How Virtual Reality training can help healthcare professionals retain crucial information.
Healthcare professionals are tasked with learning and retaining an enormous amount of knowledge and skills. Whether the task is to master human anatomy and physiology, the symptoms associated with a broad range of diseases and disorders, or the skills associated with performing some routine or non-routine medical procedure, healthcare professional undergo an enormous amount of training to ensure excellence when treating patients. In addition, healthcare professionals are expected to apply this knowledge and these skills under a broad range of challenging situations including time pressure, social stress, and other sub-optimal conditions.
Unfortunately, and as all healthcare professionals know first-hand, the brain is hardwired to forget. This has been known implicitly for centuries, but was formalized scientifically in 1885 when Hermann Ebbinghaus embarked on a journey to characterize and quantify the time-course of learning and memory, and in the process discovered the “forgetting curve”.
A typical forgetting curve is displayed below. The y-axis denotes the retention rate that ranges from 0 to 100%, and the x-axis denotes time. The blue dot in the upper left represents the initial level of learning. In this example, we assume that the learner obtained 100% of the knowledge initially. The red curve is the forgetting curve. Notice that the rate of forgetting is rapid initially and then tapers off over time. The retention rates of 60% after 20 minutes, 40% after one day, and 15% after a week are hypothetical but are in line with many scientific studies. Although the retention rates depend upon the nature of initial training and the type of information studied, the shape remains the same.
What this means is that you can train to perfection today, but you will immediately start to forget and ultimately will retain only a small portion of the information. This is a serious problem in any training setting, but is especially problematic in healthcare. The last thing that you want is for your healthcare professional to forget some critical piece of knowledge.
The neuroscience of information and skills retention and the problem of forgetting are fascinating. In this report, we discuss these issues and show how traditional approaches to training that rely predominantly on text, and some simulation or hands-on training exacerbate the problem. We then discuss the neuroscience of learning with immersive technologies like virtual reality (VR) and augmented reality (AR), and show why their grounding in experience is advantageous for guarding against forgetting. We show that the ability for endless study and practice enhances “Training for Retention”, and builds situational awareness in healthcare.
First, we need a brief primer on the neuroscience of learning.
“Learning is an experience. Everything else is just information”
This is an insightful quote from Albert Einstein that is supported by the neuroscience of learning. But why? What is it about experience that is so rich that it is fundamental to learning, and why is information so much less effective?
As outlined in the figure below, the human brain is comprised of at least four distinct learning systems. As Einstein so eloquently stated, the experience is at the heart of learning. Importantly, it is also at the foundation of VR and AR. The experiential system has evolved to represent the sensory aspects of an experience, whether visual, auditory, tactile or olfactory. Every experience is unique, adds rich context to the learning and is immersive. The critical brain regions associated with experiential learning are the occipital lobes (sight), temporal lobes (sound), and parietal lobes (touch).
The cognitive system is the information system. It processes and stores knowledge and facts. Cognitive information comes in the form of text, graphics, or video and is processed using working memory and attention. Critically, these are limited resources and form a bottleneck that slows learning with more information coming in and available to the learner (the green arrows) than can be processed (the red arrow). This system encompasses the prefrontal cortex and hippocampus.
The behavioral system in the brain has evolved to learn motor skills. It is one thing to know what to do, but it is completely different (and mediated by different systems in the brain) to know how to do it. Processing in this system is optimized when behavior is interactive and is followed in real-time (literally within milliseconds) by corrective feedback. Behaviors that are rewarded lead to dopamine release into the striatum that incrementally increases the likelihood of eliciting that behavior again in the same context. Behaviors that are punished do not lead to dopamine release into the striatum thus incrementally decreasing the likelihood of eliciting that behavior again in the same context. Real-time feedback is critical because striatal activation decays quickly (within a few 100 milliseconds) following initiation of behavior. If a correct behavior is elicited, but feedback is delayed, even by a second or two, the dopamine will be released into the striatum, but striatal activation (driven by the behavior) will be so weak that no learning will occur. Similarly, if an incorrect behavior is elicited, but feedback is delayed, the striatal activation (driven by the behavior) will be so weak that the system won’t know what behavior to unlearn.
The emotional learning system in the brain has evolved to facilitate the development of situational awareness — the ability to read nuance in a situation and the uncanny ability to know what comes next — as well as empathy and understanding of our and others’ behaviors. Whereas one can have all of the facts and figures available and can have a strong behavioral repertoire, in the end, one has to extract the appropriate information and engage the appropriate behavior in each distinct situation. The critical brain regions are the amygdala and other limbic structures. The detailed processing characteristics of this system are less well understood than the cognitive and behavioral skills learning systems, but emotional learning is at the heart of situational awareness, and strongly affects both cognitive and behavioral skills learning. An individual with strong situational awareness can accurately read any situation, adapts quickly and knows what to do in each situation, and has the behavioral repertoire to engage each situation with the appropriate set of behaviors.
Using anatomy and physiology training as an example, let’s explore the traditional approach to training. You start with textbook and classroom study, then transition to some hands-on training or a cadaver lab. Because of the cost associated with hands-on and cadaver lab training, invariably classroom and textbook training is emphasized.
From a neuroscience perspective, this traditional approach starts by engaging the cognitive system as you sit in class and study textbooks. The human body is a 3-dimensional structure that functions as a dynamic system. Thus, the goal is to obtain a 3-dimensional, dynamic representation in your brain. Although the best way to achieve this goal is to present the learner with a 3D dynamic training tool, instead you start with textbooks or slide shows that are filled with 2D static images. The learner must convert a series of 2D static images into a 3D dynamic mental representation in the brain that accurately reflects the human form. The cognitive effort needed to do this is enormous. Given the fact that working memory and attention are limited capacity resources, this process with is slow, challenging, and error-prone.
In the laboratory, further cognitive training occurs, and the behavioral system is also engaged as the healthcare professional practices particular tasks. At some point, the professional is deemed “ready” and they are sent out to a clinic or hospital where the real learning occurs, on-the-job. Healthcare professionals often lament at how little of their classroom and laboratory training actually transfers to the real world. The brain tells us why. All of the training has been sequential and disjointed. It would be much better to emphasize experience and to train knowledge and skills simultaneously.
Now consider an immersive approach to the same training. Consider an AR or VR tool for teaching anatomy and physiology where a highly accurate 3D dynamic representation of the 3D dynamic human form is presented. The learner can move and rotate the virtual body and when certain body parts are “touched” a description of the part and its function is provided. Layers of virtual tissue can be removed so that the inner workings of the body can be explored.
From a neuroscience perspective, this immersive approach engages the experiential, cognitive and behavioral learning systems in synchrony. This broad-based neural activation leads to a highly interconnected, context-rich set of learning and memory traces. These highly interconnected memory traces will be slower to decay over time leading to better long-term retention. Because immersive training tools are available 24/7 the healthcare professional can have unlimited practice, and can test themselves under adverse conditions such as time pressure that will engage the emotional learning centers in the brain to begin to build situational awareness.
Immersive tools can also be used to train the behavioral skills necessary in healthcare. These can range from something simple like the care and maintenance of a central line, to something complex like heart surgery. Although any tool of this sort must be vetted with extensive clinical testing, the potential is clear. Imagine a VR or AR system in which a virtual patient is present. You go through the steps of central line care or heart surgery. The haptics are such that you “feel” the skin push back against your scalpel.
Much like with the anatomy and physiology training tool, this immersive approach engages the experiential, cognitive and behavioral learning systems in synchrony. This broad-based neural activation leads to a highly interconnected, context-rich set of learning and memory traces that are slow to decay and lead to better long-term retention. Because immersive training tools are available 24/7 the healthcare professional can have unlimited practice and can train and test themselves under a broad range of environmental conditions. This engages emotional learning centers and builds the situational awareness that is so critical in healthcare. Imagine training for the rare, but potentially life-threatening, situation in which an emergency medical technician needs to deliver a baby in the back of a van with minimal medical equipment available. Imagine training under chaotic conditions in which a healthcare professional must perform some medical procedure in a crowded hotel lobby with dozens of panicked onlookers. Imagine time is of the essence.
Although these may be rare situations, training under these conditions is critical for developing a broad-based knowledge and skill set. The best healthcare professional is one who is confident in their abilities and knows that they can handle almost any challenge. This instills confidence in the professional, but more importantly, this confidence shows and enhances patient satisfaction and confidence in the healthcare profession.
Gone will be the days of on-the-job training. With immersive technologies, healthcare professionals can start day 1 on the job with a strong knowledge-based and behavioral repertoire that has been honed and testing in immersive environments. Immersive technology trains for retention and builds situational awareness that is critical in healthcare.
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