Description
The Medical Pause in Simulation TrainingThis PhD thesis aims to foster the understanding of the medical pause as a professional skill that should be taught in educational programs, by investigating the effects of pausing both theoretically and empirically. In Chapter 1, General Introduction, I review previous studies on pausing skills in medical education and education in general. To explain cognitive mechanisms that constitute pausing skills, cognitive load theory is introduced. Relaxation and reflection are stressed as the two major cognitive processes that make pausing effective for increasing performance and learning. Computer-based simulation (CBS) is illustrated as a promising environment for pausing skills for both educational and research purposes. This introductory chapter presents an overview of the five studies that build up this thesis. Study 1 provides a theoretical framework of the medical pause. After Study 2 validates performance measures and the task environment of a CBS, namely, a serious game. Study 3 and 4 investigate the two processes during pauses, that is, relax- ation and reflection. Finally, Study 5 tests the generalizability of the findings in another type of CBS environment, Virtual Reality (VR).
Chapter 2 establishes a systematic conceptualization of the medical pause, focusing on its importance, processes, and implementation in training programs. By employing insights from educational sciences and cognitive psychology, I first identify pausing as an important skill to interrupt negative momentum and bolster learning. Subsequently, I categorize constituent cognitive processes for pausing skills into two phases: the deci- sion-making phase (determining when and how to take pauses) and the executive phase (applying relaxation or reflection during pauses). I present a new model that describes how relaxation and reflection during pauses can optimize cognitive load in performance. Several strategies to implement pause training in medical curricula are proposed: inter- twining pause training with training of primary skills, providing second-order scaffolding through shared control, and employing auxiliary tools such as CBS with a pause function.
Chapter 3 aims to validates performance measures and the task environment of a serious game for emergency medicine (i.e., AbcdeSIM) by testing whether the measuresdeveloped in this study can predict different levels of prior knowledge. Based on theories of complex-skill acquisition (e.g., 4C/ID), I derive four performance aspects that prior knowledge may affect: (1) systematicity in approach, (2) accuracy in visual attention and motor reactions, (3) speed in performance, and (4) cognitive load. The measures are developed to represent these aspects by using machine learning, game-log analysis, and eye-tracking.
Participants were 24 medical professionals (experts, with high prior knowledge) and 22 medical students (novices, with low prior knowledge). After pre-training, they all played one scenario, during which game logs and eye movements were collected. A cognitive-load questionnaire ensued. During game play, experts demonstrated a more systematic approach, higher accuracy in visual selection and motor reaction, and a higher performance speed than novices. Their reported levels of cognitive load were lower. These results indicate that prior knowledge has a substantial impact on perfor- mance in AbcdeSIM, opening up the possibility of using the measures for performance assessment.
Chapter 4 investigates how pausing affects performance and cognitive load in in- tense situations in AbcdeSIM. On the assumption that allowing pauses and actually taking pauses are two different kinds, the effects of these two constructs are tested re- spectively. Medical students (N = 70) were randomly assigned to one of two conditions: simulation with (n = 40) and without (n = 30) the option to take pauses. All participants played the same two scenarios, during which game logs and eye-tracking data were recorded.
Overall, both cognitive load and performance were higher in the condition with pauses than in the one without pauses. The act of pausing, however, temporarily lowered cognitive load, especially during intense moments. Two different manifestations of the pause effect were identified: (1) by stimulating additional cognitive and metacognitive processes, pauses increased overall cognitive load; and (2) through relaxation, the act of pausing temporarily decreased heightened cognitive load. Consequently, these results suggest that in order to enhance students’ performance and learning it is important to encourage them to utilize the different effects of pausing depending on the given situation.
Chapter 5 examines the effects of reflective pauses on performance, given that in- structional support for reflection is provided. By using concepts from complex learning, I propose how to design cognitive and metacognitive aids (CMAs) to support reflection processes during pauses. Assuming reflective pauses with CMAs help to optimize cog- nitive load and allow for restructuring of mental models, I examine their effects on four aspects of performance and learning: cognitive load, domain-specific performance, domain-general performance, and the structure of cognitive schemas.
Medical students (N = 72) performed tasks in the AbcdeSIM task environment, in two conditions: reflection condition (n = 36) where reflection was prompted during pauses, and control condition (n = 36) without such prompts. The effects of reflective pauses only emerged in the later stage of the learning process, while no significant effects were identified in the early stage. Cognitive load decreased and the domain-general aspects of performance improved. However, domain-specific performance aspects and schema structure did not improve, probably due to lacking feedback during reflection. These results suggest that theory-based support design can make in-action reflection more effective, demonstrating that reflective pauses can enhance performance, but an adaptation period is required.
Chapter 6 explores whether the indicators found in the previous studies can be ap- plied to VR environments. Although pupillometry is well-known as a reliable technique to measure cognitive load in 2D environments, its applicability to 3D VR environments had not been validated yet. Specifically, the VR display causes light reflexes that confound task-evoked pupillary responses (TEPRs). Through this pilot study, I validate whether task difficulty can predict cognitive load as measured by TEPRs corrected for the light reflex and if these TEPRs correlate with cognitive load self-ratings and performance.
Fourteen students in health sciences performed observation tasks in two conditions: difficult versus easy tasks, whilst watching a VR scenario in home health care. Then, a cognitive load self-rating ensued. I used a VR system with a built-in eye-tracker and a photosensor installed to assess pupil diameter and light intensity during the scenario. Employing a method from the human-computer interaction field, I determined TEPRs by modeling the pupil light reflexes using a baseline. As predicted, the difficult task caused significantly larger TEPRs than the easy task. Only in the difficult task condition did TEPRs positively correlate with the performance measures. These results suggest that TEPRs are valid measures of cognitive load in VR training when corrected for the light reflex. It opens up possibilities to use real-time cognitive load for assessment and instructional design for VR training.
Chapter 7 is the General Discussion which brings the findings from all studies together. By connecting these findings, it discusses how the studies in this thesis contributed to the investigation of the pause effects and deepened the understanding of the medical pause. Throughout the five studies, the medical pause is identified as a complex professional skill that should be understood through interplay between cognitive load, self-regulation, and learning processes. Among diverse aspects of performance that pausing can enhance, the biggest beneficiary of pausing appears to relate to patient safety.
Theoretical and methodological contributions of this project are identified in three fields: (1) healthcare training (2) educational psychology (i.e. cognitive load theory, 4C/ ID), and (3) performance assessment in CBS. This project provides new approaches tosafety culture by introducing the medical pause, and facilitates the existing discussion on the interplay between cognitive load and self-regulation by establishing a new triarchic model of cognitive load with PL, SL, and EL. By using game logs and eye-tracking, it presents an advanced application of diverse data sets to measure cognitive processes in performance and learning.
Limitations of the studies are illustrated to guide future researchers to unfold the re- search on the medical pause. Also, practical implications for educators and CBS de- signers are discussed by suggesting instructional applications. For instance, the degree of support by supervisors should be negotiated based on learners’ competency levels before the training. During the training, pauses are initiated through support of the CMAs, while additional pauses can be improvised guided by the supervisors. After the training, students can repeatedly practice the scenario and the pausing strategies at home by using online access to the CBS.
Period | 2018 → 2022 |
---|---|
Examinee | Joy Yeonjoo Lee |
Examination held at |
|
Keywords
- eye tracking
- medicine
- expertise
- pausing
- Cognitive load