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?

Questions?

mummertben@mayo.edu

Thank You