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| EDITORIAL |
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| Year : 2019 | Volume
: 5
| Issue : 4 | Page : 133-137 |
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The promise of virtual reality in health-care education and training: It's all in the neuroscience
Todd Maddox1, Timothy Fitzpatrick2
1 Cognitive Design and Statistical Consulting LLC, Austin, Texas, USA
2 IKONA Health, Inc., New York City, New York, USA
| Date of Submission | 13-Nov-2019 |
| Date of Decision | 29-Nov-2019 |
| Date of Acceptance | 06-Dec-2019 |
| Date of Web Publication | 13-Apr-2020 |
Correspondence Address:
Todd Maddox
Immersive Learning and Data Scientist, IKONA Health Inc., One Penn Plaza #6243, New York, NY 10119
USA
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/digm.digm_26_19
How to cite this article:
Maddox T, Fitzpatrick T. The promise of virtual reality in health-care education and training: It's all in the neuroscience. Digit Med 2019;5:133-7 |
| Introduction | |  |
In this editorial, we discuss the promise of virtual reality (VR) as an effective education and training tool in health care. We review the neurobiology of learning and performance and show that VR broadly engages multiple learning and performance systems in the brain in synchrony. This “spreads the wealth” of educational and training opportunities across the brain while simultaneously “reducing the burden” on cognitive processing systems in the brain. We argue that traditional approaches to health-care education and training are suboptimal because they target almost exclusively cognitive learning and performance systems in the brain, whereas VR targets a broad and comprehensive array of learning and performance systems in the brain.
| The Problem of Health-Care Education and Training | | |
Education and training of patients and health-care professionals is critical for providing high-quality care and for achieving successful healthcare outcomes. Patients need education and training on issues such as preoperative, perioperative, and postoperative surgical procedures, the side effects of medications and drug interactions, the proper use of medical devices, such as a colostomy bag or a peritoneal dialysis machine, and the cognitive, emotional, and physical changes associated with various disorders or normal aging, to name a few.
Health-care professionals need education and training not only on these same topics but also on health insurance portability and accountability act (HIPPA) compliance, medical procedures such as venipuncture or the care and maintenance of a central line, surgical techniques, and most importantly interpersonal skills such as effective communication, leadership, and empathy.
Health-care education and training encompasses a broad array of cognitive skills (e.g., the ability to state the side effects of medication and drug interactions or HIPPA regulations), behavioral and motor skills (e.g., the ability to use medical devices or to perform surgery), and interpersonal and emotional skills (e.g., effective communication, leadership, and honesty and integrity).
In health care, it is also important to educate and train these cognitive, behavioral, and interpersonal skills under a broad range of environmental contexts to develop situational awareness. It is one thing to be able to recite the HIPPA regulations or maintain your peritoneal dialysis machine or communicate effectively under typical conditions, but in health care, it is critical that these skills operate at a high level under nontypical conditions as well, such as under pressure or stress.
Although an enormous amount of resources are allocated to health-care education and training, there remain significant challenges.[1] Health-care organizations struggle to achieve or maintain strong patient satisfaction scores[2] and health literacy,[3] and health-care workers express significant anxiety and stress over a lack of technical and interpersonal education and training.
In this editorial, we show that these problems are largely due to an overreliance on text, slideshows, or video to provide health-care education and training, with an underreliance on behavioral and simulation training. Text, slideshows, and video train cognitive skills, but extensive behavioral and simulation training is needed to develop the motor skills, interpersonal skills, and situational awareness that is central to high-quality health care. Behavioral and simulation training is utilized but to a much lesser degree than is necessary because of the cost associated with these training approaches.
Even so, the neuroscience is clear: a reliance on cognitive training tools does little to support education and training around behavior and motor skills, interpersonal skills, and situational awareness.
We argue that VR offers a powerful complement to behavioral and simulation training that is equally effective and more economical. Critically, VR is available 24/7 and can be implemented at scale, thus allowing patients and practitioners to obtain the extensive practice needed to develop strong behavioral repertoires and to build situational awareness. Much like behavioral and simulation training, VR achieves these aims by broadly engaging cognitive, behavioral, and emotional learning centers in the brain in synchrony and within a broad range of experiential contexts.
| The Neuroscience of Learning | | |
“Learning is an experience. Everything else is just information.”
–Albert Einstein
This insightful quote from Albert Einstein is supported by the neuroscience of learning and performance and is the primary reason why VR is so effective in health-care education and training. The human brain is comprised four distinct learning systems.
Experiential learning system
Experience is at the heart of learning and performance. The experiential system in the brain represents the sensory and perceptual aspects of each unique learning context, whether visual, auditory, tactile, or olfactory [Figure 1]. The relevant brain regions are the occipital lobes (sight), temporal lobes (sound), and parietal lobes (touch/smell). The experience provides the context and scaffolding that grounds and contextualizes all learning and builds situational awareness.
Cognitive learning system
The cognitive system is the “everything else” information system that Einstein alluded to [Figure 1]. It processes and stores knowledge and facts using working memory and attention.[4] These are limited capacity resources that form a bottleneck on the amount of information processed. This system encompasses the prefrontal cortex and hippocampus. Unfortunately, this system is slow to develop, not reaching maturity until an individual is in their mid-20s, and it begins to decline in middle age. In addition, processing in this system is adversely affected by anxiety, stress, and pressure.[5] Despite the processing limitations, developmental changes, susceptibility to stress and anxiety, and focus on information processing in this system, much of health-care education and training relies almost exclusively on this system. This explains why so much training is ineffective.
Behavioral/motor learning system
The behavioral system in the brain learns motor skills and builds “muscle memory” (Technically, muscles do not have “memory.” Rather the behavioral learning system develops memories for specific motor actions that drive muscles to perform) [Figure 2]. The critical brain structure for behavioral learning is the striatum that builds connections between environmental contexts (via the experiential and emotional learning systems) and motor behaviors.[4] These striatal connections strengthen or weaken as a function of real-time reward and punishment feedback that mediates dopamine release. Context-behavior connections that are rewarded in real-time are more likely to occur again, whereas context-behavior connections that are punished in real time are less likely to occur again. It is one thing to know “what” to do (cognitive information), but it is completely different and requires extensive practice and physical repetition to know “how” to do it (behavior). Due to the costs associated with behavioral and simulation training, extensive practice is rare in health-care education and training. Too often education is “on-the-job” in the emergency division.
Emotional learning system
The emotional learning system in the brain provides rich motivational and emotional context to the environmental context represented in the experiential learning system [Figure 2]. The critical brain regions are the amygdala and other limbic structures. Taken together, the emotional and experiential systems build situational awareness. 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. One needs to know what to do and when. This system along with the behavioral learning system is also critical for building the emotional-behavioral repertoire associated with effective interpersonal skills and empathy.
Although these four learning systems in the brain are distinct, they all reside within the same brain with massive interconnections. In nearly all health-care situations, information needs to be stored and retained (cognitive), motor skills must be perfected (behavior), situational awareness must be strong (emotional and experiential), and all of these must be present within the relevant work context (experiential). In other words, ideally, all four learning and performance systems in the brain should be activated in synchrony.
This is the promise of VR.
| A Virtual Reality Approach to Health-Care Education and Training | | |
Health-care education and training is ripe for the application of modern technologies such as VR that broadly engages multiple learning systems in the brain in synchrony. Patients will get the high-quality experiences that they so desperately need to feel informed, confident, and to reduce stress and anxiety. Health-care providers will also get the high-quality experience that they need to feel better informed, to obtain enhanced people and communication skills, and to build situational awareness.
Virtual reality for patients
With VR a patient can be transported into any “reality”. A patient can experience a full preoperative, perioperative, and postoperative surgical procedure. The patient might don a VR headset and be transported into the hospital lobby where a nurse awaits. The nurse might walk the patient through the hospital showing the patient the prep room, the surgical arena, and a typical recovery room. A patient who has already received the medical procedure might join the tour and might talk to the patient through some of the trickier parts of the procedure. All the while, the nurse and fellow patient are reassuring the patient that all will be well.
Suppose the surgery described above involved having part of the patient's colon removed and thus required the use of a colostomy bag going forward. The patient might don a VR headset and get a VR experience that shows them how to care and maintain the colostomy bag at home with the same fellow patient as the guide. Through a combination of first- and third-person perspectives, the patient gains a detailed understanding of how to care for and maintain a colostomy bag. Their fellow patient makes clear that one can live a full and productive life even with a colostomy bag. The patient begins to feel more confident and less anxious now that they understand the big picture and are familiarized with aspects of what to expect.
In both of these examples, and unlike a text, slideshow, or video-based approach, the patient is learning through an immersive experience. VR is engaging experiential and emotional centers in the brain that provide rich context and an emotional tone to the learning. The patient is gaining valuable information via cognitive centers in the brain, but activation in cognitive centers is being scaffolded by processing in other learning centers to reduce the chance of cognitive overload. If controllers or haptic gloves are utilized, then the patient can also develop the behavioral repertoire and muscle memory needed. VR broadly engages multiple systems in the brain so that the patient feels like they are there and feels like they are gaining the requisite experience. The result is greater patient satisfaction and confidence and less stress and anxiety.[6]
Virtual reality for providers
With VR, a provider can learn anatomy and physiology from a “virtual” human body that is three dimensional (3D) and dynamic and does not require extensive cognitive processing of 2D, abstract, and static text or figures. With the tap of a finger, the provider can be transported inside the blood vessels or into any organ. This frees cognitive resources to learn the names of the bones, muscles, arteries, etc., but with a rich visual mental representation upon which to attach them. With VR, a provider can learn critical technical skills such as venipuncture, care, and maintenance of a central line, or a complex knee surgery, to name just a few. Critically, as these skills require extensive practice, VR can be utilized over and over again with real-time feedback to build the necessary muscle memory.
Interpersonal skills, empathy, and situational awareness are what set the best health-care professional apart from the rest. These skills cannot be trained with text, slideshows, or video, but with VR, one has the ability to “walk a mile in someone else's shoes” and to experience a broad range of situations. Imagine donning a VR headset and “walking a mile in the shoes of a patient.” The “patient” might be listening to a health-care professional who describes their condition, but from the patient's perspective, the speech is too fast, the words sound nonsensical, and the patient is getting agitated. Analogously, a nurse in training might be transported into the middle of a busy emergency room while shadowing a seasoned nurse explaining a patient's condition to their distraught spouse, in a calm, compassionate, and empathetic manner. Using voice-over, the seasoned nurse might explain how they are showing empathy to sooth the concerns of the spouse. The nurse in training is in the situation and can feel the emotions. They can combine the information provided by the seasoned nurse with the behaviors they are observing, all within an emotion-laden, realistic experience.
These are just a few of numerous examples of how VR can be used to educate and train health-care providers. VR engages multiple learning systems in the brain in synchrony and allows providers to obtain the extensive practice necessary to build strong behavioral repertoires, interpersonal skills, and situational awareness needed to be effective.
| Summary and Future Directions | | |
The use of VR technology in all aspects of health-care education and training is increasing, especially when it comes to building behavioral repertoires, nurturing interpersonal skills, and developing situational awareness. In this editorial, we review the neuroscience of learning and show that VR engages experiential, cognitive, behavioral, and emotional learning centers in the brain in synchrony. This not only spreads the wealth of knowledge and distributes it across the brain but also distributes the burden, and critically, guards against overloading the cognitive system that will lead to errors and a lack of understanding. VR is available 24/7 and at scale, allowing the repetition and broad-based training needed to develop muscle memory and situational awareness.
The future of VR in health care is bright. Although not discussed to this point, one of the biggest advantages of VR is the ability to collect a broad set of data. Whether subjective ratings of satisfaction and confidence or objective tests of one's knowledge or ability to make the right decision, data collection is easy. Other measures such as eye-gaze patterns can also be examined. As eye gaze and eye fixation provide a window onto attentional processes, at a minimum, these can be used, along with subjective and objective measures to optimize VR content.
As other technologies come on line such as real-time and natural haptic interactions, olfactory cues, and AI-driven real-time voice and facial recognition, the use case for VR will grow. VR educates and trains one experience at a time.
| References | | |
| 1. | Tolsgaard MG, Tabor A, Madsen ME, Wulff CB, Dyre L, Ringsted C, et al. Linking quality of care and training costs: Cost-effectiveness in health professions education. Med Educ 2015;49:1263-71.  |
| 2. | Centers for Medicare & Medicaid Services. HCAHPS: Patients' Perspectives of Care Survey; 2018. |
| 3. | U. S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. America's Health Literacy: Why We Need Accessible Health Information; 2018. |
| 4. | Maddox WT, Ashby FG. Dissociating explicit and procedural-learning based systems of perceptual category learning. Behav Processes 2004;66:309-32. |
| 5. | Maddox WT, Markman AB. The motivation-cognition interface in learning and decision-making. Curr Dir Psychol Sci 2010;19:106-10. |
| 6. | Bekelis K, Calnan D, Simmons N, MacKenzie TA, Kakoulides G. Effect of an immersive preoperative virtual reality experience on patient reported outcomes: A randomized controlled trial. Ann Surg 2017;265:1068-73. |
[Figure 1], [Figure 2]
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