American educational theorist Edgar Dale’s Cone of Experience, also known as The Learning Pyramid, is one of the most recognisable and widely used models in learning theory and educational academia.
First proposed in 1946, Dale’s model breaks down the ways that we share knowledge into 10 categories and ranks them according to how effective they are for retaining information. As you can see from the diagram below, it starts with the least effective at the top (Dale’s studies led him to believe that people on average only reliably retain about 10% of what they read), and goes all the way down to the most effective (“learning by doing” increases retention to 90%).
Notwithstanding academic scrutiny over how accurate Dale’s percentages really are, the basic concept has become incredibly influential. Educators the world over will tell you that, by and large, students acquire and retain information more effectively by listening to someone explain compared to reading; the use of images takes things up a notch, while watching a demonstration in person, which after all combines visual and auditory elements, is another step up again.
At this point, many people now draw a line between ‘passive’ and ‘active’ learning. In the bottom half of the pyramid, learners are not just receiving knowledge, they are acting on knowledge, ‘learning by doing’ either by practicing, simulating or doing the real thing. And that’s when knowledge and skill acquisition become really effective.
As well as being about learning, Dale’s theories can be applied to communication – after all, learning and knowledge sharing are a form of applied communication. When you ask questions about how to improve knowledge sharing, you are asking questions about the most effective modes of communication. Do you present a written text, give a lecture, use graphics or video, give a demonstration or get people actively involved in practising under guidance somehow?
At Proximie, these are questions that we are very much interested in from the perspective of surgical training, development and the sharing of expertise. Since our inception, one of our defining goals has been solving the riddle of how you take surgical expertise, remove barriers that exist to its open and free transmission, and therefore amplify and multiply it rapidly – therefore bringing more surgery to more people, as and when they need it. We have a model for this we call the three P’s – how we can improve the way surgeon’s Prepare for, Perform and Perfect surgical procedures by removing barriers to collaboration and knowledge exchange.
Another way to phrase this same challenge would be – how do we make it easier for surgeons to communicate more effectively, so they can provide a better service to more people? We are committed in our belief that Augmented Reality (AR) is the answer. And Dale’s famous Learning Pyramid helps to explain why.
A challenge for communications
Let’s consider a theoretical example of a challenge Proximie might be used to resolve. Imagine a particular community, a town or city or region, where demand for a particular surgical procedure is high, but there just aren’t enough qualified surgeons with the requisite skills and knowledge. Waiting lists are getting longer and longer, some patients are being forced to travel long distances to get the treatment they need, outcomes in terms of the percentage of patients receiving effective treatment are worryingly low.
In another city or region some distance away, there is a hospital with a specialist department that leads on this particular area of practice. A handful of patients have travelled here for treatment from the locality where there is a skills shortage, but the distance and cost makes this impractical. But what this surgical team are prepared to do is to enter into a coaching relationship whereby they can pass on their expertise, upskill more practitioners in the struggling hospital and in that way work towards helping them meet demand.
The question then is, how can this be done most effectively? Secondments are ruled out as the specialist department has its own demanding workloads and nobody can be spared. But that’s ok – this is the 21st Century after all. Surely, with all the communications technology at our disposal capable of connecting people in real time wherever they happen to be in the world, facilitating a mentoring programme to help two groups of surgeons exchange knowledge and expertise over distance shouldn’t be a problem?
For surgery, the question of how effectively knowledge can be communicated, retained and applied is quite literally a matter of life or death. You cannot have someone trying out a new technique on a patient unless they are absolutely 100% certain about what they are doing or are receiving appropriate guidance from an expert. So yes, there are plenty of technologies available that would allow a specialist surgical team to communicate with another in some distant location, passing on their expertise quickly and efficiently. The real issue is how efficiently and effectively the recipient would be able to use that knowledge.
Let’s go back to Dale’s pyramid. The specialist team could write a list of instructions for a procedure and email them over to the colleagues they are coaching. But we clearly wouldn’t trust this as a reliable basis for anyone learning a new surgical technique, and Dale would agree, placing reading ‘top’ of the most unreliable methods for communicating knowledge. Having a telephone conversation – and therefore relying on hearing alone – would fare little better.
What about sending over illustrated instructions, or a video guide? Video is widely used in surgical training and coaching, but more often in situations where someone’s own practice is scrutinised and analysed. You might also see livestream video used to allow remote colleagues to ‘watch a demonstration’ of a specialist performing a procedure.
But to borrow Dale’s scale, we’re still only at 50% effectiveness for learning and knowledge sharing, and for the high-stakes purposes of surgery, that simply isn’t enough. The problem is, with communications channels like email, telephone, video and live streaming, we’re still in the realms of ‘passive’ knowledge acquisition. If we really want to upskill our surgeons robustly and effectively, so we can be confident they are picking up on complex skills and concepts well enough to apply them in their practice, we want to be moving into ‘active’ learning, with hands-on practice, collaboration and carrying out ‘live’ procedures under guidance.
When we’re talking about remote coaching scenarios, is this even possible?
The AR impact
When it comes to how we process and engage with information presented to us, AR does something unique. Let’s imagine a surgeon trying to learn a new technique from a colleague based many miles away. Let’s say they are in some kind of simulation scenario, or even carrying out an actual procedure. The mentor talks them through what to do via a speaker phone – cognitively, there is a disconnect between listening to the instructions, and focusing on what their own hands are doing. Or if they are watching a video, or their mentor is live on screen demonstrating as they talk – there is still that conflict, trying to process the instructions on the one hand, and apply them on the other.
What makes AR so special, and why we put it at the heart of the Proximie solution, is that it integrates digital information and our direct sensory perception into one. It does this visually, with the majority of AR applications, Proximie included, using video and screens to blend what we see in front of us (first-hand perception) and additional digital content, be that data feeds, graphics, video, 3D virtual projections or anything else.
When it comes to following instructions or learning a new skill or concept, this is important. Think about times you have tried to follow a recipe in a book to cook a new dish – how many times did you end up checking and re-checking the method and quantities for the ingredients? That is because of the disconnect mentioned above, our brains finding it hard to switch from information A to task B and back again. In a surgical scenario, the risk of making a wrong step this introduces is too high.
What Proximie does is it puts the instructions right there in front of you as you carry out the task. If you used it for making a meal, you could have the recipe right there in your field of vision as you prepared the ingredients, or a video playing of someone cooking the same dish for you to follow. Just by observing what you are doing through the medium of a screen or, more and more likely as the years go by, through some AR-capable wearable device, you no longer have to keep shifting focus back and forth. All the information is right there, one field of vision, one focus.
We don’t use Proximie for following recipes, but the same principle applies in teaching and mentoring surgical practice. Complex concepts and technical details can be visualised digitally and projected into a practitioners’ field of vision as they work, making it much easier to grasp compared to listening to or reading explanations or instructions. Remote mentors don’t have to be content just talking through a procedure, or sending graphics, or speaking on a live video feed. They can ‘scrub in’ virtually, recording themselves demonstrating a technique on the patient as they see them on their video feed; the projection of what they are doing then appears on the recipient’s feed for them to follow.
AR is often described as immersive, interactive, intuitive, making it possible to take multiple modes of communicating knowledge and integrating them all with a person’s first-hand perception of the real world. But from a learning perspective, and from our perspective, what makes AR particularly powerful is that it enables active participation, learning by doing. Using Proximie, surgeons upskilling or learning new techniques are not just relying on watching, listening and observing, the passive modes. It enables live, digitally enhanced instruction as they practice, with the augmented guidance appearing before them as they work, and whoever is observing them giving immediate feedback as if they were stood looking over their shoulder.
To turn Dale’s model on its head, this is why we believe AR sits at the very top of the tree when it comes to effective, efficient knowledge sharing. It enhances visual learning by making it interactive, making passive reception active, hands-on. It allows information to be conveyed into your immediate field of perception, smoothing the way to processing information as you work without switching focus or breaking your flow. It combines multisensory modes of communication, whether text, images, audio, visual demonstration, and immerses the recipient in them, an active experience without being shut away in an abstract virtual world.
For our mission to help spread and multiply surgical expertise effectively, we see AR as a vital tool that has the potential to transform how we understand learning and knowledge sharing.