One Step at a Time: Step by Step Versus Continuous Video-Based Learning to Prepare Medical Students for Performing Surgical Procedures

Tahmina Nazari*, Floyd W. van de Graaf, Mary E. W. Dankbaar, Johan F. Lange, Jeroen J. G. van Merrienboer, Theo Wiggers

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review

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OBJECTIVE: The objective of this study was to compare the effects of cognitive load and surgical performance in medical students that performed the open inguinal hernia repair after preparation with step-by-step videodemonstration versus continuous video-demonstration. Hypothetically, the step-by-step group will perceive lower extraneous load during the preparation of the surgical procedure compared to the continuous group. Subsequently, fewer errors will be made in the surgical performance assessment by the step-by-step group, resulting in better surgical performance.

DESIGN: In this prospective study, participants were randomly assigned to the step-by-step or continuous video-demonstration. They completed questionnaires regarding perceived cognitive load during preparation (10-point Likert scale). Their surgical performance was assessed on a simulation hernia model using the Observational Clinical Human Reliability Assessment.

SETTING: Erasmus University Medical Center, Rotterdam, the Netherlands.

PARTICIPANTS: Participants included medical students who were enrolled in extracurricular anatomy courses.

RESULTS: Forty-three students participated; 23 students in the step-by-step group and 20 in the continuous group. As expected, the step-by-step group perceived a lower extraneous cognitive load (2.92 +/- 1.21) compared to the continuous group (3.91 +/- 1.67, p = 0.030). The surgical performance was not statistically significantly different between both groups; however, in subanalyses on a selection of students that prepared for 1 to 2 hours, the step-by-step group made less procedural errors, 1.67 +/- 1.11, compared to the continuous group, 3.06 +/- 1.91, p = 0.018.

CONCLUSIONS: Our results suggest that preparation using step-by-step video-based learning results in lower extraneous cognitive load and subsequently fewer procedural errors during the surgical performance. For learning purposes, demonstration videos of surgical procedures should be presented in a segmented format. (C) 2020 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

Original languageEnglish
Pages (from-to)779-787
Number of pages9
JournalJournal of Surgical Education
Issue number4
Publication statusPublished - 2020


  • medical education
  • surgery
  • inguinal hernia repair
  • step by step teaching
  • stepwise
  • segmentation


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