Learning: Behavior Grounded in Experiences.

Anesthesiology, V 123 • No 1 10 July 2015 B ehavioral modification is the branch of learning theory concerned with analysis and adaptation of human behavior. Psychologists ivan Pavlov (1849–1936, Director, institute of experimental Medicine, St. Petersburg, russia, 1891–1936) and John B. Watson, Ph.D. (1878–1958, Professor and Chair, Psychology, Johns hopkins University, Baltimore, Maryland, 1908–1920), considered the founding fathers of modern behaviorism, along with B. F. Skinner, Ph.D. (1904–1990, edgar Pierce Professor of Psychology, harvard University, Cambridge, Massachusetts, 1958–1974), described the phenomenon of stimulus–response psychology; environmental events elicit specific learned repetitive behaviors.1 learning may be described as the act of acquiring new or modifying and reinforcing existing knowledge or behaviors. as clinicians, we are faced with an ever-expanding body of knowledge and technological advancements that need to be learned, that is, integrated into our practice. how best to accomplish this? Sathishkumar et al.2 give us a clue to the answer as they discuss behavior modification in their study of intraoperative hypoglycemia management. The authors describe their institutional experience with a monitoring system that makes real-time data regarding a patient’s blood glucose available to practitioners in the operating room. The behavior elicited (the learning) by this “reminder stimulus” (the experience) was measured by the authors observing the “treatment response” by the anesthesia provider.2 Providing a reminder stimulus and assessing its educational effect on clinical behavior is tremendously thought provoking. The authors propose that the simple act of making the data more available (the stimulus) elicits a more frequent response by clinicians who strive for euglycemia by administering insulin (the target behavior) in the setting of demonstrable hyperglycemia. Behavioral scientist B. F. Skinner, Ph.D., defined the concept of “operant conditioning,” wherein the consequences of a given behavior influence the future occurrence of the behavior.1 We all know the classic example: if a rat hits a bar and is rewarded by a morsel of kibble, the animal will hit the bar until its appetite is satiated. in medicine, the relation between clinical decision making and resultant behaviors and their outcomes is less clear. The expectation that clinical decisions (i.e., behaviors) will be consistently rewarded by resultant positive outcomes is idealistic at best. Perhaps, the most intriguing element of a recommendation to use this intraoperative behavior modification tool is that the target behavior itself is controversial. volumes have been written in exploration of the question: What is the true range for optimal perioperative glucose control? Despite years of ongoing research, this target has not yet been defined. although we understand that perioperative euglycemia is important, we have no firm evidence-based limits to guide our treatment. Despite the contemporary climate of goal-directed therapies and ongoing research on the topic, a data-driven optimal glucose range continues to elude us. Such is the ambiguous craft of medicine. When tied to a stimulus–response model of learning, the use of an audiovisual reminder for clinical management may become problematic. Will a behavior persist when the cue is not present? as clinical anesthesiologists, we are incredibly dependent on our monitoring technology, our apps, and our visual aids, for everything from crisis management to preoperative cardiac evaluation. There is an indisputable body of evidence confirming that these aids significantly improve patient care and patient safety. however, practice Learning