple, schematic way. The vertical axis considers the attributes of the
sensory stimuli perceived by an individual; this perceptual categorization
ranges from uncoded (stimuli perceived in more or less raw state, because
they cannot be adequately perceived in coded form or because the
combination of stimuli is novel) to highly coded (stimuli are perceived as
pre-processed "chunks"- often represented as words or symbols-as a result
of familiarity and learning). The horizontal axis portrays conceptual
categorization as ranging from concrete (here and now, specific case) to
abstract (universal and timeless, general principles). Edelman notes that an
important difference between perceptual and conceptual categorizations is
that the former originate in local stimuli involving the five senses and the
latter depend mainly on non-local stimuli originating in memory and
experience. These categories provide quite different methods of dealing
with the world, but they interact constantly, with concepts shaping and
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
formulated, more systematically studied and reviewed, scientific
3
knowledge. We find this type of information in journals and textbooks,
expressed almost exclusively as symbols, words, formulas, and tables, with
figures and occasional images such as x-rays and photomicrographs that
themselves require highly coded, abstract knowledge to interpret. This is
the region of intellectual thought and action, isolated to a great extent from
the variability and idiosyncrasies of the real world. That which is difficult
to quantify tends to get ignored. The northwest region has technical
knowledge, which provides for direct applicability of abstract scientific
knowledge to concrete situations. This knowledge is often manifested in
physical devices, such as an ultrasound machine, IV delivery set, or
medication.
Knowledge in the southeast region contains uncoded abstractions which,
while they cannot be handled with precision, may nevertheless contain the
most powerful influences on behavior. It is here that core beliefs and values
lie, influencing our thinking and behavior in fundamental ways, often at an
unconscious level. Some argue that one cannot abstract without coding, but
Boisot distinguishes between codes that one merely names (e.g.,
"professional ethics," "compassion," or "truth"-or even empathy and
artistry) and having an uncoded, personal knowledge of what they mean.
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
knowledge, which can be interpreted as an ability to sense, understand, and
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
and accurately to determine which features of a complex set of stimuli are
salient is a mark of the expert practitioner, learned through a process of
'enskilment' that comes not from mechanistically internalizing a stock of
knowledge, but from being actively engaged with a practice environment.
Fig. 3. Artifacts within the E-space, an example from HIV antiretroviral
therapy.
A great deal of scientific and technical information bears on management
of this patient's situation. In Fig. 3, the northeast, Scientific Knowledge
region contains knowledge of the HIV life cycle, viral mutation, and
development of drug resistance (and basic science supporting that
knowledge, e.g., genetics, biochemistry, pharmacology) and, perhaps, data
about compliance among different patient populations. The northwest,
4
Technical Knowledge region contains a set of objects that manifest our
scientific and technical knowledge: medications in the form of pills that
interrupt the life cycle, perhaps a brochure or videotape on why and how to
take the drugs.
If the northern regions contain the more biological aspects of management,
to the south are the more psychosocial aspects. Having applied scientific
knowledge and elected a technical method of treatment, success now
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
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
"successful" iterations persisting as knowledge in the learner's E-space.
In its original form, the arrows of Kolb's cycle moved only counterclockwise. Further, Kolb viewed concrete experience and active
experimentation as dealing only with the concrete world and its events.
Boisot argues that Kolb's distinctions between "real," external activities and
internal, concept-building activities are limiting. The cycle can be
strengthened if we view active experimentation as "the deliberate and
conscious manipulation of well-coded data complexions" and we think of
reflective observation as "a detached, non-committal search for patterns,
operating either internally or externally, at a lower level of coding. The first
takes place in the world of the given, of things with hard edges that can be
moved about without dissolving; the second takes place in the world of the
possible, one in which things shade into one another to yield new
configurations." This modification maps the learning cycle into the Espace. Further, since the active experimentation stage becomes a source of
analytic activities, then the cycle, still starting from concrete experience,
can run in both directions.
Fig. 4. Kolb’s Learning Cycle
Kolb derives four statistically definable learning styles, each of which can
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
integrate the four styles. From an educational viewpoint, this necessarily
involves providing learning experiences that promote such integration.
Experiences that concentrate attention only on one region of the E-space
ultimately limit growth. In most formal clinical education, the cycle is
shifted to the northeast, occupying mainly those areas of the E-space that
are more highly coded and abstract. And opportunities for learning-and
growth-are restricted, not by the limitations of the learner, but by the design
of learning experiences.
5
Viewing Descartes' error in terms of the E-space, when learning is
dominated by the highly coded, more intellectual northern regions, reason
can be impaired; conversely, when reasoning is dominated by the uncoded,
more emotional southern regions, it can also be impaired. The virtual
practicum model seeks to eliminate the Cartesian Mason-Dixon line that
divides the E-space, to reinforce a natural approach to judgment and
decision-making that appropriately integrates thought and emotion.
represented as media elements (graphics, video, sound, text) within
which the learner can move, work, and learn.

Students learn through simulated clinical practice, particularly
simulated teaching cases which compress time and space, giving the
experience of evaluating, managing, and counseling a patient over a
virtual time span ranging from days to years. There are documentarystyle "interviews" with genuine patients, providing narrative impetus
and context for considering health and illness from the patient's
perspective.
The Virtual Practicum model seeks more fully to exploit the E-space and to
achieve, simultaneously, increased educational efficiency and
effectiveness. It incorporates all elements of Schön's reflective practicum
model in an automated, electronic, replicable, and disseminable form. A
key to both the reflective and virtual practicums is simulation of the
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.
Multichannel communication can help achieve these qualities by greatly
expanding the repertoire of stimuli that can be conveyed to a learner. As
Boisot notes, "Multichannel communication is communication in a natural
mode; it is the deployment of coordinated gesture, speech, tone, clothes,
movement, in the service of messages whose complexity would overwhelm
the single channel." While we cannot be complete in depicting all features
of clinical practice, video and sound can convey many of the less coded,
essential features of that environment. In fact, key features may be
dramatically emphasized, as our common experience of television and film
attests. Digital multimedia technologies, including motion video, can be
delivered today via CD-ROM and tomorrow via a broadband Internet;
these technologies can be used to provide for multichannel communication,
to deliver complex, intellectually and emotionally rich sets of learning
experiences to a global audience.

It provides a virtual world sufficiently immersive and intrinsically
enjoyable to allow even busy professionals to ignore, for a time, the
pressures and distractions of the real world. The virtual practicum may
also reduce the risks to real patients as students develop and apply new
knowledge and skills, since these are done in a technology-generated
environment before applying them in the real world.

It is a collective world in its own right, providing an inviting, strong
sense of place that one can visit repeatedly to learn, containing
language, materials, and tools which have analogs in the real world of
practice and which borrow from the esthetics of best-practices in
computer game design; a key feature is use of narrative and case-based
reasoning to increase engagement, enhance reflection, and improve
learning.

It embodies particular ways of seeing, thinking, and doing via cycles
of experience, reflection, abstraction, and experimentation in the
tradition of Dewey, Schön, and Kolb; "story-telling" used in the case
presentations provides an underlying structure and context for
discussions and reflection that "assert themselves with increasing
authority" and intensity.
Schön's reflective practicum can be used to define the elements of the
Virtual Practicum. Kolb's learning cycle can be used to consider the
deployment of these objects more fully to exploit the E-space.

Activities include clinically realistic patient encounters, documentarystyle interviews with real patients and practitioners, and computergenerated exercises that allow for heuristic learning of facts and rules
(Schön's "scales and arpeggios").

All this is done under the guidance of senior practitioner (in the best
case a master teacher and master clinician) who may
3
The Virtual Practicum Model
Using Schön's description of the reflective practicum (cited above) as a
template, we derive the elements of the virtual practicum:

It provides a technology-based "Virtual Clinic" or "Virtual Minifellowship" that approximates the world of clinical practice,
6

teach in a conventional sense, "communicating information,
advocating theories, describing practice examples" via mini-lectures
and case discussions
when successful, can result in powerfully engaging and effective learning
experiences.

function as a coach, "demonstrating, advising, questioning, and
criticizing" via case discussions and guided (with feedback) reflection
and experimentation.
4
Figure 5. Virtual Practicum Elements in the Learning
Cycle and (implicit) E-Space.
The virtual practicum ties Schön's ideas directly to Boisot's E-space and Kolb's
learning cycle. Fig. 5 shows how practicum elements are associated with
different stages of the learning cycle; the underlying E-space is omitted for
clarity and it is understood that the learning cycle fully occupies the E-space as
in Fig. 2. Importantly, the figure fails to show the interplay among the various
elements nor the fact that each element plays some role in all of the learning
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
blending of stimuli that play out at different rates. This choreography of
stimuli, responses, and feedbacks can be difficult to construct and optimize but,
Conclusions
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,
if executed well, can at least supplement, and perhaps greatly improve on,
real life clinical education.
However, there are dangers. Virtual practicums are difficult and costly to
design and produce and there is, so far, no community of educational
technology practitioners to develop them. Even when extremely well done,
their novelty may delay their adoption, since it is difficult to convey the
quality of the experiences they provide when “marketing” them. There is
also a danger that we will, like Pygmalions, become too deeply enraptured
with our Virtual Galateas, blinding us to the fact that the realities created
are fabricated, with limitations that may be more significant than we realize
and, at best, miseducative.
3
Particularly in ambulatory care, where conditions are less controlled than
with hospitalized patients.
7
REFERENCES
That all said, I have raised issues that are of general importance to the
education of care providers, independent of whether technology is used.
Dewey’s observation that there is no discipline so severe as the “discipline
of experience subjected to the tests of intelligent development and
direction” (Dewey, 1938) is just as applicable to everyday training in the
clinical trenches. But technology allows us in some way to step out of the
rushing stream of everyday practice. As educators, we can take time to reexamine our assumptions, to consider more carefully what and how we will
teach, to take time really to do it well. As students we can enter a learning
environment that can focus our attention, engaging us in experiences that
expand not only our factual and theoretical knowledge, but the beliefs,
attitudes and habits of thinking that filter and shape our perceptions of the
practice world.
ACKNOWLEDGEMENTS
This work was supported in part with funding from the U. S. Centers
for Disease Control and Prevention via a subaward from the
Association of Teachers of Preventive Medicine and the National
Cancer Institute, National Institutes of Health, Bethesda, MD, USA
(Grant Numbers 5RO1CA6477704 and 5R25CA5787504).
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See Henderson, JV. Comprehensive, Technology-Based Clinical
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Senge PM. The Fifth Discipline: the art and practice of the learning
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