Teaching First or Teaching LastDoes it matter in simulation based surgical scenarios?
Benjamin Zendejas Mummert, MD
David A. Cook MD, MHPE
David R. Farley, MD
Mayo Clinic, Rochester, MN
Simulation-Based Scenarios
• Military, Aviation, Healthcare
• “Safe” Rehearsal
Briefing Simulated Scenario Debriefing
Briefing Simulated Scenario Debriefing
Simulated ScenarioBriefing Debriefing
DebriefingBriefing Simulated Scenario
Simulation-Based Scenarios
• When to teach?
Briefing Simulated Scenario
Debriefing
Teaching First
• Knowledge upfront
• Scenario stress
•Demand attention
•Information overload
Teaching Last
• Scenario activates prior knowledge• Knowledge gap• More receptive
• Scenario stress
Study Design
Pre-Post Test Crossover Design
Knowledge and Attitudes
Instructional Modules 3 x 2
• 6 Sessions
• 3 Scenarios / Session
Sessions Module Scenarios1 & 2 Endocrine
Surgery1. Thyroidectomy 2. Pheochromocytoma3. Neck Hematoma
Sessions Module Scenarios1 & 2 Endocrine
Surgery1. Thyroidectomy 2. Pheochromocytoma3. Neck Hematoma
3 & 4 Trauma 1. Chest Trauma2. Pelvic Fracture3. Head Trauma
Sessions Module Scenarios1 & 2 Endocrine
Surgery1. Thyroidectomy 2. Pheochromocytoma3. Neck Hematoma
3 & 4 Trauma 1. Chest Trauma2. Pelvic Fracture3. Head Trauma
5 & 6 Team Training
1. Communication 2. Situation Awareness3. Leadership
Pre-Test
Scenario 1
Brief Scenario Debrief Scenario 2 & 3 Post-Test
Simulated Sessions (3 hours)
Teaching-FirstSessions 1, 4 & 6
Teaching-LastSessions
2, 3 & 5
N = 49 38 Surgical Residents
11 Med Students
# Sessions Attended
N
1 262 193 4
Total 76
Study Participation
Teaching-First 42
Teaching-Last 34
14 Concordant
9 Alternate
0
2
4
6
8
10
Pre-Test Post-Test
Teaching First Teaching Last
Knowledge
10 MCQ Test
95%CI 0.79, 2.33
Large ES 0.8
∆ 1.56
P= NS
Test Scores
Attitudes
0%
20%
40%
60%
80%
100%
Briefings Scenarios Debriefings
Teaching-First (n=42) Teaching-Last (n=34)
Where did you feel the most stress?
P=0.01
Attitudes
0%
20%
40%
60%
80%
100%
Briefings Scenarios Debriefings
Teaching-First (n=42) Teaching-Last (n=34)
What was the best learning experience?
P=0.004
Teaching-First Reactions
Teaching-Last Reactions
Summary
Teaching-Last • Stress during scenarios • 10-20% Knowledge improvement • “Eu-Stress”?
Conceptual Frameworks• Stress• Activation of Prior Knowledge • Cognitive Load Theory
Teaching-First
Brief + Lecture
DebriefScenario
Stress Cognitive Overload
Attentional Resources
Teaching-Last
Brief Scenario
Stress Activation Prior
Knowledge
Debrief + Lecture Knowledge
Gain
Implications
• Use of Instructional Design Theory
• Activate Prior Knowledge
• Minimize Cognitive Overload
Future Directions
How our results apply to:
• Other competencies - skills?
• Other settings – WBL?
• Different levels of expertise?
Long-term retention?