The purpose of this study was to compare dyad and individual learning during a simulation-based bradycardia scenario to better understand the impact of dyad training on emotional state (stress, anxiety), cognitive load, and educational effect. As expected, on the initial day of training, students in the dyad groups had lower stress and anxiety levels and achieved better performance metrics when compared to individuals (teams of two individuals outperformed teams with only one individual). Interestingly, the cognitive load was identical in both groups. Stress, anxiety, and performance were similar on individual post-intervention testing on day 4.
The finding that students in the dyad groups had lower stress and anxiety levels for their initial training experience would support the theory that partnership reduces emotional turmoil in simulation scenario participants. In contrast to our hypothesis, this less stressful and less anxiety-provoking educational experience did not seem to translate to an overall lower performance on testing 3 days later. The single exception was time to recognizing the indication for TP, but students initially in a dyad otherwise had similar performance to individuals on post-intervention assessment on Day 4. Prior studies have shown that moderately increased stress may improve memory consolidation [10–13] which may suggest that the individuals should have performed better on post-intervention assessment on Day 4 given their higher stress and anxiety scores on Day 1. What is unclear, given the short duration of this study, is if this benefit would be borne out on retention testing done several weeks or months later, when a well-consolidated memory may be more important.
Studies have demonstrated that dyad training is an effective, or at least non-inferior, method of medical education in acquisition of procedural skills in bronchoscopy , coronary angiography , lumbar puncture , and ultrasound  as well as clinical encounter skills , with numerous theories for why this serves as an effective knowledge transfer. Tolsgaard  raises the possibility that the time spent in dyad practice may be inversely related to the gains in learning of the dyad participants (i.e., shorter practice time yields greater benefit to dyads than longer sessions); our students’ scenario, at only eight minutes actively engaged in simulation (plus an additional eight minutes for the standardized video debrief), was the shortest of the known dyad studies, and thus would have expected greater gains by students in the dyad group, which was not borne out on our post-intervention testing. However, our study also was a less procedurally-focused topic than many of the above, raising some question of applicability of much of the prior literature. Cognitive load theory [16, 17, 34] suggests that a complex task like diagnosing and managing symptomatic bradycardia (particularly at the medical student level) may be well suited for learning as dyad. Tolsgaard  notes that dyad structure would provide a larger reservoir of cognitive capacity to utilize for information processing and may therefore improve learning. It was thus an unexpected finding that cognitive load was not statistically different between the dyad and individual groups on Day 1 (or Day 4). One would anticipate that cognitive load would be reduced in the dyad groups due to the collaborative experience and the ability to divide tasks. However, this assumption was not supported by our data. This may be due to the different type of task asked of these students (highly cognitive and minimally procedural, rather than mostly procedural), or could be related to our small sample size and risk for Type II error.
Interestingly, students reported a preference for working through this scenario as individuals (56%) instead of dyads, despite higher levels of stress and anxiety (though many students only experienced the scenario as an individual). Considering this was a low-stakes formative assessment, it may be that students liked the challenge of trying to perform alone and felt the increased stress more accurately represented real life scenarios they may face. Interpretation of this survey result is also challenging as students in the individual group did not get to experience a cross-over dyad session but were likely able to answer this question based on prior simulation based educational experiences both alone and with partners.
In the current climate of healthcare education, costs continue to climb while resources remain limited. If dyad training is as effective as individual training, this could be helpful in scheduling students more efficiently, as twice the number of learners would be able to utilize the same volume of resources. However, this study was not designed to investigate the learning effect, and we cannot conclude equivalency from our study, particularly due to our small sample size.
It remains to be determined if larger collections of learners (groups of 3 or more) could be taught simultaneously using SBME with similar educational outcomes or whether those simply observing a simulation scenario and participating in the debrief would have similar benefit. Other future directions for research include: comparison of training preference, emotional state, perceived cognitive load, and performance by future specialty; comparison of individuals, dyads, larger groups, and observers; and delayed retention testing. Further research is needed to clarify the optimal role of collaborative versus individual learning for non-procedural skills (as in this study) compared to more hands-on procedural skills.
The limitations of this study include its small sample size, relatively short time to post-intervention assessment, performance scoring by unblinded investigators who were also the course directors, the absence of specific instructions to collaborate during the scenarios for the dyad group and the subjective survey method for measurement of workload, anxiety, and stress. Sample size was limited by class size, making it a fixed limitation and difficult to otherwise address in this single-site study, however all the available students participated in this study. Adding additional class years in the future and expanding the course to other educational institutions would reduce the risk of Type II error and allow for further sub-analyses by gender or future specialty, for instance. The short time to post-intervention assessment was due to preset constraints of the IBC schedule. The medical school required that IBC be completed in the period of one week for each group of students. Moreover, IBC is held near the very end of the academic year, thus there was not a feasible opportunity to delay retention testing to a time outside of the week of the scheduled IBC. It is possible that there may be retention differences between those who went through the initial simulation as dyads and those who went through individually if we were able to assess performance at a more distant time. Additionally, determination of certain time metrics, such as time to awareness of bradycardia and time to recognizing an indication for TP, required verbalization from the participant or interpretation by the scorer, which may have led to unintentional confounding.
Additionally, it is worth noting that the stress, anxiety, and cognitive load that a learner experiences while undergoing simulation-based education may not accurately reflect these measures if the learner were experiencing the same scenario in real life. The learning effect from the potentially different emotional state may cause either an improvement or detriment to memory consolidation (Piquette et al., 2014; Vine et al., 2015; Harvey et al., 2010). It is also likely that a higher-level trainee, such as resident or fellow, would have a lower stress response to this complex patient scenario; if so, it is also unknown what impact this emotional state would have on learning.