#KeyLIMEPodcast 199: “Messy Montessori Medicine”

What is the impact of sequencing discovery learning before direct instruction for simulation-based technical skills training? Read on, and check out the podcast here (or on iTunes!)


KeyLIME Session 199:

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Kulasegaram K et. al.,  Do one then see one: Sequencing discovery learning and direct 1 instruction for simulation-based technical skills training Acad Med. 2018 Nov;93


Reviewer: Linda Snell (@LindaSMedEd)


See one, do one, mess it up? Do one first?

Or see one, do a few and get better with practice and feedback?

Teaching a technical skill has often been done using mastery learning, allowing learners an opportunity to direct their own learning with practice.

We know that ‘activating’ learners can enhance self-regulated learning (SRL) but how much learner control, and how to integrate SRL with instructor-led sessions is under-studied. A systematic review and meta-analysis of simulation-based training showed researchers compare SRL and instructor-led interventions often, yet few study how to combine the two.

The arguments:

  • For discovery learning: enhances transfer of learning, learner self-regulation, is more learner centric.
  • For direct instruction: discovery learning induces unnecessary cognitive load, results in inaccurate or weak mental models, and poses undue stress on trainees.

In head-to-head comparisons of pure direct instruction versus pure discovery learning the latter is a weaker form of instruction.

But it is not an either-or: now we talk about ‘guided discovery’ and about finding the optimal sequencing of direct instruction and discovery learning, which in non-medical settings (concept and classroom teaching) has shown a better transfer of learning  to real life contexts. Most of the latter studies are of learning concepts, not skills training, and have not looked at efficiency (e.g. instructor time), or learner self-efficacy.


The authors hypothesize that the sequence of discovery, followed by direct instruction would benefit students’ transfer of skills, but not their retention or immediate post-test performance. [why?] They also examined how the two sequences impacted students’ perceptions of self-efficacy and competence.

Key Points on Method

Recruited 32 Med 1 and 2 students naïve to suturing to learn suturing on a skin-pad simulator.

Randomized to:

A: 30 min demonstration and instruction, followed by practice with feedback, a mid-point self-efficacy test and suture test, the 30 min practice, with an immediate post self-efficacy test and suture test.

B: 30 min discovery phase with a diagram to follow, but no other guidance, a mid-point self-efficacy test and suture test, then 30 min demonstration and instruction, followed by practice with feedback, with an immediate post self-efficacy test and suture test.

1 week later both groups repeated the suturing test (‘retention’), then a ‘transfer test’ where the suturing was done in a simulated abdominal cavity using  different tools. As well, they completed self-efficacy questionnaires prior to both retention and transfer tests.

The transfer test was the primary outcome.

Secondary outcomes were self-efficacy tests and all other suturing tests.

A single blinded rater used an OSAT global rating scale for all.

Appropriate statistics done – ANCOVA, ANOVA

Key Outcomes

Analyzed 16 in each group. ‘Do then see’ had slightly more suturing experience.

1ry outcome: Do then See were better on the transfer task, with no interaction with experience (3 vs 2.5) with no interaction with experience.

2ry outcomes: Both groups improved from mid-point to immediate post-test with significant drop in performance on retention test. No significant differences between groups overall.

Self-efficacy best at immediate post-test then declined. See then Do group had significantly higher self-efficacy than the Do then See group. The group mean self-efficacy for the Do then See group never rose above the lowest group mean for the See then Do group.

Possibly providing opportunity for discovery learning might enhance transfer learning outcomes, while also using less instructor time (half the time required of faculty in a mastery-based course.)

Learner perception of competence may not be accurate – the Do then See group might be lower as they struggled prior to formal instruction.

Why did Do then See group perform better at transfer? Perhaps it forces learners to experiment with, and produce a number of variations in how to perform the task; evidence that variation during learning yields improved acquisition and transfer of performance. Or initial struggle may focus learners better when with the instructor. In constructivist learning theory learners construct their own ‘meaning’ of the task by scaffolding it on their previous knowledge – activating previous knowledge while engaging with the task.

Key Conclusions

The authors conclude that ‘allowing learners to experiment before they interact with an instructor may help balance learner autonomy and instructor time pressures’.

They suggest that educators and curriculum developers should consider how to combine learner SRL and direct instruction within training sessions, and across curriculum.




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