Healthcare Training: Integrating Real and Virtual Learning

by Evelyn Levine

Suppose you are a medical student in training, learning how to evaluate patients in a cardiac emergency room. Ideally, you want to perfect your skills before you see an actual patient. 

You have limited time and resources. The emergency room setting is always busy and sometimes understaffed. Usually time is of the essence. 

You need information: The patient’s history, medications, activity level, along with results of current and previous stethoscope exams, EKGs, ultrasounds and other records. You also must assess the patient’s current presentation, pain level, physical examination and other tests.

You have questions: What other tests might be needed? Is any immediate action required? Should you consult with other doctors/experts?

You need to learn how to do this right. You can listen to lectures; study and memorize facts, you can learn by observing those more experienced in action, and even by trial and error. But since practice makes perfect, wouldn’t it be preferable to actually try to perform these skills in a safe environment where you could learn from your mistakes – if that were possible?

The e-REAL Paradigm and Potential

 e-REAL, the vision of Dr. Fernando Salvetti, is a mixed-reality immersive and interactive learning simulation environment that addresses this and similar needs. e-REAL allows people to interact with tools and objects from the real world which are augmented by computer-generated information, which can be a mix of visual, auditory, olfactory and other sensory modalities.  This may include talking avatars and 3D projections on the wall, all of which can be experienced without any special equipment.

What makes this type of visual storytelling so effective as a training tool is that the learner is presented with realistic and challenging scenarios.  Learners can go back and forth between specific observations and overall paradigms; and focus on both technical and behavioral aspects of performance. 

Research has shown that visualization helps learners better store information, assists cognitive retention, and behavioral performance. Some of e-REAL’s key features which facilitate learning, according to the available research, include:

  • Learning in context:  Learning is facilitated by utilizing a realistic, real-world environment.
  • Feedback: Effective feedback is critical to learning. Visualization helps instructors immediately identify errors and difficulties as well as to measure competencies.
  • Social components: This type of simulation incorporates methods to practice communication and cooperation skills which are especially critical in crisis management teamwork. The simulation assesses soft skills (e.g., teamwork, leadership skills, situational awareness).
  • Self- development: This type of learning results in greater self-awareness and is empowering to the learner.
  • Learner engagement: Finally, participants enjoy this type of learning and are more engaged in the learning process.

According to Dr. Salvetti, initial research has shown that e-REAL is an engaging and effective tool for training future doctors and other healthcare workers. Consequently, it has the potential to reduce costly and dangerous errors and enhance care for all those (all too) real patients.

Fernando Salvetti is the co-designer of the e-REAL simulation developed in conjunction with the Harvard Center for Medical Simulation (more information can be found at   Professor Salvetti is an international e-learning consultant whose research in immersive and interactive learning environments focuses on how they enhance neural processes in learning and memory.

Evelyn Levine works as a Training and Staff Development Director for the U.S. Courts. She writes on worldwide learning and development trends in public and private sectors.  She can be reached at