title: Cognitive load in distributed and massed practice in virtual reality mastoidectomy simulation.
abstract: OBJECTIVE
  Cognitive load theory states that working memory is limited. This has implications for learning and suggests that reducing cognitive load (CL) could promote learning and skills acquisition. This study aims to explore the effect of repeated practice and simulator-integrated tutoring on CL in virtual reality (VR) mastoidectomy simulation.
  
  
  METHODS
  Prospective trial.
  
  
  METHODS
  Forty novice medical students performed 12 repeated virtual mastoidectomy procedures in the Visible Ear Simulator: 21 completed distributed practice with practice blocks spaced in time and 19 participants completed massed practice (all practices performed in 1 day). Participants were randomized for tutoring with the simulator-integrated tutor function. Cognitive load was estimated by measuring reaction time in a secondary task. Data were analyzed using linear mixed models for repeated measurements.
  
  
  RESULTS
  The mean reaction time increased by 37% during the procedure compared with baseline, demonstrating that the procedure placed substantial cognitive demands. Repeated practice significantly lowered CL in the distributed practice group but not in massed practice group. In addition, CL was found to be further increased by 10.3% in the later and more complex stages of the procedure. The simulator-integrated tutor function did not have an impact on CL.
  
  
  CONCLUSIONS
  Distributed practice decreased CL in repeated VR mastoidectomy training more consistently than was seen in massed practice. This suggests a possible effect of skills and memory consolidation occurring over time. To optimize technical skills learning, training should be organized as time-distributed practice rather than as a massed block of practice, which is common in skills-training courses.
  
  
  METHODS
  N/A.
authors.affiliation: Department of Otorhinolaryngology-Head and Neck Surgery, Rigshospitalet.
authors.forename: Steven Arild Wuyts
authors.initials: SA
authors.lastname: Andersen
authors.affiliation: The Alexandra Institute, Aarhus, Denmark.
authors.forename: Peter Trier
authors.initials: PT
authors.lastname: Mikkelsen
authors.affiliation: Center for Clinical Education, Center for HR, The Capital Region of Denmark, Copenhagen.
authors.forename: Lars
authors.initials: L
authors.lastname: Konge
authors.affiliation: Department of Otorhinolaryngology-Head and Neck Surgery, Rigshospitalet.
authors.forename: Per
authors.initials: P
authors.lastname: Cayé-Thomasen
authors.affiliation: Department of Otorhinolaryngology-Head and Neck Surgery, Rigshospitalet.
authors.forename: Mads Sølvsten
authors.initials: MS
authors.lastname: Sørensen
mesh_terms: D000328:Adult; D002983:Clinical Competence; D003071:Cognition / Q000502:physiology*; D003198:Computer Simulation; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D059032:Learning Curve; D008297:Male; D008416:Mastoid / Q000601:surgery*; D008568:Memory / Q000502:physiology*; D013517:Otorhinolaryngologic Surgical Procedures / Q000193:education* / Q000379:methods; D011446:Prospective Studies; D013337:Students, Medical / Q000523:psychology*; D014584:User-Computer Interface; D055815:Young Adult
keywords: Cognitive load; distributed practice; massed practice; mastoidectomy training; technical skills training; virtual reality simulation