Reflective Acupuncture Practice: Walking the Walk and Talking the Talk

The approach to professional education at the Tri-State College of Acupuncture seeks to instill the Western spirit of research and critical inquiry combined with an appreciation of the East Asian practice of mindfulness, which we have termed "reflective acupuncture practice" (RAP). In this approach to educating students in the school's programs in acupuncture and Oriental medicine, master practitioners, each with at least two decades of experience practicing and teaching acupuncture in North America, serve as the central focus around which students learn to critically observe, then emulate, the actual practice of these masters.

The use of master classes as a pivotal learning experience was inspired by the work of the late Donald Schon, former Ford Professor Emeritus at MIT, on reflective practice in professional education. Schon developed his approach as a critique of and counterpoint to academic education in the professions in the 1960s. Drawing from the concepts of case-based and problem-based professional education of his day, Schon moved beyond these still somewhat academic approaches, in which the cases used were textbook perfect and the problems cited were contrived, albeit for educational clarity. In Schon's approach, a fish bowl process that placed master practitioners center-stage for an audience of participant student observers was utilized to focus achievement of academic knowledge first and foremost around the actual practice of experts. In this reversal of the traditional educational process, much of the knowledge deemed to be most critical is not gained just from textbooks, nor even just from textbook-perfect example cases or contrived problems, but from the technical know-how and artistic flair of masters practicing their craft.

In such a reflective learning experience, which Schon dubbed "reflective practicum," a safe place is developed in which future professionals might learn to become reflective practitioners themselves by watching masters reflect on what they do and how they know what to do at any stage of the clinical encounter while actually doing it - not just quoting the texts, but "talking the talk" while "walking the walk."

In grand rounds master classes with master practitioners at the college, each student is asked to behave like a medical anthropologist in some exotic culture doing ethnographic fieldwork. The exotic cultures in this case are the various master and senior practitioners' ways of practicing an East Asian medicine in North America.

These exotic cultures exist in their pure sense in the offices of each master practitioner. Alternatively, in this sort of observation class, students have the rare opportunity of viewing a "hot house" version of these different practices, up close and personal. The process of treatment in observation classes is magnified through a theater-type setting, with the master practitioner "center-stage," surrounded by some 30 to 50 observers, and with state-of-the-art video monitors to facilitate close-up viewing.

This educational format generates an enormous amount of energy as it accentuates the salient specific and non-specific factors, the more clear-cut techniques and the craft, as well as the all-too-elusive artistic flair that each experienced practitioner employs in the dance between practitioner and patient. This occurs because the practitioners are not just doing what they normally do with patients. They are consciously reflecting on and articulating their know-how, gained from extensive experience, while in the process of doing the practice. This entails reflecting in action on their actions and interventions, and sharing those reflections with students. Such blow-by-blow descriptions by master practitioners often yield pearls of wisdom that would be very difficult to gain in any other professional educational forum.

The patient is unavoidable impacted by all of the questions, observations and clarifications that circulate, which become additional and perhaps critical non-specific factors that contribute to the outcome of treatment. A medical anthropologist viewing such an event might argue that this paradigm more closely resembles a public ritual healing ceremony than a private patient-practitioner clinical encounter. This environment allows the extraordinary to occur more easily and visibly than in day-to-day private practice.

Students are taught that it is their job as participant observers to ask master practitioners questions about their favorite filters; the palette of points they use; their tried and true techniques; and their recurrent ways of verbally and non-verbally reframing the patient's experience of illness through AOM filters. Students are encouraged to ask their questions in a way that respects each master practitioner's style of working in its own right, without comparing it with any other style of practice. An anthropologist does not ask a person in a Korean culture why they do not eat American food, but rather observes as carefully as possible the kinds of foods one eats in that culture; the timing of the meals; whether families eat together or if people alone; whether there are health reasons why various foods are eaten in a given preparation; and so on. An ethnographic perspective tries to control for bias while in the field by staying attentive to what is actually occurring in that culture, from that culture's point of view.

Critical inquiry, research methods and clinical decision-making are central areas of study in any doctoring profession. In fields like physical therapy, occupational therapy, speech audiology and pharmacy, which have all developed first professional doctoral programs alongside their post-bachelor's or master's entry-level programs, this area of critical inquiry occupies a large role in the shaping of a higher-level learning experience for doctoral training.

This higher level of critical inquiry, critical thinking and capacity for reflective practice has been informed by case-based and problem-based approaches to professional education, and Schon's seminal work on reflective practice in the professions has infused such fields as teacher education, social work and human services.

AOM colleges are certain to feel the need to augment or supplement their current master's degree-level curricula as they develop first professional (entry-level) doctoral programs, and would do well to investigate these problem- and case-based approaches, as well as those centered on reflective practice, as they attempt to integrate Western critical inquiry and the spirit of research into their programs. It is our contention, and the mission of the Center for Acupuncture Educational Research (CAER), which is the research arm of TSCA, to inspire qualitative research approaches incorporating ethnographic and case-review perspectives into the training of a higher level of AOM practitioner. Such practitioners will be capable of communicating with doctor-level colleagues from any academic or professional field, while preserving what is unique about a practice that already knew how to tend to the mind as well as the body, and the art as well as the craft of it all, well before Westerners ever subjected this practice to a Western biomedical quantitative research gaze.

CAER joined with the Society of Acupuncture Research (SAR) in presenting a pre-conference reflective acupuncture practicum at its Fall 2003 conference in Cambridge, Massachusetts, to share these perspectives on AOM educational research with an audience of practitioners, educators and researchers. All participants focused on the often overlooked issue of whether and when practitioners elect to needle active, reactive points as opposed to exact textbook locations.

This was a follow-up to CAER's inaugural reflective practicum even at the college in New York City eight months before. There, a similar audience, with many of the same master practitioners and researchers, reflected on the actual needle techniques utilized by master practitioners according to the points selected, and the ways in which they reframed the patient's experience of needling sensations to make the experience not only tolerable, but interesting, educational and therapeutic.

What became clear in these two reflective practicums was the fact that some master acupuncture practitioners think very little about just treating diseases, dysfunctions or distress per se, and focus very little on the actual technical acupuncture diagnosis. Rather, they choose to focus on the art of maintaining a therapeutic clinical encounter that initiates change in the patient's condition wile inspiring hope that more change is forthcoming, all while carefully executing their precise needling and other AOM techniques.

CAER is planning a third reflective practicum to focus on how such master practitioners use the practitioner-patient relationship to initiate therapeutic change, the entire art of shen ming tong or "divine penetrating illumination" as Ted Kaptchuk translates it, in a new chapter in his classic The Web That Has No Weaver. Divine penetrating illumination refers to the doctor's ability to initiate healing without even touching patients or before they even sip the first bit of a soup they have been prescribed. This art eludes Western biomedical research, yet may be pivotal in the advanced practice of any AOM discipline.

As Western AOM educators tackle teaching critical inquiry and research in the doctoral programs to come, they must look at approaches that preserve the divine in what we all hope to do in our practice of this wonderful medicine and art.