CYBERDOCtv: Integrated Patient Safety/Wellness Multimedia Web-Based Curriculum Featuring Onset and Maintenance Blogging



By

Marshall F. Gilula, M.D. and Paul R. Barach, M.D.,MPH

Department of Anesthesiology, Center for Patient Safety, UM-Jackson Memorial Hospital,  Miller School of Medicine, University of Miami





GENERAL INTRODUCTION: CYBERDOCtv is a multimedia web-based healthcare curriculum. This program combines patient safety and wellness knowledge into a unique futuristic gaming simulation that teaches team functioning and group strength. Both gaming and simulation use aspects of dissonance resolution which is a major aspect of this four-year production. The first year’s program introduces the story of DR TOMORROW (Gilula 1992a), a renegade healing team machine from 30,000 years in the future attempting to correct the entropy imbalance of 21st Century Earth by changing the culture of the planet one person at a time. Planetary culture must be transformed from a culture of greed, terror, and war into a culture of peace, social balance, and safety. The science fiction storyline stresses the power of the individual when combined into a group or team of other, like-minded individuals to reduce conflict and use dissonance resolution to produce harmony. Music and animated graphics provide the student with multisensory exercises which resemble actual techniques described in the science fiction storyline. The techniques aim to “resolve dissonance” wherever it is found in life on this planet. Dissonance can manifest in musical, psychological, societal, and planetary terms. Dissonance can be more subtle than the most subtle conflict and is therefore frequently unnoticed. At it’s very worst, dissonance is capable of disrupting the essential protective magnetic frequencies of the Earth itself. “Dissonance Resolution” is a nonviolent technique that is mathematically and electronically combined with the group’s music. In some cases, Dissonance Resolution is blended into the music, by making deliberate use of somewhat unpleasantly dissonant musical patterns that “resolve” into pleasant, harmonious, and resonant music. The same mathematical process is applied to animated (kinetic) graphics that accompany the sound patterns. Simultaneous focusing on both visual and auditory stimuli has been common to gaming and simulations for decades. CYBERDOCtv optimizes this multichannel focusing by using dissonance resolution and teaching graduated steps that resemble the increasing levels of expertise (Beginner to Expert) found in today’s hi-tech games and simulations.

PATIENT SAFETY AND WELLNESS: Interactive web-based educational content combines the subject matter of Patient Safety and Wellness and also includes periodic web casting with enhanced kinetic graphics and streaming stereo audio. Web casting is one of several electronic techniques used to emphasize the fundamental unity and interconnectedness of all forms of life on Earth. Although some of the website design includes commercial content to help defray the considerable production costs, web casting itself will be kept commercial-free. If sufficient unrestricted funding is obtained, the entire programming will be kept commercial-free. Otherwise, ethical commercials related to patient safety and wellness products will be permitted.

This four year curriculum teaches factual health-related material, consciousness exercises and aspects of group function and team training that are both formal and informal by design (See MarshallGilula-Yr1.doc on the CD). Aesthetically-pleasing multisensory sound and light patterns capitalize on both Western and Eastern cultural themes to teach mental focusing, discipline, and self-regulation. (Please see CYBERDOCtv1.wav and CYBERDOCtv2.wav which are presented as .wav files on the CD) The first musical pattern includes unique tri-tone chanting of Tibetan monks which has dissonant sounds that become resonant upon repeated listening. The second musical pattern contains deliberate musical dissonance which clearly progress to resonant patterns on the first listening. Originally written in the Seventies and then web-published in five segments during the Nineties, (Gilula 1991a,b,c 1992a,b) the DR TOMORROW story has already been through several iterations. The current iteration (see MarshallGilula-DrTg3.doc) stresses the formation and naturalistic growth of a team. The seven-member group of both earth and extraterrestrial origin teaches about man-machine synergism. The team also promotes the idea of understanding electronic devices with electromagnetic fields as having some degree of sovereign consciousness and therefore deserving respect. Characters in the storyline teach the same type of thinking about all plant life found on the planet.

Multisensory exercises and consciousness skills also enhance learning and discussing salient points from various patient safety scenarios. The scenarios are blended with seven main categories of Wellness Medicine. Wellness Medicine is also known as CAM, or Complementary-Alternative Medicine. Nutrition, Exercise, and Self-Regulation makes up the fundamental “holy triad,” of wellness. The other four categories are: Neuromuscular Integration, Biomolecular Environment, Acupuncture/Nonallopathic Modalities, and Spiritual Attunement/Medical Intuition.

WEBSITE AND BLOGGING: Blogging (weB LOGGING) adds yet another dimension of interactivity from the very outset and throughout the entire course of the project. One author (Doctorow et. al. 2002) gives a substantive, dry definition: “A blog is a web page that contains brief, discrete hunks of information called posts. These posts are arranged in reverse-chronological order (the most recent posts come first). Each post is uniquely identified by an anchor tag, and it is marked with a permanent link that can be referred to by others who wish to link to it.”

Blogging as a carefully monitored interactive aspect, will also attract web surfers who blog on CYBERDOCtv. CYBERDOCtv management will, in turn, blog on the blogs that appear in the website space designated for web logging. Hopefully CYBERDOCtv blogs will get some internet attention and stimulate web logging with an up-beat, positive accent. This educational purpose may partially replace the frequently-found war-blogging which often is a juvenile type of adversarial ad hominem communication (“flaming”) born of perceived safety in the anonymity and remoteness of electronic communications. Posters on the site will encounter a standardized message stating that the content of the web logs are being analyzed to determine what type of effect the program content is having on the quality and content of the web logging. Any blogs that are used in the production will be accompanied by ethical attributions. Ethical concerns with blogging and other forms of online journalism suggest that content of individual posts on the website may not be used as incoming feedback to alter the content and direction of programming without correct attribution (Blood 2002). This is still a highly conflictual issue. It will be impossible to avoid some degree of effective incoming feedback.

The ongoing outreach effect of programming content and process, however, will be designed and deliberate. Blogging will hopefully seed and make it possible to communicate cultural aspects of CYBERDOCtv for internet gaming with a surrealistic science fiction story line. Internet game designing is not for the faint of heart. Actual gaming will not be present until the end of the first year of production. Science fiction elements of the storyline are taught to the viewers as learnable consciousness techniques involving concentration and mental focus. Art and fiction often shape life, and in this sense the program will have a surrealistically positive flavor. In this situation, the shaping will be deliberate. Blogging is another aspect of the production with cultural implications. The essential objective of blogging is to encourage the principle of “blogging back whomever blogs you.” Naturally, CYBERDOCtv will review and qualitatively analyze whoever has reviewed the DR TOMORROW story as well as changing trends in the overall CYBERDOCtv format, content, and process. Since the origin of blogging at the turn of this century (Rodzvilla 2002), there has been an ongoing controversy about whether or not blogging IS a form of journalism, and whether it is realistic to hope that there might be a code of ethics associated with blogging.

TRILINGUAL TEACHING AND MULTILINGUAL WORLDVIEW: Each of the curriculum’s four years teach 1000 basic “survival” vocabulary words in Spanish, Russian, and Japanese. Healthcare of the future, just as populations of the present, will be taught in a multicultural arena to students who need to be multicultural. The language modules will focus on “testing to mastery” of a small but serviceable aural-oral vocabulary. As with all parts of the curriculum, the testing is “pass/fail.” The basic goal of this portion is to cultivate familiarity with and affection for the different sounds as a way of developing increasing respect and empathy for different cultural groups. Teaching Patient Safety and Wellness both require at least a willingness to appreciate and learn the intercultural differences regarding wellness and healthcare. As with some other parts of this four-year curriculum, production aims of each year will include a dedicated but optional take-home microsimulation (CD or DVD) with differentiated levels of expertise ranging from beginner to advanced intermediate. Although the basic courses will use the roman alphabet, all the optional microsimulations will have extensive references and practice exercises for learning not only the sounds of each language, but also the Cyrillic alphabet for Russian, and Japanese’s three other alphabets: Kanji, Katakana, and Hiragana. These optional extras will allow the student to consider learning to read and write in the “survival” languages.

DISSONANCE RESOLUTION is the central key and fulcrum for leveraging effective learning of both Patient Safety and Wellness within an integrated web-based curriculum. Patient safety and wellness are intimately related because the essence of patient safety rests on the fundamental precepts of wellness. Optimal medical care results from any approach that encourages the patient to be in the driver’s seat and to take an active, family-centered role in healthcare. Dissonance resolution can put the spotlight on patient relaxation. Dissonance resolution is also a conceptual way of understanding how a person achieves mastery over disease and debilitation. Although “conflict resolution” has been used in psychology and behavioral sciences, dissonance resolution is a way of also recognizing less severe degrees of conflict and emphasizing the finer tuning and adaptation which humans can achieve. Resolving the finer degrees of dissonance is another route to mastery of stress and achievement of high-level wellness. Musical, psychological, and neurophysiologic analogies are all useful for explaining how and why we use dissonance resolution to optimize both the content and process of our educational program series.

GENERAL ASPECTS OF DISSONANCE RESOLUTION: The DR in DR TOMORROW represents Dissonance Resolution, which is the central theme and key mechanism of the CYBERDOCtv learning system. We use both kinetic graphics and stereo .mp3 and .wav files to potentiate psychophysical and neurophysiologic cognitive dissonance resolution. (See the CD for an animated Shockwave logo, MarshallGilula-animated.swf serves this purpose.) Inserted here in the text is an ordinary graphic file that resembles the animated Shockwave logo (MarshallGilula-Fig1.jpg)(Miller 2004). Even this unanimated graphic can be used for visual focus while listening to either of the two stereo sound files, CYBERDOCtv1.wav, and CYBERDOCtv2.wav, that will be included on the CD. The basic idea is to involve the viewer in focusing simultaneously on both visual and stereo sound stimulation as a way of establishing both mind and body discipline. These early consciousness tools are very much of a scaled-down version of what happens to the viewer as a participant when he or she is focusing on a matrix of shapes and sounds that are constantly changing. The time and energy required to learn how to focus on a gaming simulation can be decreased by initial practice with less complex stimuli such as a single, static graphic and then a kinetic (animated) graphic. Combining visual stimulation with stereo auditory patterns initially evokes internal dissonance which both conscious and unconscious processes serve to resolve as the viewer-participant becomes involved and then progressively engrossed in the simulation.


Figure 1: CYBERDOCtv logo

MUSICAL ASPECTS OF DISSONANCE RESOLUTION: Dissonance Resolution, or explanations and definitions of just plain Resolution, usually include esoteric language related to mathematical ratios describing various musical intervals and how those intervals relate to the fundamental or “dominant” frequency. The dominant frequency is the same as the “key” of a musical composition. Continuously playing a monotone is, by definition, monotonous and unpleasant for most listeners. And yet unchanging variability that never returns to the “dominant” baseline is also unsatisfying for the majority of listeners. Depending on the genre, music can have different patterns of how the variations of frequency and time durations progress. Usually the frequency progressions tend to cluster within a group of customary patterns for many musical genres. Many forms of classical (for example, Bach) and rock (e.g. Grateful Dead) music have stereotypic patterns that some enthusiastic listeners (fans or groupies) appear to tolerate endlessly without the same discomfort or ennui that others in the same environment may experience after the first few dozen times of hearing the same composition.

Musical improvisation is a specific arena that intimately involves dissonance and resolution of that dissonance. Musical amateurs who are learning to “jam” need time to clearly hear themselves in a group context. The beginner learns to tune an instrument by comparing the differences between a standardized note on a tuning device and the note produced by one’s own instrument. Newer tuning devices allow the musician to see an electronic readout of the degree of disparity, or dissonance, between one’s own instrument and the standardized pitches. Learning how to play in tune with a standardized set of pitches is followed rapidly by learning how to fit into a pattern or group of patterns produced by one or more other musicians. Sophisticated improvisation can involve extremely rapid sensing of dissonance and acquiring the ability to resolve dissonance on the fly. The same internal process can be viewed in both psychological and neurophysiologic terms. Dissonance resolution is a dynamic core element of any process that involves becoming an expert in any field.

PSYCHOLOGICAL ASPECTS OF DISSONANCE RESOLUTION: The definition of Cognitive Dissonance and resolution of cognitive dissonance are important parts of psychology. “Cognitive dissonance is...discomfort felt at a discrepancy between what you already know or believe, and new information or interpretation” (Atherton 2003). Insight about personal behavior arrives at the cost of significant discomfort. Sometime it’s better not to know. Dissonance resolution in psychotherapy can represent cognitive and emotional (affective) elements of some psychological growth techniques. Neighbor (1992) uses cognitive dissonance in the form of an “intellectual wedge” that is driven between learners’ current beliefs and “reality” as part of medical training. When this approach works, it involves dissonance resolution because the by-product of resolving dissonance is resonance and coherence.

NEUROLOGICAL ASPECTS OF DISSONANCE RESOLUTION: Dissonance Resolution within the nervous system is easy to demonstrate neurophysiologically because we can detect electrical fields and currents by analyzing neural activity with EKG (heart) and EEG (brain) techniques. Our program focuses particularly on the neurological aspects of the heart and of the brain. Basic science research has documented well the existence of afferent connecting pathways of information going from the heart to the central nervous system (Armour and Ardell 1994). The heart is therefore a source of incoming information that is received and decoded in the brain and then fed back to the heart itself. FFT (Fast Fourier Transforms) or other methods of frequency analysis with both the EKG and the EEG have shown a difference in the coherence of electrical frequencies during different emotional states. During states of focus, appreciation, love, and other positive feelings, the basic EKG frequencies tend to line up behind other waves of similar frequencies, and when this happens to a high degree, the person is said to be in a “coherent” state. (Tiller,WA, McCraty, R., Atkinson, M. 1996) Angry, hostile, disorganized states tend to show a lack of coherence in the basic EKG frequencies. Characteristics of neurophysiologic tracings during states of significant empathy often show bioentrainnment and coherence. Bioentrainment is when a form of electrical activity in one individual matches or “drives” that of another individual. The entrainment does not have to involve peaceful or coherent activity. It has been shown electrophysiologically that feelings of anxiety, anger, and disorganization can be shared and entrained between two individuals. During dissonance resolution we may expect to find neurophysiologic evidence of coherence, resonance, and bioentrainment. Dissonance resolution is designed into our program to enhance learning, to enhance coherent and resonant states, and to make learning more pleasurable and occur at a progressively higher level.

Studies of coherence and biofeedback phenomena show that the human nervous system can be brought under voluntary control, but there is yet a deeper level of control which seems to operate just out of conscious awareness. If an individual is sufficiently relaxed, it is possible to communicate directly with one’s own wiring system. Biofeedback researchers have described a type of “passive volition” achieved by subjects who can control their EKG or EEG. Passive volition involves becoming deeply relaxed and then gently willing a change in the body/mind function that is being monitored such as EKG or EEG.

Neurological aspects of dissonance resolution include become more and more sensitive to very subtle levels of internal disharmony. Learning to identify the internal disharmony is similar to learning the “passive volition” of EEG or EKG control. Learning to type requires some focus and concentration, and the same is true for learning voluntary control over physiologic functions. It does not require special intellectual abilities to learn either typing or voluntary internal control. Identifying internal disharmony becomes progressively easier through practicing with the focus, concentration, and meditation exercises that are part of CYBERDOCtv. By the end of the first year, any student who has persisted with the program will feel at least minimally comfortable doing dissonance resolution. Since some of our patterns will contain both harmonious and disharmonious patterns, an unskilled individual may first “resonate” with the disharmony (dissonance) and then, with practice, gradually ‘resonate” with the functionally higher resonance present in the same pattern. .

GENERAL SPIRALING EFFECT OF GROWTH/LEARNING/EXPERTISE: The process of continuing learning and becoming an expert in any process or set of processes has been likened to an upwardly progressing spiral. (MarshallGilula-Fig2.gif here) (Judd, 2004)


Figure 2: Progress in Growth, Knowledge, and Education

The spiral has been described in many different ways: as cylinders, cones, and as variable shapes: “Knowledge goes round and round, but also up and down and in and out.” (Cranton and Cohen 2000). There is frequent difference of opinion as to just how conically-shaped this upward progress is. Some argue that the cone drawn above should rather be inverted. One interpretation of Figure 2 would be that it represents a process with a steep learning curve that becomes much easier after an initial investment of time and energy. This might represent many types of computer software and complex games. Expert gamers, however, might argue that an inverted pyramid typifies most quality games and simulations. But most educators, healthcare professionals, and gamers would agree that each horizontal revolution of this upwardly-progressing spiral has one or more rough spots and transitions. These barriers are well-illustrated by the concept of dissonance. Just how the dissonance gets resolved is not so easy to explain. Some neurophysiologic dissonance resolution seems to be self-correction on the part of the human nervous system, especially when there is some conscious awareness or attention focused on the problem at hand. One example would be when two or more individuals are doing EEG biofeedback and experience an entrainment of their brain wave frequencies. Various psychotherapies, yoga, and other types of meditation can promote the achievement of internal coherence. Exposing the human nervous system to dissonance in graded doses that are not overwhelming can do the same thing. Coherent states can correlate with relaxation, more efficient learning, and unique or creative problem-solving.

When gamers are exposed to alternating degrees of complexity, the nervous system goes through the process of resolving the cognitive conflicts that are presented by the program. However, becoming adapted to unfamiliar controls and keystrokes to achieve novel simulation behaviors invokes a self-tuning neurological mechanism as the end-user first experiences discomfort and then gradually becomes comfortable with the simulation controls and their results. This is not merely a matter of reducing a degree of cognitive dissonance or cognitive conflict, but actually relating to the core discomfort coming from a lack of familiarity with both neural controls and game controls. The entire progression of focusing on static and then on animated, and then on variably animated visual objects accompanied by their corresponding musical patterns throughout the program’s modules ultimately makes it easier for the learner to continue focusing at the higher, more difficult and “more expert” levels of the program. Gaming programmers usually focus on making the levels increasingly more difficult to navigate, but do not focus on how to optimize the quality of the gamer’s learning and progressions. CYBERDOCtv will do both by giving the learner practice exercises to be used against a progression of more difficult scenarios that involve patient safety and wellness.

A SPIRALING CONVERSION OF DISSONANCE RESOLUTION: The complex multimedia nature of CYBERDOCtv is an ideal vehicle for using dissonance resolution to enhance the learning quality along dimensions heretofore unexplored in virtual reality. Mastery of content is the object rather than obtaining a passing score on a multiple choice test, and the program aims to invoke intense motivation from the participants. This interactive curriculum will grow in response to feedback from both the learners and the teachers. Progression of the DR TOMORROW storyline into an internet gaming context will put a unique interactive edge into the combination of Patient Safety and Wellness. CYBERDOCtv will pose a severely pleasant challenge to the technology, to students and users, but most of all to teachers and programmers.

REFERENCES:

Armour, J. Andres and Ardell, Jeffrey L., Eds. (1994) Neurocardiology, Oxford University Press, New York, 443 pp.

Atherton, J.S. (2003) Learning and Teaching: Cognitive Dissonance [On-line] UK: http://www.dmu.ac.uk/jamesa/learning/dissonance.htm Accessed: June 14, 2004

Blood, Rebecca (2002) The Weblog Handbook : Practical Advice on Creating and Maintaining Your Blog. Perseus Publishing, Cambridge, MA. p 114.

Cranton, Patricia and Cohen, Laurence Robert. (2000) “Spirals of Learning” in The National Teaching & Learning Forum. 9:5, 6 pp. Oryx Prex, James Rhem & Associates, Available from http://ctl.stanford.edu/teach/NTLF/v9n5/research.htm June 14, 2004

Doctorow, Cory, et. al. (2002) Essential Blogging. O’Reilly & Associates, Inc. Sebastopol, CA. 244 pp.

Gilula, Marshall F. (1992a) DR TOMORROW. Part 1 of 5. 26 pp. The entire story is available at the outset of the program online and may also be available in hardcopy. Available from http://www.etext.org/Zines/Quanta/tomorrow1.html June 14, 2004

Gilula, Marshall F. (1992b) DR TOMORROW. Part 2 of 5. 17 pp. Available from http://www.etext.org/Zines/Quanta/tomorrow2.html June 14, 2004

Gilula, Marshall F. (1991a) DR TOMORROW. Part 3 of 5. 13 pp. Available from http://www.etext.org/Zines/Quanta/tomorrow3.html June 14, 2004

Gilula, Marshall F. (1991b) DR TOMORROW. Part 4 of 5. 11 pp. Available from http://www.etext.org/Zines/Quanta/tomorrow4.html June 14, 2004

Gilula, Marshall F. (1991c) DR TOMORROW. Part 5 of 5. 16 pp. Available from http://www.etext.org/Zines/Quanta/tomorrow5.html June 14, 2004

Judd, Robert. (2004) Robert Judd Studios, Tempe, Arizona. June 12, 2004.

Miller, Iona R. (2004) Ionasphere Studios, Grants Pass, Oregon. February 3, 2004.

Neighbor, R. (1992) The Inner Apprentice : An Awareness-Centered Approach to Vocational Training and General Practice. Kluwer Academic, Lancaster, 240 pp.

Rodzvilla, John (ed.)(2002) “Weblogs: A History and Perspective”, Chapter 2, page 2. Rebecca Blood indicated that sites were first identified as weblogs in December 1997 by Jorn Barger [http://www.robotwisdom.com] in We’ve Got Blog, Perseus Publishing, Cambridge, MA. 242 pp.

Tiller, W.A., McCraty, R., Atkinson, M. (1996). “Cardiac coherence: A new, noninvasive measure of autonomic nervous system order.” Alternative Therapies in Health and Medicine 2 (1): 52-65.