Of the myriad barriers patients face when it comes to kidney education, low health literacy, low baseline awareness, access to information and readiness to learn are among their top challenges. From a provider’s perspective, a lack of time combined with competing educational priorities and confusion around diagnosing kidney disease leads to low confidence and frustration with their ability to provide more chronic kidney disease (CKD)-specific patient care. With one third of all Americans at risk of developing kidney disease and 90 million Americans facing low health literacy, we can be confident these trends will remain for tens of millions of people for years to come. The status quo in education is ad hoc and lacks the personalization needed to deliver effective learning outcomes. Clearly, we need to build a better education experience for patients and providers alike— one that recognizes our inherent barriers and leverages proven strategies to overcome them for each individual patient.
What is learning science?
To address this problem, we turn to learning science —the marriage of psychology and neuroscience of learning. Learning science makes clear that there are two components to effective education. The first component is the educational content. Educational content represents the critical pieces of information that must be conveyed to patients and providers, from basic kidney functions to understanding lab values. The second component involves the delivery of that content. This addresses the medium through which the content is presented to the patient (e.g., text or video), as well as the nature and timing of the delivery.
Why this is a learning problem
In the CKD arena, as in any area of health care, educational content is developed by subject matter experts (SMEs). Even a cursory review of available CKD educational content makes clear that extensive, high-quality content already exists today.
The problem with kidney education today is not with the content itself; rather, the problem is with its delivery.
That is, even when a patient is able to access this content, other barriers often remain in their way. Optimizing content delivery is an approach that transcends an educational topic itself, and, in fact, is the purview of learning science. Learning scientists are not clinical subject matter experts, but instead focus on the psychological processes inherent in the learner and the neurobiological basis of learning. They use this knowledge to determine how best to organize and deliver the topic-specific content in a way that optimizes learning and long-term retention.
Goals of a learning scientist
Education programs have two goals: to speed initial learning and to enhance long-term retention. In an ideal world, you want learners to understand everything they are being taught, and to remember as much of those lessons as possible, for as long as possible. Although initial learning and long-term retention are related, strong initial learning does not guarantee long-term retention and mastery. Let’s take these two goals with us as we assess the status quo in health education.
Think about how patients typically learn new concepts, facts, and figures. An individual is presented with information, usually in the form of printed handouts, classes or videos. The first questions a learning scientist will ask are:
“Which brain region(s) are needed to process this information, and what are the processing limitations of those brain region(s) that should be addressed during content delivery?”
This is where knowledge of our biological limitations is critical. The part of the brain used for information processing is called the prefrontal cortex. The goal of the prefrontal cortex is to use short-term (working) memory and attention to process the information. So, given that working memory and attention spans are quite limited, it becomes absolutely vital that we do not exceed these two attributes during the learning process. If either (or both) are exceeded, learning will be adversely affected, and critical pieces of information will not be learned. We’ve all been there, trying to remember details from a study session, lecture, or even this article! But recall our two learning goals: in order to move from our first goal of speeding initial learning to our second goal of enhancing long term retention, we need to find a way to transfer that newfound knowledge in the prefrontal cortex back to the memory stores in a part of the brain called the hippocampus.
We have the tools we need
We have some good news! Learning scientists long ago identified three tools that have been shown to address these challenges.
The first tool is called microlearning. One of the best ways to reduce the working memory and attention load during content delivery is to use microlearning, an approach that focuses on conveying information about a single idea with as few “extras” as possible within a brief time span of around 5 to 10 minutes. Taken together this reduces the load on working memory while minimizing the likelihood that the learner’s attention span is exceeded. Microlearning offers the best chance for information processing to be effective and initial learning to be optimized.
The second is called spaced testing. To speed the transition from initial learning to long-term memory retention, microlearning should be complemented with spaced testing. Spaced testing should be incorporated to help ensure initial learning and to identify previously trained information that is poorly retained.
The third tool is called retraining. As a learner progresses through a syllabus, new information should include a mix of poorly learned information (identified by spaced testing) to strengthen long-term memory representations, as well as new material that builds upon the old.
With this approach you know that the prior knowledge is well represented and will serve as a foundation for future learning. Said another way, if that prior knowledge is poorly represented, then it is fruitless to introduce new material because there will be no knowledge foundation upon which to build, and learning will be ineffective.
What does this look like?
Let’s dive into an example within the kidney education space to demonstrate how these tools might look and function in practice. People with stage four kidney disease, the stage prior to kidney failure, often go through a series of classes to help familiarize and prepare them for their available treatment options as they near End Stage Kidney Disease (ESKD). These classes cover dozens of topics, from treatment goals and medications to lab values and nutrition. Like many health education programs, these are often done in person through a series of hour long instructional sessions with a nephrology-trained provider.
Now let’s apply our three tools with our ultimate goals in mind: increasing initial learning and enhancing long term retention. First, we can break up each of these courses into their constituent subtopics (i.e. goals, medications, nutrition), aiming for 5 to 10 minutes worth of information (microlearning). The first lesson on treatment goals would be followed by a 1 to 2 minutes break where the learner is allowed to relax, which enables their brains to begin to consolidate the information they have just learned. Next, we move on to a 5 to 10 minute lesson on medications, which might include new delivery formats like video, text, animation and even interactivity. After a second break for consolidation, it’s time for the first test (spaced testing). With frequent testing, we will quickly be able to assess initial learning and identify areas that will require retraining.
Remember, you cannot build upon of a weak (or missing) foundation.
This method continues on for the duration of the session, however long and however many sessions are required for a learner to fully grasp the subject matter in a way they can use to manage their own health. Here is the key takeaway: if a patient needs to learn 60 minutes’ worth of information, it is better for that patient to spend 90 minutes in a program that utilizes microlearning, spaced testing and retraining, than to spend an hour listening to a lecture. Even if a program takes several days, weeks, or months to reach completion, the educational outcomes realized in the learning science-based approach far exceed those you can expect from the status quo. Additionally, though this example is for an in-person educational program, the same methods apply virtually as well. Given that many consultations these days are done remotely in an effort to keep people safe and healthy, and like many we expect this trend to expand in the years ahead, we need to have better tools for educators who will spend their time educating remotely and remain reliant upon traditional methods of instruction without the benefits of face to face interactions.
Every education program aims to achieve two goals: to increase initial learning and to enhance long term retention. Oftentimes, in health care settings especially, the realization of these goals is inhibited by barriers including low health literacy, low baseline awareness, and the complex nature of health information being presented. Fortunately, given that these are learning challenges, we can turn to decades of research in learning science for answers.
Three tools are especially useful to us in our quest to improve initial learning and retention: microlearning, spaced testing, and retraining.
We have shown that applying these strategies to existing kidney education efforts is not only possible, but that doing so will drastically improve the outcomes we are hoping to achieve. Future articles will discuss how these same concepts have been woven into the fabric of our learning platform at IKONA, with the addition of time-, literacy- and preference-based parameters that lead to truly personalized learning for every patient.