Updated: Aug 29, 2020
By Todd Maddox, PhD and Tim Fitzpatrick
Kidney disease is a public health crisis in the United States. The so-called “silent killer” ranks as the ninth leading cause of death in America and affects over 37 million individuals. With diabetes and hypertension as its two leading causes, a third of all Americans are at risk. And in terms of financial impact, approximately 20% of Medicare dollars —over $114 billion each year— are spent on patients fighting the disease.
For those who enter kidney failure, or end stage renal disease (ESRD), which typically happens when you have only 10 to 15 percent of your kidney function left, dialysis is the most common treatment option. Among all patients on dialysis, about 90% are treated in a hospital or dialysis clinic. However, the recent Executive Order on Advancing American Kidney Health aims to increase the number of patients receiving dialysis treatments at home as well as the number of kidneys made available for transplantation.
One of the best ways to reduce the prevalence of kidney disease, to address it effectively once the disease takes hold, and to help patients decide what type of dialysis (in clinic or at home) or a transplant is right for them is through high-quality education and training. This education and training should be targeted at the three pillars of healthcare: patients, providers, and the patient-provider interaction.
In this report we focus on the use of immersive technologies, like virtual reality, as a complement to traditional kidney care education and training approaches. We begin by briefly outlining the education and training needs of patients and providers. Next we discuss the neuroscience of human learning. We make the point that a plethora of high quality educational content exists (e.g. NIDDK, NKF, Mayo Clinic), but that the education and training problems reside with the modes of delivery of said content. There is too much emphasis on providing information through text or PowerPoint, and not enough emphasis on experiential learning. Finally, we tell the stories of three hypothetical individuals who struggle with traditional kidney education and training programs. In each case, we outline a kidney care learning journey that incorporates storytelling using virtual reality, and builds upon the strength of experiential learning. We close with some concluding remarks and areas for further discussion, consideration, and research.
Education and Training Needs
Neuroscientific Basis of Learning
Patient-Focused Education (Samuel)
Provider-Focused Training (Susan)
Patient-Provider Interaction (Aiko)
Education and Training Needs within Kidney Care
Patients and providers are desperate for high-quality, effective kidney care education and training. For patients, education on how to manage diabetes and hypertension is important. Likewise, education around kidney structure and function, slowing the progression of kidney disease, and available treatment options is critical. When faced with kidney failure and a host of other potential health issues, patients need education on their options that include in-clinic hemodialysis, at home dialysis options and transplantation. If a home option is chosen, then the patient needs training on how to care and maintain any new and unfamiliar equipment.
Clinicians and frontline staff have similar needs. Personnel must understand the relationship between related health issues like diabetes, hypertension and kidney disease, and how that impacts their patients and their treatment considerations. An understanding of the structures and functions of the kidneys is critical. Finally, they must know how to care and maintain the equipment required for treating their patients.
Just as important, and unfortunately often overlooked, is the need for effective education and training around the patient-provider interaction. It is one thing to have expertise around kidney structure and function, kidney dialysis, and transplantation, but it is something completely different to know how to convey that information to patients in an effective and empathetic manner.
Frontline health professionals play a key role in the overall experience and health outcomes of the patients she or he interacts with. A confident, consistent, and well-prepared care team member leaves an indelible impression. Importantly, the opposite is also true.
Neuroscience of Learning
High quality educational content on all aspects of kidney structure and function, dialysis and transplantation is prevalent. One need only visit the National Kidney Foundation website, or the National Institute of Diabetes and Digestive and Kidney Diseases to find a trove of information.
The healthcare education and training problem around kidney care is not with the content, but rather with the mode of delivery. By far the most common approach to kidney education and training for patients and providers is to read written documents, view PowerPoint or watch videos. From a psychology and neuroscience of learning perspective, this traditional approach to training predominantly engages the cognitive skills learning system in the brain (Figure 1). Cognitive learning occurs in the prefrontal cortex of the brain, and requires working memory and attention, both of which are limited capacity resources.
While these traditional approaches like text, diagrams and images are 2-dimensional, static, and abstract representations, the subjects themselves (kidneys, systems, devices) are 3-dimensional and dynamic.
The amount of cognitive resources, in the form of working memory and attention, needed to construct a 3D dynamic representation in the brain, from 2D, static and abstract knowledge (even when supplemented with video) is a nearly impossible task — and one that is prone to error.
Figure 1: Learning and performance systems in the brain.
"Learning is an experience. Everything else is just information."
This insightful statement from Albert Einstein is supported by the neuroscience of learning. Simply put we learn best through experience. Critically, the neuroscience literature shows that there are at least four distinct learning systems in the brain. Each is “tuned” to a particular type of learning. These are the cognitive, behavioral, emotional, and experiential learning systems.
The most effective learning occurs when the experiential system is highly engaged and in synchrony with engagement of the other learning systems.
Each of these systems has different operating characteristics, and thus the “experiences” that most effectively engage each system are different.
Experiential learning involves a sensory and perceptual representation of the sights, sounds, tactile and olfactory aspects of a learning environment by engaging the occipital, parietal, and temporal lobes of the brain. Behavioral learning is critical in healthcare. It is one thing to know “what” to do, but another to know “how” to do it. Learning “how” is about learning behavior. Behavioral learning occurs in the striatum, a subcortical structure in the brain and requires real-time immediate feedback to increase the prevalence of correct behaviors, and decrease the prevalence of incorrect behaviors. Thus, a cognitive understanding only marginally influences behavioral learning. Emotional learning is critical for effective communication and empathy building, but is also critical for situational awareness. A healthcare professional with strong situational awareness can read any situation and adjust accordingly. Situationally aware individuals also have an uncanny ability to predict the future, and know how to react to sudden changes. Emotional learning occurs in the amygdala and other limbic regions and can up- and down-regulate cognitive and behavioral learning. Behavioral learning and situational awareness require extensive practice and physical repetitions.
We turn now to the stories from three hypothetical individuals. Samuel is an in-clinic dialysis patient who has decided to switch to home dialysis. Susan is a frontline healthcare professional learning to care, maintain and operate several types of home dialysis for her patients. Aiko is a dialysis patient who is preparing to have a kidney transplant but is stressed and anxious about the surgery and yearns for a deeper understanding of the procedure and how it will change her life.
Patient Focused Kidney Care Education and Training
Two years ago Samuel landed in the hospital with kidney failure. He has been on hemodialysis ever since, driving 10 miles to the local kidney dialysis clinic three times a week. He spends hours there and feels tied down, with little opportunity to travel or relax at home with family and friends. A colleague at work recently informed Samuel that home dialysis is an option. Samuel wanted to learn more. He talked to his nephrologist who directed him to a number of websites where he could find documents describing the pros and cons of home dialysis. Samuel struggled to fully comprehend how his day-to-day life would be different on home dialysis, but in the end, he decided that he wanted to give it a go. [For a discussion of the problems associated with medical device decisions based solely on documents follow this link.]
Although different dialysis providers offer different training curriculum, Samuel’s dialysis provider offered a 12 week home dialysis training course that promised to train Samuel on the home dialysis machine. The education and training curriculum involved a combination of online learning (at home) for approximately 4 weeks and once a week in-person classroom instruction at the dialysis clinic’s training facility for 8 weeks.
The learning curve was steep, especially since Samuel had no healthcare experience upon which to build. He found the online learning to be challenging and he struggled to grasp the terminology and to paint a picture in his head of what it would be like to actually care, maintain, and use the dialysis machine. Even so, and after a lot of fits and starts, Samuel was able to learn the information contained in the online classes and reading materials, and he was able to pass the written exam required to move to the in-person classroom phase. Unfortunately, it took him 8 weeks, not 4 weeks to gain enough knowledge to pass the test.
Although a bit discouraged by the extra time needed to pass the written test, Samuel was excited to start the in-person training. Upon entering the in-person classroom though, something unexpected happened.
When Samuel showed up for his first week of in-person training, very little seemed familiar. The information he had covered and memorized in the online classes did not translate well to the hands-on practical tasks in front of him. The picture in his head of what home dialysis would be like was completely different from what he was learning in the in-person classroom. In fact, at times he was not even sure whether the instructor was covering the same material.
These struggles to reconcile the online training with the in-person hands-on training continued for the duration of Samuel’s training, and these struggles led Samuel to require 12 weeks, not 8 weeks to complete the in person, hands-on training.
Though Samuel’s training program was originally supposed to last 12 weeks, he and many of the other dialysis patients in his class needed 20 weeks to feel adequately prepared to care, maintain, and operate the home dialysis machine unsupervised.
A broader challenge
Consider the situation facing any dialysis patient like Samuel who recently decided to switch from in-clinic to in-home dialysis. The patient must be educated and trained on all aspects of the specific dialysis machine being used. This includes a cognitive understanding of the machine such as each part, its function, and the steps needed to follow to care, maintain, and use the machine. This also includes a behavioral understanding of the machine such as how to connect all of the relevant parts, in what order, as well as how to hook a patient up to the machine and run it.
Behavioral learning can only occur through experience.
Figure 2 shows the timeline for the typical approach to dialysis device training. Time-to-train is on the x-axis and behavioral competence with the dialysis machine is on the y-axis. The figure depicts the type of training as well as the learning and performance regions in the brain activated by that training. Samuel began with online text-based education. Notice that text-based education engages only the cognitive system in the brain, and thus no behavioral competence is obtained. This learning takes place in an experiential vacuum. This is challenging and time-consuming, and taxes working memory and attention to the limit. Samuel’s online education culminated in a competence test that he had to pass to move on to hands-on clinical training with an instructor. In his case cognitive training took 8 weeks.
Figure 2: Timeline of traditional dialysis device training.
It is important that the online education content, and the hands-on clinical training content are aligned. All too often the topics covered do not match, as in Samuel’s case, which slows learning. Usually the clinical training is conducted in a group setting with the clinical educator demonstrating the use of the dialysis machine and the patients mimicking these procedures. This engages cognitive and experiential centers in the brain. Because the emphasis is on a group setting, each patient gets only periodic one-on-one behavioral training. This is denoted by the partially filled pink circle in the figure. In addition, only typical situations are covered, thus offering little situational awareness training. This is denoted by the partially filled yellow circle in the figure. Hands-on clinical training is also time-consuming and culminates in a behavioral competence test, at which point the patient is deemed ready to go home and to care, maintain, and operate the dialysis machine unsupervised. In Samuel’s case, hands-on clinical training required 12 weeks. Ongoing “in-home” training, if any, is generally sporadic at best, leading to gradual increases in behavioral competence.
Figure 3 shows the timeline for an immersive technology approach to dialysis device training. Training begins with a mixture of traditional online information and a series of 360 virtual reality (VR) experiences aimed at providing all of the same information presented in the online text-based education, but from an experiential standpoint. Critically, immersive education of this sort engages cognitive and experiential learning centers in the brain in synchrony. This spreads the wealth of information and spreads the burden reducing cognitive load. This speeds learning and retention allowing the patient to demonstrate cognitive competence more quickly and with more confidence. Critically, and unlike typical online text-based education, VR experiences can be constructed that present the patient with challenging situations that they may rarely see at home, but if they do encounter them they could be fatal. This builds a broad knowledge base and situational awareness that does not develop with traditional approaches. Although no behavioral competence is developed, the patient is primed for behavioral learning. In this example initial training occurs within 4 weeks.
Figure 3: Timeline of immersive technology dialysis device training.
Once cognitive competence is demonstrated, the patient enters the interactive VR or augmented reality (AR) training phase. Here a virtual instructor guides the patient through the care, maintenance, and use of the dialysis device. Because the training is one-to-one, cognitive, behavioral, emotional and experiential systems in the brain are engaged in synchrony throughout all of the training. This speeds the development of the relevant behavioral repertoire, and quickly culminates in behavioral competence and broad-based situational awareness. Samuel is now cognitively and behaviorally competent in 8 weeks, compared to the 20 weeks for traditional training. With VR and AR, ongoing training is also possible. Thus, Samuel can stay current on any changes in the operation of his machine, or a new machine should his need to be replaced.
Dialysis device education and training that relies on immersive technologies, such as VR and AR, as opposed to traditional approaches that rely on online text-based and hands-on clinical training, lead to faster learning and stronger retention of relevant information, all at scale. Broad-based behavioral repertoires and situational awareness develop quickly and naturally in patients. Patients are at home quickly and with confidence – one experience at a time.
Provider Focused Kidney Care Education and Training
By this time last year, Susan had been on the job hunt for a while – looking for an entry level opportunity in the fast-growing healthcare profession – before she finally came across an opening for a home dialysis patient care technician in her area. Fortunately, the position came with several months of paid training, so her lack of experience in the industry would not be an obstacle in getting up to speed in her new role.
Susan landed the job and was soon scheduled to begin training the following month through a combination of online learning (at home) and in-person classroom instruction at the company’s regional training facility. The training was going to be challenging as she needed to gain expertise with three home dialysis machines for two different home therapies. She was surprised to learn that although the machines accomplished similar tasks for patients, the operational differences were far more complex and detailed than she had expected.
The learning curve was steep, especially for not having the healthcare experience that a few of her classmates had gained through recent direct care roles. Susan had always been a good performer on tests, and this case was no different. She was able to learn the information contained in the online classes and reading materials, and it served her well in taking the written exams.
Then something unexpected happened.
When Susan showed up to her first week of in-person training, very little seemed familiar. The information she had covered and memorized in the online classes did not translate well to the hands-on practical tasks in front of her. In fact, she was not even sure whether the instructor was covering the same material, let alone which material she ought to be focusing on most.
This went on for the duration of Susan’s training. She was able to pass written tests based on the textbooks and reading materials, but would feel completely unprepared for the dynamic, realistic learning environment.
Though Susan’s training program was originally supposed to last 12 weeks, she and many of her classmates needed close to 9 months to feel adequately prepared for their role and responsibilities.
A broader challenge
Consider the situation facing any direct care worker like Susan, recently hired by a dialysis provider to serve patients in their homes. The nurse or patient care technician must be educated and trained on all aspects of the specific dialysis machine or multiple dialysis machines being used. This includes a cognitive understanding of each part, its function, and the steps needed to follow to use the machine. This also includes a behavioral understanding of the machine such as how to connect all of the relevant parts, in what order, as well as how to hook a patient up to the machine and run it. Behavioral learning can only occur through experience. Finally, broad-based situational awareness is critical.
Susan needs to be able to troubleshoot rare but life threatening situations quickly, accurately and with a calm demeanor.
Figure 4 shows the timeline for the typical approach to dialysis device training. The most common approach is to begin with library or textbook education in the form of text, slide shows, and perhaps video. Notice that library education engages only the cognitive system in the brain, and thus no behavioral competence or situational awareness is obtained. This learning takes place in an experiential vacuum. This is challenging and time-consuming, and taxes working memory and attention to the limit. Library and textbook education often culminates in a competence test that must be passed to move on to hands-on clinical training with an instructor. In this example, cognitive training takes 6 months.
Figure 4: Timeline of traditional dialysis device training.
Although not always the case, it is important that the library and textbook education content, and the hands-on clinical training content are aligned. All too often the topics covered do not match which slows learning. Often the clinical training is conducted in a group setting with the clinical educator demonstrating the use of the dialysis machine and the nurses-in-training mimicking these procedures. This engages cognitive and experiential centers in the brain. Because the emphasis is on a group setting, each nurse gets only periodic one-on-one brain training. This is denoted by the partially filled pink circle in the figure.
Behavioral training is also time-consuming and culminates in a behavioral competence test, at which point the RN is deemed ready to go out in the field. In addition, only typical situations are covered, thus offering little situational awareness training. This is denoted by the partially filled yellow circle in the figure. In this example, hands-on clinical training requires an additional 3 months. Ongoing “on-the-job” training, if any, is generally sporadic at best, leading to gradual increases in behavioral competence.
Figure 5 shows the timeline for an immersive technology approach to dialysis device training. Training begins with a combination of traditional educational materials complemented with a series of 360 virtual reality (VR) experiences aimed at providing all of the same information present in library education, but from an experiential standpoint.
Critically, immersive education of this sort engages cognitive and experiential learning centers in the brain in synchrony. This spreads the wealth of information and spreads the burden reducing cognitive load. This speeds learning and retention allowing the nurse to demonstrate cognitive competence more quickly and with more confidence.
Equally as critical, and unlike typical library training, VR experiences can be constructed that present the nurse-in-training with challenging situations that they may rarely see on-the-job, but ones that can be fatal. They can experience stressful situations such as an unruly patient. This builds a broad knowledge base and situational awareness that does not develop with traditional approaches. Although no behavioral competence is developed, the nurse-in-training is primed for behavior change. In this example, initial training occurs within 1.5 months.
Figure 5: Timeline of immersive technology dialysis device training.
Once cognitive competence is demonstrated, the nurse-in-training enters the interactive VR or augmented reality (AR) training phase. Here a virtual instructor guides the nurse-in-training through the care, maintenance, and use of the dialysis device. Because the training is one-to-one, cognitive, behavioral and experiential systems in the brain are engaged in synchrony throughout all of the training, which speeds the development of the relevant behavioral repertoire, and quickly culminates in behavioral competence. The nurse is now cognitively and behaviorally competent in 3 months, compared to the 9 months for traditional training. With VR and AR, ongoing training is also possible. Thus, the nurse can stay current on the operation of new dialysis devices and technology as it comes on the market. [For a detailed example using AR follow this link.]
Notice the similarity between Figures 2 and 4 and Figures 3 and 5. The problems with traditional education and training approaches are the same regardless of whether the emphasis is on patients or providers. Analogously, the advantages of an approach that uses VR to complement traditional training are the same regardless of whether the emphasis is on patients or providers.
Dialysis device education and training that relies on immersive technologies, such as VR and AR, as opposed to traditional approaches that rely on library and hands-on clinical training, lead to faster learning and stronger retention of relevant information. Broad-based behavioral repertoires and situational awareness develop quickly and naturally in nurses. Nurses are on-the-job ready quickly and with confidence – one experience at a time.
Patient-Provider Interaction: A Shared Experience
Aiko is a 59-year old mother of three. Aiko was diagnosed with Type 2 diabetes over a decade ago now, but was hospitalized four years ago when her kidneys “crashed”, landing her in the hospital rather unexpectedly. Though she has been on dialysis ever since that first surprise trip to the hospital, recently she was informed that her long wait for a kidney transplant might finally be over. Aiko is excited about the prospect of having a healthy kidney that will free her from the dialysis regiment that has controlled her life for years, but naturally she is anxious and stressed about the upcoming surgery and its implications for returning to normal life.
Like 90% of Americans, Aiko has struggled to understand her medical conditions and treatment. When she talks to her care providers– whether it’s her nephrologist, dialysis RNs or frontline care technicians – she often struggles to comprehend much of what they are describing. Even when she feels that a concept or treatment is beginning to make sense during a conversation with her care team, she quickly realizes she must be missing something when it comes time to perform the procedure or make a decision. The terminology is unfamiliar, communication seems fragmented, and treatments and procedures are frustratingly complex. Truthfully, Aiko often finds herself trusting her care team blindly, because at the end of the day, they are trained professionals and it’s just too difficult to keep up and make sense of the situation. Trusting the care team is just plain easier than figuring out what she needs to know in order to have an informed opinion or understanding of her care.
And like most people, Aiko finds she is unable to generate vivid pictures in her head to help her understand her medical condition and treatment accurately. But beyond the issue of comprehension, her problems are exacerbated by constant questioning from her family members and loved ones. She is embarrassed that she does not understand her situation better, but she is equally frustrated by the lack of effective learning resources provided by her care team.
Now, even though she has been waiting for this opportunity for years, Aiko must prepare for a complex and scary surgery that will require a stay in the hospital, followed by a significant recovery period at home. Aiko is stressed, anxious, and feels helpless due to her overall reliance on being told what to expect next, much of which stems from her lack of knowledge and understanding.
A broader challenge
Patient literacy is low, and this is due in large part to the lack of effective patient education and training tools. These ineffective informational materials, along with one-on-one conversations with nephrologists, serve as the two primary sources of learning for patients with kidney disease. While written materials lack effectiveness, conversations with providers lack consistency and scale.
Together, the two primary sources of learning for kidney disease patients are coming up short where there is tremendous potential to make an impact in their lives and health outcomes.
As Aiko’s situation demonstrates, talking to nephrologists and reading documents filled with challenging medical terminology is only marginally ineffective. This follows because all of this information is processed by the cognitive learning system in the brain. Although the cognitive learning system in the brain is truly remarkable, it is unrealistic to expect that this system can build the accurate mental representations patients like Aiko need.
As elaborated above, experience is at the heart of a virtual reality solution for patient education and is at the core of effective communication between healthcare professionals and patients. Imagine a virtual reality experience in which Aiko dons a VR headset and a virtual kidney is displayed in front of her. Her nephrologist can see what Aiko sees using a tablet. The nephrologist describes the function of the kidney within the broader renal system while Aiko views a dynamic virtual display showing the whole system with the kidney highlighted. Suppose a second VR experience begins by outlining the timeline of Aiko’s upcoming kidney transplant. The nephrologist talks Aiko through the whole procedure while using VR assets to highlight specific time points and surgical techniques. By providing a shared experience that is 3D and dynamic, Aiko is able to easily generate the mental representation that she so desperately needs.
This follows because VR engages experiential, emotional, and cognitive learning centers in the brain in synchrony.
These VR experiences enhance Aiko’s understanding of kidney function and the specifics of her kidney transplant surgery, but what about all of her anxiety and stress around the hospital stay and post-operative healing? Again, a VR experience is in order. Imagine a VR experience focused on preoperative and perioperative hospital familiarization. Aiko could be transported into the lobby of her local hospital where she is greeted in VR by a resident nurse. The nurse shows Aiko where she goes to be admitted, and takes Aiko on a tour of the hospital where they visit preoperative patient waiting rooms, the operating room and post-operative recovery unit. The nurse shows Aiko how the bed works, where the bathroom is located, and how to use the all-important call button. At this point, another Linda enters the room. Linda introduces herself as a former kidney transplant patient. She assures Aiko that the surgical team is top-notch and that her hospital stay will be a breeze. Linda talks about some of the critical post-operative procedures and what Aiko needs to pay special attention to when she gets home, and throughout her recovery.
Because all of the hospital staff are well versed in the same VR experiences, if Aiko has a question the hospital staff can refer back to the VR experience when answering the question. Because both Aiko and the staff have a shared experience, communication is more effective and understanding is enhanced. Of course, if at any point Aiko wants to refresh her memory, or share the experience with a family member she simply pulls out her VR headset and gets a refresher.
This experience-based approach to education and training broadly engages multiple learning systems in Aiko’s brain. She now has a strong and meaningful mental representation in her brain that she can convey to friends and family, and most importantly one that enhances her understanding and confidence about her care plan. These experiences are shared by her healthcare providers facilitating understanding and communication. VR enhances patient and provider understanding and communication, reduces stress and anxiety, and enhances confidence and satisfaction when Aiko needs it most.
The challenges in kidney care are clear. Patients and providers have available high quality educational content, but that content lacks an effective mode of delivery and feedback mechanism. Too often that content comes in the form of dense text that is challenging to process within the working memory and attention constraints of the human cognitive processing system. When text-based delivery is used microlearning, space training and periodic testing should be incorporated to enhance initial learning and to facilitate long-term retention. The neuroscience of learning suggests that content is best presented experientially and in a way that broadly engages cognitive, behavioral and emotional learning centers in the brain in synchrony. Immersive technologies like virtual (and augmented) reality meet this need.
This report told the story of three individuals struggling to obtain high quality and effective kidney care training. Although the focus in this report was on kidney dialysis and transplantation, the same approach could be taken with education and training around kidney structure and function, kidney problems, or the leading causes of kidney disease like diabetes and hypertension for that matter.
In every case, a mixture of traditional and immersive learning approaches is the key to developing effective learning journeys for patients and providers.
Our collective challenge and opportunity ahead lies in our ability to properly identify key areas within our own environments and clinical workflows where the integration of new learning approaches will impact outcomes at every scale. From supporting individual patient decision-making to shifting entire businesses to new settings and upskilling a large, remote workforce to meet the demands of these shifts, there are endless opportunities to get this right.
The patient-centered care and labor models of tomorrow will be enabled by the utilization of highly effective, immersive learning tools available today.
These are real situations and challenges, but so too are the solutions we have available to adapt and overcome these obstacles today – one experience at a time.