Todd Maddox examines how Extended Reality (XR) is an ideal tool to enable faster and more efficient familiarization with complex medical devices.
edical devices are essential for safe and effective prevention, diagnosis, treatment and rehabilitation of illness and disease. Many are used in the patient’s home allowing patients to lead normal lives, and to address their health needs on their own or with loved ones. Critically, high-quality education and training on these devices is required to avoid complications resulting from incorrect care and maintenance. For example, the Continuous Positive Airway Pressure (CPAP) system commonly used to treat obstructive sleep apnea, is a complex system that requires sterilization on a daily basis to avoid infection. In addition, poor cleaning and maintenance of a colostomy bag can be life-threatening. Finally, medical devices such as in-home peritoneal dialysis machines to address kidney disease, and insulin infusion pumps to treat diabetes are central to patient care, but these systems must be maintained to avoid complications. Although the existence of these medical devices increases the patient’s freedom and quality of life by allowing them to be treated at home, medical personnel are not readily available should something go wrong. This makes quality education and training critical to success.
By far the most common approach to medical device education is to have patients read documents describing the device and outlining the steps needed to care and maintain the device. Patients are expected to study and memorize the steps so that they can effectively care and maintain the device and avoid complications. This approach leaves it to the patient to determine proficiency and leaves the patient at risk when proficiency has not been achieved. With more complex systems, such as a peritoneal dialysis machine, document training will be supplemented with classroom and hands-on training with an expert. Although clearly superior to document training alone, this is time-consuming, costly, and is difficult to scale.
The neuroscience of learning and performance suggests that this traditional approach to medical device training is sub-optimal for at least two reasons. First, document training focuses almost exclusively on cognitive learning, when what is needed is broad-based experiential and behavioral learning. Second, hands-on training with an expert, although effective, is rarely extensive enough to ensure broad-based proficiency.
In this report, we discuss the neuroscience of learning and performance. We show why traditional approaches to medical device training are sub-optimal and can leave patients vulnerable to complication. We also show how immersive technologies like virtual reality (VR) and augmented reality (AR) hold great promise for optimizing medical device training.
As outlined in the figure below, the human brain is comprised of at least four distinct learning systems: experiential, cognitive, behavioral and emotional. As alluded to by Einstein, experience is at the heart of learning, and forms the foundation of VR and AR. The experiential system represents the sensory and perceptual aspects of an experience, whether visual, auditory, tactile or olfactory. Because every experience is unique and is immersive, this adds rich context and nuance to the learning. These enhance generalization and transfer of learning. 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. This is the “everything else” that Einstein noted. The cognitive system processes and stores knowledge and facts that usually come in the form of text, graphics, or video. The cognitive system is truly amazing and is more developed in humans than in any other organism, but it relies on working memory and attention that are limited resources and form a bottleneck that slows learning. More information comes into the system and is available to the learner (the green arrows) than can be processed (the red arrow). This system encompasses the prefrontal cortex and hippocampus. Importantly, this system is slow to develop and starts to decline in middle age when health issues begin to arise.
The behavioral system in the brain has evolved to learn motor skills. It is one thing to memorize the steps needed to care and maintain a medical device, but it is completely different (and mediated by different systems in the brain) to know how to perform those steps. The behavioral learning system is fascinating, but its detailed processing characteristics are beyond the scope of this report. Suffice it to say that 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.
The emotional learning system in the brain has evolved to facilitate the development of situational awareness — the ability to read nuance in a situation, to know what comes next, and to deal effectively with stress, pressure, and anxiety. This system affects processing in the cognitive and behavioral systems and helps patients learn to care and maintain medical devices under stress or pressure, or when “things just aren’t going right”. The critical brain regions are the amygdala and other limbic structures. Emotional learning is at the heart of situational awareness.
Using an insulin infusion pump as an example, let’s explore the traditional approach to training. The patient starts by reading documents that outline step-by-step how to care, maintain, and use the insulin pump. Then the patient may receive some hands-on training where they observe as an expert cleans and sets the pump up for usage. The patient may be given the opportunity to demonstrate the steps to the expert while receiving feedback. Because hands-on training is so time-intensive and costly, document and do-it-yourself training is usually emphasized.
From a neuroscience perspective, this approach starts by engaging the cognitive system as the patient reads documents and attempts to memorize the steps. Because the infusion pump is a 3-dimensional object and the system is dynamic (pushing insulin into the body), it is challenging to fully understand how the system works when the information being processed by the patient is 2-dimensional, static, and usually text-based. The patient must convert 2-dimensional static information into a 3-dimensional dynamic mental representation in the brain that accurately reflects the operation of the infusion pump. The cognitive effort needed to do this is enormous. Given the fact that working memory and attention are limited capacity resources, this process with be slow, challenging, and error-prone.
During the hands-on training, the patient can “experience” the system in action while watching an expert. This combines experiential learning with cognitive learning. When the patient is given a chance to care and maintain the device while receiving corrective feedback from the expert, behavioral learning is added to the mix. Although effective, behavioral learning is gradual and incremental and proficiency takes extensive practice, usually more than is provided in traditional training settings. In addition, it is rare that uncommon situations are trained.
At some point, the patient is deemed “ready” and they are allowed to take the infusion pump home. It is at this stage when the patient is at the greatest risk. They have a basic understanding of the care and maintenance of the infusion pump, but do not have extensive experience, and lack confidence. The brain tells us why. All of the training has been sequential and disjointed. Training starts with documents that train the cognitive system. Experience is then added to the mix, with behavioral training occurring last. What the patient really needs is for cognitive, experiential and behavioral learning to occur simultaneously, and in the environment where the infusion pump will be used (i.e., in the home). In addition, they need situational awareness training to deal with cases in which they are under stress or pressure, or when things are not going according to plan.
Now consider an immersive approach to infusion pump training. Suppose the patient dons a VR headset and is immersed in a 360 experience with an expert who has used an infusion pump for years. The patient can watch as the expert demonstrates and verbally describes the step-by-step procedures needed to care and maintain the infusion pump. The patient can view this from a third-person perspective, but also from the first-person perspective. The expert can demonstrate common pitfalls and how to address them, while describing them verbally. The expert can do all of this while demonstrating a calm demeanor. The patient can view the VR experience and can complete knowledge checks at the end to ensure that they have the requisite knowledge. They can view the experience as many times as they like until they are confident in their own skills.
To train the behavioral aspects of infusion pump care and maintenance, one could utilize an interactive VR setup, or an AR solution. Imagine using your tablet or a hands-free AR device that uses computer vision to identify the make and model of your infusion pump. The AR system uses visual assets such as arrows, highlights, text and such to guide you step-by-step through the care and maintenance of the system. As each step is completed, you are rewarded with success and move on to the next step in the process. You can practice the process as many times as you like, and even under time pressure.
From a neuroscience perspective, this immersive VR/AR approach engages all four learning systems in synchrony. In AR, assets are providing the necessary cognitive information. The learning is happening in real-time and through experience, with the patient generating the relevant behaviors and being rewarded or punished. 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 these VR and AR training tools are available 24/7 the patient can have unlimited practice, and can train and test themselves under a broad range of environmental conditions. If they are unsure of a step, they simply pull out their VR headset or tablet, start the VR or AR software and are guided through the relevant steps.
Gone will be the days where medical device training for patients is inadequate, and patients are at risk of complication. With immersive technologies, patients can be given standardized and highly effective training from day 1. They can obtain experiential familiarization and practice as many times as they like. They can receive training on rare, but life-threatening situations so that they are prepared for anything. Because these immersive technologies broadly engage multiple learning systems in the brain in synchrony, the patient will obtain a strong knowledge base and behavioral repertoire that have been honed and testing. Patients will be more satisfied and confident, and fewer complications will arise.