Copyright 2009
Why this Forum?
At Eric?s suggestion I have put the The Common Vein up for consideration as a potential collaborative project
Mission of The Common Vein
The aim of the common vein is teach medicine through strict adherence to principles, and to use images liberally as an educational tool.
What is the Common Vein
The Common Vein is an electronic, web based, project that provides an arborised and integrated knowledge tree of medicine and biology enhanced with parallel examples in the world around us. The knowledge tree is framed with an infrastructure of simple principles and step-wise progresses to advancing complexity.
Background
I have had an idea about medical education ever since I was a medical student in South Africa when I sat in a microbiology class in 1971 (before the age of computers) recognizing that there were recurring principles that formed the basis of the lectures. The organisms size, shape, growth characteristics for example were recurring themes and I therefore created empty tables on my notes and filled in the blanks as the lecture proceeded usually with no uniform method of presentation. This gave me some power over the information and forced me to think before I wrote ? powerful element for learning.
I proceeded to approach all my note taking this way in the subsequent years of medical lectures and also always looked for the principles behind the detail. During the clinical years I continued with an emphasis on principles The learning process began to have context For examples in taking a history ? how does one remember the right questions to ask ? and I came to the conclusion that the questions related either to loss of function of the organ or as a result of irritation. Pain was a universal symptom of irritation while nausea was a a symptom of irritation of the GI tract and cough a an irritative symptom of the bronchi and lungs. Dyspnea on the other hand could represent of lung and heart ?failure? while muscle weaknes was a failure of the muscles.
The ability to give power to student by providing the the principles of medicine runs parallel in concept to providing the constitution for legal world or the ten commandments for some of the rules that govern moral behviour. This approach gave me a more global perspective and applied the same principles
Emphasis on Principles
It is my belief that it is fundamentally more important to focus on the principles initially so that the detail which follows has context. This seems to have been the stated preference of many of my colleagues and students I have communicated over the years, but to find a book or text that focuses on principles is a rarity. One of the most popular medical texts ? Harrison?s Principles of Internal medicine, despite its name, has little focus on principles and rather focuses on detail.
The Common Vein, as its name implies, has as its main purpose, focus and elemental commitment to principles that are common to structure, function, disease diagnosis and treatment. These are the hallmarks of medicine and medical practice. The principles are profoundly simple but the dogged and disciplined attention to repeating and applying the principles at all levels of knowledge is a prime focus of the project. This focus not only allows placing the information and knowledge in context but also promotes understanding.
I am unaware of any other text that elevates principles to the extent that the common vein does
Extensive Use of Images
The written word is very powerful and is particularly powerful for those who are blessed with language skills and a powerful left brain. I happen to have been blessed with a dominance of right brain power and so classical text books, and their digitized counterparts which are dominated by text are difficult for me. I had no choice in medical school since computers were not yet discovered. Now that there is a digital medium that enables the inexpensive reproduction of images, it is time for those involved in education to focus just as well on the right brained people of the world who want to understand medicine with the tools that they were born with. This I believe is a unique selling point for the project. Additionally images are a universal language and can be used to transmit ideas and educate those who do not speak English.
The action potential elicited by nerve stimulation is a difficult concept to grasp. Step by step unfolding of the concept using an image for each step allowed me to understand the complex material. As an author of this electronic chapter, I personally artistically rendered the innumerable images that advanced the idea slowly with one idea presented at a time, so that the total picture unfolded slowly but completely and hopefully this could also be the case for others. (Physiology of Pain) There was no need to put all the detail in a single image as has been the case for written texts, since expense for image reproduction was not a consideration.
The new generation is all about images for better or for worse. This generation will produce doctors and lawyers with the new media that they are surrounded by, and therefore we should accommodate their needs. Although complexity of the detail of medicine still needs the written word, it is helped by a medium which can and does speak a thousand words.
Classical medical texts (Grays Grants Moore Robbins) have a traditional formality which provides an important professional and dignified front. The Common Vein has a slightly softer feel and is peppered with images provided to promote learning and understanding. For example the spiral valves of Heister are explained in terms of an Archimedes water screw (Spiral Valves) The image not only inspires memory of the valve but also inspires a questioning of who Archimedes was and what the water screw was about. In the end the learning process moves forward ? not necessarily for better grades but for better understanding and in the end for better doctors and people.
Additionally because of my interest in art , a profound belief that images can teach, and because there is such beauty in structure, each module of an organ or subject contains an art section of drawings or renderings. These are reused in the medical art module which is available on the home page near the bottom of the menu as ?Art in Medicine? or it can be found at Art in Medicine and Biology.
The cultural aspect is important and unique and is augmented with historical perspectives in each module as well and sometimes with poetry for those who so inclined.
There are currently 14,000 images on the web site, some are anatomic many are radiological, and some are artistic renderings. As a radiologist my collection of radiological images is extensive deep and frequently used in the text. This serves the medical student, nursing, and general medical community well since the availability of these images on the wards due to PACS technology, and more importantly the integral nature of medical imaging with day to day and minute to minute patient care makes familiarity with radiological images essential . No other texts for medical students have this breadth nor depth of radiological images.
I am unaware of any other text that elevates and utilizes images to the extent that the common vein does
Digital Format
The electronic market for medical students, particularly for anatomy and physiology has been dominated by medical text that has been digitized from classical established texts (Moore?s Clinical anatomy Gray?s anatomy Guyton physiology Robbins pathology) that were designed and written as books. This was a definite improvement over the purely analog form, because it has a different feel and flow and suits some learning styles. Although it adds a tremendous value to learning it is not manipulable to the full potential that a truly digital format may allow.
In contradistinction, the digital format of information proposed here, and which is the basis of the common vein, starts with the notion that there is a commonality of principle when dealing individually with the disciplines of medicine ? structure, function disease diagnosis and treatment. Prospectively the information is slotted into fixed fields of a database by the author who is able to take control of the information right from the start. Each organ for example is therefore defined in template terms of its structure, function, the diseases that affect it, the way we diagnose those diseases and the way we treat the diseases. Each of these disciplines e.g. structure has specific descriptive template that is adhered to in the authorship. For example all structures and all organs are defined by their size, shape, position and character, by their connections, their parts, and embryology. (Introduction to Structure) In disease the derangement of one or more of these structural aspects will clue the physician, radiologist, pathologist, or surgeon into the diagnosis. For example a normal liver will not be palpated 4 fingerbreadths below the right costal margin and if it is larger than the 4 fingerbreadths then it is abnormal. The anatomical and radiographic criteria of normal size of the liver are well established and the difference between normal and abnormal sometimes rests purely on size. Even the diagnosis of cancer for example rests on the basis of nuclear to cytoplasmic ratio, which is a measure of the size of the nucleus in relation to the cytoplasm. It is therefore not only a method of writing the information but it has profound practical application.
Once all the organs are defined according to structure function disease diagnosis and treatment the potential to organize the information in any desired way becomes infinite. For example if you are a student or medical school that prefers to learn by a horizontal method ie , you organize the information and knowledge base by discipline ? ie you first learn anatomy of all the organs, then physiology and progressively move to the other disciplines, then you extract the disciplines from the database and organize them to your preference. On the other hand if you want to learn by vertical means ie an integrative technique and you want to study the heart you can organize your learning in that way. If you think you want to study the size of organs to get a perspective you would be able to extract that data accordingly. eg see (Size of Structures)
Thus the student can tailor the material to individual preference.
This format on the other hand provides the publisher with an ability to sell packets or units of data or knowledge. Thus the student may like the way anatomy is written but not physiology, and so they could purchase just the anatomy module or just the anatomy of the heart. A hundred dollar purchase of an entire text book may not be within the budget of a student. On the other hand $10 over a year for 20 organs (credit type purchase) provides a distinct advantage to the publisher and to the student who can afford $20 per month but not a $100 outlay. This model is similar to the sale of two condominiums being financially more beneficial to both parties since the seller gets more for the property than he or she might have by selling a house, and the purchase for buyer falls within affordable range. I am not a businessman but there seems to be an advantage to the concept at least for some individuals.
I am unaware of any other text that is as modular as the common vein which gives the user and the publisher pliability and control.
Unique Format
Within the word heart there is an encyclopedia of information. The purpose of education is to take the student progressively from simplicity to complexity in a fluid and smooth transition that is not wrought with a sudden jump to complexity that frustrates the learning process. In the chapter on approach to learning (http://thecommonvein.net/rsna05/doc.asp?docid=5384) this approach is outlined.
The word heart should be followed by a sentence worth that crystallizes the essence of the heart and the therefore it should contain the most unique features of the structure and function, the most common diseases, usual diagnostic tools and common treatments. If it contains these elements then the definition is true to the word according to TCV principles. After the sentence the next level expands to a paragraph of each of the 5 facets (structure function disease diagnosis and treatment) and then each of these expands into a chapter and so forth creating an inverted 5 faceted pyramid or inverted cone. The information can get progressively more complex but it has a defined path along which it can progress.
This format accomplishes three goals
1) Stepwise progression from simplicity to complexity
2) An ability for the program to say alive and grow in complexity over time
3) An ability to have the program appeal to a wide ranging audience as it grows
In the publishing world these steps are taken by the dictionary at the first level, by the text books of varying complexity at the next levels, by the review journals at the next and by the research journals at the next. They are however not connected, graded nor integrated.
The format of TCV is logical and unique.
Integration of the Basic Sciences with the Clinical Sciences
The integration of the basic sciences with the clinical sciences occurs by the nature of the design of the program. The programs on the aorta, gallbladder, colon, pancreas, lung esophagus and breast are most complete and demonstrate the integrative advantages of the program.
http://www.thecommonvein.net/rsna05/index.asp?accesstypeid=157.
The project is ambitious and requires an organization with resources to assist with content building. There has been sufficient accrual of content to demonstrate the concept, but it requires the resources of an organization to enable it to materialize.
To reveal that the macrocosm of our society is a logical extension of the biological systems in our bodies
This aspect is a small but I believe important and unique element to the program because it frames the individual in health and disease in the context of the larger society in which we live (http://thecommonvein.net/rsna05/doc.asp?docid=5737)
Content
What will you include in your project that warrants its creation in an electronic format
The content can be viewed on the web site. The navigation and manipulability of the program requires electronic format. The focus and domination of images also warrants use of the electronic format.
Detail the software features you expect the program to contain
The software design has been established and a newer navigation system is being developed. Software for security and billing will need to be instituted.
How is the audience currently receiving/learning this information?
Multiple textbooks dedicated to each subspecialty which by design do not have a consistent nor uniform format across the disciplines
Is this product derived from an existing textbook or a text in progress?
No
Subject
What field and subfield(s) does the project cover
It starts out with anatomy physiology and pathology and advances to the clinical sciences that cover clinical diagnosis and imaging and then treatment
Is the coverage comprehensive or selective?
The emphasis is on principles and therefore the detail at the first level is not comprehensive
Approach
How is the subject treated: succinctly, expansively, conceptually, and practically?
Starts out succinctly conceptually and practically and has the potential to be built expansively
Does the approach appeal to understanding or memorization?
Definitely understanding
Is it elementary or advanced?
Starts out as elementary information
How technical is it?
Not but can be as it grows
Is it at the cutting edge, or is it a better restatement of existing knowledge?
Better restatement of existing knowledge but cutting edge of educational method
Audiences
Please list all audiences for whom the project is written, indicating which one is primary.
Primary audience is the medical student but also could be utilized for premed students, nurses physician assistants and nurse practitioners
Can advance over time
What need will the project satisfy for each group?
Image based and principle based
Integration of basic sciences with clinical sciences
Timeliness
Please indicate why the project will be particularly responsive to the needs of the audience at the time of its planned publication.
The new generation is computercentric
The new generation utilizes images and imagery more so than previous generations
Right brained members of the population have not previously had the educational tools to support their method for learning
Radiological images are realistic accurate and are often the centre and source of diagnosis Radiological images are found on all floors of the hospital as part of the PACS systems and therefore are an integral part of day to day patient care. Early familiarity with radiological images is essential to the education of medical students and practitioners.
Images, Animations, and Audio/Video Clips
Explain use of graphics and likely number.
There are currently 14,000 images and number of images that will be used can only grow significantly limited only by manpower to code and upload and create legends for the images It is able to accommodate movies video clips sound bytes
Describe the purpose of drawings, diagrams, imaging, and micrographs.
Images speak a thousand words and sometimes can help comprehend complex concepts. Artistic renderings that may help tell a story such as described above for the spiral valves of Heister, strawberry gallbladder and phrygian cap are techniques that foster memory and culture
Indicate need and rationale for use of animation and/or audio and video clips.
Plan is make a video library as the one already established for static images. Cardiac motion for example is easily captured and reproduced for the web They enhance the learning process. Potential to create a large video image library
Features
What outstanding features will the project offer? List new ideas or conceptual or organizational approaches, search devices, graphic explanations, uniquely useful information, etc.
I believe this has been covered in the opening statements under ?purpose?
Competition
What are the differences between the proposed project and existing competitors in degree of innovation, breadth, depth, or timeliness, as well as amount of new material? Does the proposed project complement or supplement significant other products? List the competing titles in your proposal.
As far as I understand the market there is no product with the same vision nor with the same potential utility. The scope crosses multiple disciplines and very few books do this to the extent already established on the TCV website. I am convinced about the utility, value, and practicality since I have been on the side of the medical student and the side of the clinician for many years and have a good sense what knowledge has practical value. I use these concepts every day of my clinical career and teaching career. The accomplishment and materialization of the project will only be limited by lack of sufficient support. A company that provides full throttle support to help fill in the content will have a product that I believe and have believed, will be the future of medical education.
Audience
The audience is primarily the medical student but the program like a tree is at the earliest branches which can continue to evolve into greater complexity.
Software Specifications
The program runs off a web server and requires internet explorer. It is database driven and currently uses Microsoft Access. The intent is to transition it to a sequel server database. The navigation system is cumbersome and is currently being revised to avoid the excessive clicks required to get to a particular destination.
Detailed Content Outline
The website can be found at URL http://www.thecommonvein.net/rsna05/index.asp?accesstypeid=157
Sample Material
The website can be found at URLhttp://www.thecommonvein.net/rsna05/index.asp?accesstypeid=157
Recommend review of aorta gallbladder pancreas colon lungs which are fairly comprehensive