1. 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

2. Simulation-Based Scenarios Military, Aviation, Healthcare “Safe” Rehearsal BriefingSimulated Scenario Debriefing

3. BriefingSimulated Scenario Debriefing

4. Simulated Scenario BriefingDebriefing

5. Briefing Simulated Scenario

6. Simulation-Based Scenarios When to teach? BriefingSimulated Scenario Debriefing

7. Teaching First Knowledge upfront Scenario stress Demand attention Information overload

8. Teaching Last Scenario activates prior knowledge Knowledge gap More receptive Scenario stress

9. Study Design Pre-Post Test Crossover Design Knowledge and Attitudes Instructional Modules 3 x 2 6 Sessions 3 Scenarios / Session

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

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

12. 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

13. 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

14. N = 49 38 Surgical Residents 11 Med Students # Sessions Attended N 126 219 34 Total76 Study Participation Teaching-First 42 Teaching-Last 34 14 Concordant 9 Alternate

15. 0 2 4 6 8 10 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

16. 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

17. 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

18. Teaching-First Reactions

19. Teaching-Last Reactions

20. Summary Teaching-Last Stress during scenarios 10-20% Knowledge improvement “Eu-Stress”? Conceptual Frameworks Stress Activation of Prior Knowledge Cognitive Load Theory

21. Teaching-First Brief + Lecture DebriefScenario Stress Cognitive Overload Attentional Resources

22. Teaching-Last Brief Scenario Stress Activation Prior Knowledge Debrief + Lecture Knowledge Gain

23. Implications Use of Instructional Design Theory Activate Prior Knowledge Minimize Cognitive Overload

24. Future Directions How our results apply to: Other competencies - skills? Other settings – WBL? Different levels of expertise? Long-term retention?

25. Questions? mummertben@mayo.edu Thank You