Teaching First or Teaching Last Does it matter in simulation based surgical scenarios? Benjamin Zendejas Mummert, MD David A. Cook MD, MHPE David R. Farley,

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Teaching First or Teaching Last Does 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 BriefingSimulated Scenario Debriefing

BriefingSimulated Scenario Debriefing

Simulated Scenario BriefingDebriefing

Briefing Simulated Scenario

Simulation-Based Scenarios When to teach? BriefingSimulated 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

SessionsModuleScenarios 1 & 2Endocrine Surgery 1. Thyroidectomy 2. Pheochromocytoma 3. Neck Hematoma

SessionsModuleScenarios 1 & 2Endocrine Surgery 1. Thyroidectomy 2. Pheochromocytoma 3. Neck Hematoma 3 & 4Trauma 1. Chest Trauma 2. Pelvic Fracture 3. Head Trauma

SessionsModuleScenarios 1 & 2Endocrine Surgery 1. Thyroidectomy 2. Pheochromocytoma 3. Neck Hematoma 3 & 4Trauma 1. Chest Trauma 2. Pelvic Fracture 3. Head Trauma 5 & 6Team Training 1. Communication 2. Situation Awareness 3. Leadership

Pre-Test Scenario 1 BriefScenarioDebrief Scenario 2 & 3 Post-Test Simulated Sessions (3 hours) Teaching-First Sessions 1, 4 & 6 Teaching-Last Sessions 2, 3 & 5

N = Surgical Residents 11 Med Students # Sessions Attended N Total76 Study Participation Teaching-First 42 Teaching-Last Concordant 9 Alternate

Pre-TestPost-Test Teaching FirstTeaching Last Knowledge 10 MCQ Test 95%CI 0.79, 2.33 Large ES 0.8 ∆ 1.56 P= NS Test Scores

Attitudes Figure 3: Attitude Survey Results Proportion of participants responding to each survey question and only statistically significant comparisons are shown. Where were you the most nervous?Choose the Better Learning Experience P=0.01 P=0.03 P=0.004 Where were you the most nervous?Choose the Better Learning Experience P=0.01

Attitudes Figure 3: Attitude Survey Results Proportion of participants responding to each survey question and only statistically significant comparisons are shown. Where were you the most nervous?Choose the Better Learning Experience P=0.01 P=0.03 P=0.004 Where were you the most nervous?Choose the Better Learning Experience P=0.01 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? Thank You