Note - This delves into the concept of "experience" and sheds some light on what it actually is, and more importantly, where we can get more of it. Scroll down or hit the link to download a pdf copy
You’re checking up on your emails when suddenly you feel a sharp pain in your chest. You begin to sweat; there is also a feeling of nausea. You call 911. Imagine the operator has you choose between three different emergency personnel.
1. Brand new paramedic, but scored the top of his class on all of his tests.
2. Has three college degrees, one of which is a B.S. in Emergency Management, but has not worked much in the field.
3. No college degree, slightly above average test results, 25 years experience in a large city as a transport paramedic
Which do you choose?
Nothing like a life or death decision to clarify value. Even a college degree, in this example, is not as important as actual experience. Experience commands higher salaries and benefits, garners more respect and influence, and presents more opportunities. And yet, experience takes so much time to get. And in many professions, the opportunities for gaining experience are largely haphazard and inconsistent. How do you gain experience as a soldier if there is no war? What about a physician in a small town with few patients?
For the purpose of this article, we'll be looking at how people (emergency personnel) gain experience - what is happening in the brain, how and where the information is stored and what happens when it is recalled. By understanding how the brain structures and stores experience, it becomes possible to structure your simulations to replicate this. This involves procedural memory mechanisms, which are the conscious and unconscious processes the brain uses to gain and assimilate experience.
Experience is difficult to define because it can mean so many things, however, it is helpful to think of experience as a spectrum - a person has a little experience or they have a lot of experience. By focusing on the end point, the finish line that results in total mastery, we can help nail down a definition. Again, due to the vast conceptual scope we call experience, I will offer three definitions, which each act as a facet of experience.
1. Familiarity with a skill or field of knowledge acquired over a period of time, which, presumably, has resulted in superior understanding or mastery
2. Knowledge or practical wisdom gained from what one has observed, encountered or undergone.
3. Deeply ingrained proficiency
I'm on record as preferring that last definition there, because it places experience in the context of the brain, deep within, as well as speaking to a level of mastery.
A quick primer is necessary to discuss procedural memory. I'm not going to get into the differences between long-term and short-term memory (I might in a later article) as it is enough to look at memory at the basic level. Memory comes in two basic categories:
Declarative - Information that is consciously learned and recalled, such as facts or verbal. Also called Explicit Memory
Declarative memory has two subcategories:
1. Episodic - specifically personal experience, often emotionally charged, considered to be the memory of autobiographical events. It's how you can remember where you were standing when you heard the news of 9/11.
2. Semantic - General world knowledge that unlike episodic memory, is not personally based. Knowledge of mathematics is a good example.
If I recall the most difficult pediatric traumatic arrest of my career, I'm largely using episodic memory. Specifically I am accessing certain areas of my prefrontal cortex (the higher thought center of the brain) which is sending and recalling information from my hippocampus (the storage center of the brain). This being an emotionally charged event, my amygdala (fear/emotion center) also comes into play, as it also deals with strong emotional events.
Pattern recognition is important however, it is critical to focus on the process aspect. Imagine a library with no catalog system, simply a librarian who knows where everything should go. The "experienced" librarian will have a process for finding the correct book, the correct pattern. A brand new one will just see a lot of books that have no relevance. Years and years of retrieving and storing patterns means the librarian becomes extremely fast. Unconsciously fast.
This is why for many experts, when asked a question, they almost immediately have a response. Most of the time spent as actually thinking about to phrase the information into a comprehensible format but the knowledge is already recalled. It's also why emergency physicians are able to act so quickly when dealing with various body systems involving complex medical concepts.
This partly explains why it takes so long to become "experienced." While an experienced person can tell you what they know, they would not be able to communicate to you effectively all the details they observed and the consequences of their treatments. Even if perfect recall was possible, they would not be able to transmit it in a medium that your brain would incorporate into procedural memory. You would store it as declarative, like a story, versus a procedure you would follow.
Let’s look at the difference, brain and memory-wise, between a brand new paramedic, fresh out of paramedic school, vs a ten-year veteran. They both will have a large store of declarative information concerning emergency medicine, information such as medication names and effects or the symptoms of a right-sided infarction. The veteran will have a larger store of procedural memory because he has performed the procedure of patient assessment thousands of times.
The distinction here is that while most knowledge is declarative the ability to recognize and recall, the application of knowledge is far more procedural in nature.
We were dispatched for a complaint of shortness of breath and dizziness. I found the patient sitting on a stool, she was leaning against her husband. He was telling us why he called and I went to see how responsive she was by asking her name, trying a sternal rub to elicit a painful response, etc. Suddenly my preceptor says, “Stop Blake, she’s coded.” He instantly moves me aside, pulls the patient to the ground and checks for a pulse. Sure enough, she had no pulse and I found myself suddenly working a cardiac arrest…
This call actually happened to me when I was undergoing the precept process as a new medic. So what happened? My preceptor noticed incontinence, which is often a sign of cardiac arrest, he noticed she wasn't leaning, as I thought, she was completely limp. (Her husband was holding her up, giving a false flag--how does a dead person sit up? When they are propped up!) I hadn't noticed it because my assessment process, my procedural memory, was not as fast as my preceptor's.
After the call, my preceptor told me he had seen that before. I was frustrated because I knew the symptoms I saw were clear signs of cardiac arrest. If I had taken a test on it right before the call, I would have passed easily. So why couldn't I recognize it?
Because I had not performed the procedure of recognizing the symptom. Simply put, I had to see it for myself. Once I did, the details of the procedure were encoded into my memory. It added just a small portion onto the general network of procedures my brain uses to perform patient assessment. It added to my level of experience.
My preceptor told me not to worry about it, he saw my line of questioning and knew I would figure out the patient's condition in a few more moments, had he not intervened. But I wanted to get better, I remember saying to him. His response was, "You just have to run the calls."
A Million Little Algorithms
In the Pattern Recognition article, I look at how sensory details collected by the brain can form a pattern. The other half is to understand this pattern fits into an algorithm, that itself is a small nuance of a larger body of knowledge. By recreating this pattern via simulation, we can begin to recreate actual experiences.
As the number and depth of these experiences grow, we will start to approach a similar effectiveness that comes with real world experience. This is fidelity of a different sort, not the sensory-based fidelity of traditional simulations with their high-resolution textures or expensive particle calculations. (Though those have their place) Rather, this is fidelity of the brain's hidden "magic"-- its ability to build procedural memory networks, unconsciously and automatically.
The task ahead might seem daunting. It is. There is a reason I started my simulations on the fire & incident command side versus medical side - there is an order of magnitude more complexity involved, particular with patient assessment.
The amount of details, of game assets, of interconnected systems, is vast. Developing a "master algorithm" nearly gave me an aneurysm. At first glance, this seems like something that would take billions to produce and the long-term collaboration of thousands of people. It's not.
It is becoming possible and more affordable to create this level of simulation and to replicate procedural memory networks. (It arguably was possible in 2014). Procedural generation, A.I., machine learning, are force multipliers in the development space and will help reduce the level of time needed to create simulations.
When that happens, we will be using procedural generation to train people in fractions of the time normally required. I don't mean time normally required to be competent, thought that will be an obvious benefit as well. I mean the time normally required to become a master.
There will still be clinicals and there will still be hands-on training. But no longer will you be required to "wait" for the "good calls" rather, they will be brought to you, in as much quantity, complexity, and variety as needed. When that happens, training will become cheaper, faster, and more effective. And we will save even more lives.