Neurobiology of Learning

The process of learning involves structural and functional synaptic changes in the central nervous system.^{1, 2, 3} Multiple distinct components of neurons demonstrate use-dependent plasticity.⁴ Data suggests that specific synaptic and nuclear signaling events facilitate acquisition and retention of information.⁵ Improved efficiency in synaptic transmission has been associated with several mechanisms of knowledge construction, including increased neuronal connectivity, faster conduction, improved blood flow to distinct areas of the brain via angiogenesis, and new and strengthened synaptic connections.^{6, 7, 8, 9, 10, 11, 12, 13, 14}

Synaptic modifications have been directly linked to behavioral learning processes in animal models.^{10, 11} Human studies using pathology and functional brain imaging have established that different types of learning stimulate different parts of the brain, and distinct parts of the brain are activated when we attempt to retrieve knowledge.^{14, 15, 16, 17, 18} Although a great deal remains to be known about the neurobiology of learning, research has established that the brain has the potential for continual development and undergoes reorganization through the process of learning.¹

Adult Learning Principles

The neurobiology of learning coincides with the development of adult learning principles. These principles translate science into action by providing a foundation for effective teaching. The term “andragogy” was first coined by Malcolm Knowles in the 1970s to differentiate adult learning from “pedagogy” or childhood learning.⁴⁵ Knowles outlined six key learning principles that serve as the foundation of adult learning (Figure 1). These principles establish that experience provides the basis for adult learning; adults need to be involved in planning and evaluating their own instruction and are most interested in learning subjects that have immediate relevance to them.⁴⁶

Benjamin Bloom, in collaboration with other educational scholars, established a framework for categorizing educational goals. Known as Bloom’s taxonomy, it consists of categories of successive skills that make up a continuum of cognitive learning (Figure 2).⁴⁷ Recent adaptations include a change in terminology from noun to verb forms and an expanded 2-dimensional framework.⁴⁸ Bloom’s taxonomy is a useful tool in designing and assessing educational curricula.

While not established as a traditional adult learning principle, the concept of the “learning edge” is an optimal adaptation of the aforementioned Yerkes-Dodson Law in practice. Given the unique relationship between stress and knowledge construction, this framework operationalizes the ideal zone of anxiety for knowledge formation. By plotting difficulty of a task versus capability, a competency zone evolves (Figure 3). Accelerated learning can occur in this zone, provided the learner is not overly stressed. The learning edge is the point at which a learner is mentally stimulated and challenged, outside of their comfort zone, but still within an environment where they feel unthreatened.⁴⁹

Conference Settings

Larger conferences—including grand rounds, journal clubs, and noon conferences—are a mainstay of fellowship education. To optimize these sessions for learning, educators can take some relatively simple steps. First, to help fellows manage intrinsic load, educators should embrace a “content diet.” Key learning objectives should be limited and clearly stated from the start and then repeated at the end of each conference. While it is tempting to be comprehensive about topics when leading a conference, CLT teaches us that providing more material can often be detrimental to true learning given the limited capacity of our working memory. Content that does not directly support stated objectives can be provided as reference material for fellows to review at other times.

Incorporating ways for fellows to be interactive is essential for them to remain attentive and engaged during conferences. While passive didactic lectures increase short-term retention, they are not associated with long-term learning since adults learn better by doing, as noted by Knowles. One simple method of conference interaction proposed by Doug Lemov is “Think-Pair-Share.”⁵⁰ In this approach, fellows are asked to think about a prompt or question. Then they pair with a co-fellow to share their thoughts before reconvening with the entire group. Asking fellows to discuss their thoughts encourages greater participation, builds confidence and creativity in problem solving, and leads to deeper understanding.

Educator tips:

1. Less is more.
2. Interaction increases learning.

Clinical Rotations

Much of learning in cardiology fellowship happens spontaneously, such as on rounds, at the bedside, in the echo lab, and alongside the many day-to-day activities that take place throughout training. One way of augmenting learning in these moments is to engage fellows in simple gamification. Gamification applies the standard elements of game playing (ie, badges, levels, leaderboards) to learning and training. While adding a little fun to the workday, gamification also creates a safe learning environment by making failure less risky for fellows. Educators can identify gaps in knowledge without the fellow feeling uncomfortable. Additionally, with competition at play, there is release of dopamine that increases knowledge retention. For example, on the cardiology consult rotation, educators can start the day by asking every member of the team to state one cardiac-related point they learned in the past 24 hours. An appointed medical student can keep track of all learning points throughout the week. At the end of the week, the team can review those points and vote on three favorites. The team members responsible for those points receive bragging rights…and possibly also coffee from the attending that afternoon! As noted, both spaced retrieval (ie, recalling a learning point from the day prior) and repetition with spaced intervals (ie, reviewing points at the end of the week) are important for long-term memory formation.^{36, 37, 38, 39, 40, 41} Alternatively, an educator can create a quick game of “Heart Bingo” at the start of the week, filling each box with a cardiac-related activity. Members of the team work to complete these activities throughout the week, and the first person to complete an entire row, column, or diagonal wins (Figure 4).

Educator tip: Play more, learn more.

Acquiring New Skills

Almost everyone in medicine is familiar with the old motto “see one, do one, teach one.” Yet every cardiologist who has been in a complex percutaneous intervention knows that teaching such procedures is not that simple. A new six-step framework of training procedural competency has been developed by Taylor Sawyer and colleagues using advancements in the science of learning: learn, see, practice, prove, do, and maintain.⁵¹ The first two steps provide fundamental knowledge and observation of the skill prior to introduction of psychomotor acquisition. Importantly, initial practice for skill development is often performed in a simulated setting where repetitive practice is allowed before fellows prove they are ready to perform the behavior in a clinical setting. All patient interactions must be done under direct supervision with support and guidance as fellows progress to independent practice. Maintenance of skills is achieved by continuous clinical practice and, if necessary, supplementation with simulation-based training.

Feedback is an essential part of skill acquisition for a cardiology trainee. Recently called into question is a commonly taught method of feedback, the “sandwich approach,” wherein the educator provides one constructive or negative piece of feedback sandwiched between two positive comments. This ineffective means of giving feedback, as discussed in many business articles and blogs, undermines both the content of the feedback and the relationship educators have with fellows.⁵² A better feedback framework is Ask, Tell, Ask.⁵³ First, the fellow is asked to name one thing they did well and one thing they could do better. Second, the fellow is told how they did, using specific behavior-based examples. Finally, the fellow is asked to postulate specific ways they can improve, making an action plan together with the educator.

Educator tip: Give feedback on observed skills and then repeat, repeat, repeat.

Daily Fellow Routines

To attain competency in cardiology and to continue that competency for the duration of a career, fellows must practice routine and effective skills for independent learning during training. Passive reading and reviewing content for hours rarely translates to significant retention. Fellows should be encouraged to find ways to make content and concepts stick. Thus, educators should deliberately discuss and model practices that lead to effective learning. As noted, the simple kinesthetic activity of using a pen and paper to write down learning points activates multiple sensory pathways, allowing for increased likelihood of retention.^{26, 29} Educators should write things down when encountering new content and ask fellows to do the same.

If facilitating board preparation sessions, educators should integrate multiple areas of cardiology rather than covering a single topic. This incorporates the concept of interleaving. When planning noon conferences and grand rounds schedules, revisit topics frequently to allow for spaced repetition. Before revisiting topics, fellows should be encouraged to recall what has been previously taught on the topic, fostering retrieval practice. This can be done both in group sessions and at home when the fellow is independently studying. Finally, fellows should be inspired to climb Bloom’s taxonomy pyramid regarding the content being learned (Figure 2). Evaluation and creation of cardiology concepts are the primary goals for fellows during training.

Educator tip: Form habits that make concepts stick.