Why Content and Cognition Matter: Integrating Conceptual Knowledge to Support Simulation-Based Procedural Skills Transfer

  • Jeffrey J. H. CheungEmail author
  • Kulamakan M. Kulasegaram
  • Nicole N. Woods
  • Ryan Brydges
Original Research



Curricular constraints require being selective about the type of content trainees practice in their formal training. Teaching trainees procedural knowledge about “how” to perform steps of a skill along with conceptual knowledge about “why” each step is performed can support skill retention and transfer (i.e., the ability to adapt knowledge to novel problems). However, how best to organize how and why content for procedural skills training is unknown.


We examined the impact of different approaches to integrating why and how content on trainees’ skill retention and transfer of simulation-based lumbar puncture (LP).

Design and Participants

We randomized medical students (N = 66) to practice LP for 1 h using one of three videos. One video presented only the how content for LP (Procedural Only). Two other videos presented how and why content (e.g., anatomy) in two ways: Integrated in Sequence, with why content followed by how content, or Integrated for Causation, with how and why content integrated throughout.

Main Measures

Pairs of blinded raters scored participants’ retention and transfer LP performances on a global rating scale (GRS), and written tests assessed participants’ procedural and conceptual knowledge.

Key Results

Simple mediation regression analyses showed that participants receiving an integrated instructional video performed significantly better on transfer through their intervention’s positive impact on conceptual knowledge (all p < 0.01). Further, the Integrated for Causation group performed significantly better on transfer than the Integrated in Sequence group (p < 0.01), again mediated by improved conceptual knowledge. We observed no mediation of participants’ skill retention (all p > 0.01).


When teaching supports cognitive integration of how and why content, trainees are able to transfer learning to new problems because of their improved conceptual understanding. Instructional designs for procedural skills that integrate how and why content can help educators optimize what trainees learn from each repetition of practice.


basic science clinical skills training instructional design simulation cognition/problem solving transfer 



The authors extend their thanks and appreciation to the Currie Fellowship program at the Wilson Centre, University Health Network and the Canada Graduate Scholarship program at the Natural Sciences and Engineering Research Council for funding JJHC’s PhD studies. We thank the staff at the Surgical Skills Centre, Mount Sinai Hospital, Toronto, for sharing equipment and resources, Thomas Sun at Sun Innovations for his ongoing innovation and technical support of our projects, and the Wilson Centre for providing space to conduct the experiment.

Funding Information

We are very grateful for the funding from the Bank of Montreal Chair in Health Professions Education Research and from the Department of Medicine, University of Toronto.

Compliance with Ethical Standards

We received institutional ethics approval from the University of Toronto prior to participant recruitment. All participants provided informed consent prior to engaging in the study protocol.

Conflict of Interest

The authors declare that they do not have a conflict of interest.

Supplementary material

11606_2019_4959_MOESM1_ESM.docx (14 kb)
ESM 1 (DOCX 13 kb)


  1. 1.
    Ericsson KA. Deliberate Practice and the Acquisition and Maintenance of Expert Performance in Medicine and Related Domains. Acad Med 2004;79(10).Google Scholar
  2. 2.
    Ericsson KA. The influence of experience and deliberate practice on the development of superior expert performance. In: The Cambridge Handbook of Expertise and Expert Performance. 2006:683–703.Google Scholar
  3. 3.
    McGaghie WC, Issenberg SB, Barsuk JH, Wayne DB. A critical review of simulation-based mastery learning with translational outcomes. Med Educ 2014;48(4):375–385. Google Scholar
  4. 4.
    Hatala R, Brooks L, Norman G. Practice makes perfect: The critical role of mixed practice in the acquisition of ECG interpretation skills. Adv Health Sci Educ 2003;8(1):17–26. Google Scholar
  5. 5.
    Moulton C-AE, Dubrowski A, MacRae H, Graham B, Grober E, Reznick R. Teaching Surgical Skills: What Kind of Practice Makes Perfect?: A Randomized, Controlled Trial. Ann Surg 2006;124:66–75. Google Scholar
  6. 6.
    Larsen DP, Butler AC, Roediger III HL. Test-enhanced learning in medical education. Med Educ 2008;42(10):959–966. Google Scholar
  7. 7.
    Larsen DP, Butler AC, Lawson AL, Iii HLR. The importance of seeing the patient: test-enhanced learning with standardized patients and written tests improves clinical application of knowledge. Adv Health Sci Educ 2012;18(3):409–425. Google Scholar
  8. 8.
    Kulasegaram KM, McConnell M. When I say … transfer-appropriate processing. Med Educ 2016;50(5):509–510. Google Scholar
  9. 9.
    Baroody AJ, Feil Y, Johnson AR. An Alternative Reconceptualization of Procedural and Conceptual Knowledge. J Res Math Educ 2007;38(2):115–131. Google Scholar
  10. 10.
    Rikers RMJP, Loyens SMM, Schmidt HG. The role of encapsulated knowledge in clinical case representations of medical students and family doctors. Med Educ 2004;38(10):1035–1043. Google Scholar
  11. 11.
    Rikers RMJP, Loyens S, te Winkel W, Schmidt HG, Sins PHM. The Role of Biomedical Knowledge in Clinical Reasoning: A Lexical Decision Study: Acad Med. 2005;80(10):945–949. Google Scholar
  12. 12.
    de Bruin AB, Schmidt HG, Rikers RM. The role of basic science knowledge and clinical knowledge in diagnostic reasoning: a structural equation modeling approach. Acad Med 2005;80(8):765–773.Google Scholar
  13. 13.
    Mylopoulos M, Woods NN. Having our cake and eating it too: seeking the best of both worlds in expertise research. Med Educ 2009;43(5):406–413. Google Scholar
  14. 14.
    Woods NN, Brooks LR, Norman GR. The value of basic science in clinical diagnosis: creating coherence among signs and symptoms. Med Educ 2005;39(1):107–112. Google Scholar
  15. 15.
    Woods NN, Neville AJ, Levinson AJ, Howey EH, Oczkowski WJ, Norman GR. The value of basic science in clinical diagnosis. Acad Med 2006;81(10):S124–S127.Google Scholar
  16. 16.
    Woods NN, Howey EHA, Brooks LR, Norman GR. Speed kills? Speed, accuracy, encapsulations and causal understanding. Med Educ 2006;40(10):973–979. Google Scholar
  17. 17.
    Woods NN. Science is fundamental: the role of biomedical knowledge in clinical reasoning: clinical expertise. Med Educ 2007;41(12):1173–1177. Google Scholar
  18. 18.
    Woods NN, Brooks LR, Norman GR. The role of biomedical knowledge in diagnosis of difficult clinical cases. Adv Health Sci Educ 2007;12(4):417–426. Google Scholar
  19. 19.
    Baghdady MT, Pharoah MJ, Regehr G, Lam EWN, Woods NN. The Role of Basic Sciences in Diagnostic Oral Radiology. J Dent Educ 2009;73(10):1187–1193.Google Scholar
  20. 20.
    Baghdady MT, Carnahan H, Lam EW, Woods NN. Integration of basic sciences and clinical sciences in oral radiology education for dental students. J Dent Educ 2013;77(6):757–763.Google Scholar
  21. 21.
    Baghdady MT, Carnahan H, Lam EWN, Woods NN. Dental and Dental Hygiene Students’ Diagnostic Accuracy in Oral Radiology: Effect of Diagnostic Strategy and Instructional Method. J Dent Educ 2014;78(9):1279–1285.Google Scholar
  22. 22.
    Baghdady MT, Carnahan H, Lam EWN, Woods NN. Test-enhanced learning and its effect on comprehension and diagnostic accuracy. Med Educ 2014;48(2):181–188. Google Scholar
  23. 23.
    Kulasegaram KM, Min C, Howey E, et al. The mediating effect of context variation in mixed practice for transfer of basic science. Adv Health Sci Educ 2014:1–16.
  24. 24.
    Kulasegaram KM, Manzone JC, Ku C, Skye A, Wadey V, Woods NN. Cause and Effect: Testing a Mechanism and Method for the Cognitive Integration of Basic Science. Acad Med 2015;90:S63-S69. Google Scholar
  25. 25.
    Kulasegaram KM, Chaudhary Z, Woods N, Dore K, Neville A, Norman G. Contexts, concepts and cognition: principles for the transfer of basic science knowledge. Med Educ 2017;51(2):184–195. Google Scholar
  26. 26.
    Castillo J-M, Park YS, Harris I, et al. A critical narrative review of transfer of basic science knowledge in health professions education. Med Educ 2018;52(6):592–604. Google Scholar
  27. 27.
    Kulasegaram KM, Martimianakis MA, Mylopoulos M, Whitehead CR, Woods NN. Cognition Before Curriculum: Rethinking the Integration of Basic Science and Clinical Learning. Acad Med 2013;88(10):1578–1585. Google Scholar
  28. 28.
    Cheung JJH, Kulasegaram KM, Woods NN, Moulton C, Ringsted CV, Brydges R. Knowing How and Knowing Why: testing the effect of instruction designed for cognitive integration on procedural skills transfer. Adv Health Sci Educ 2017.
  29. 29.
    Brydges R, Nair P, Ma I, Shanks D, Hatala R. Directed self-regulated learning versus instructor-regulated learning in simulation training. Med Educ 2012;46(7):648–656. Google Scholar
  30. 30.
    Haji FA, Cheung JJH, Woods N, Regehr G, de Ribaupierre S, Dubrowski A. Thrive or overload? The effect of task complexity on novices’ simulation-based learning. Med Educ 2016;50(9):955–968. Google Scholar
  31. 31.
    Martin JA, Regehr G, Reznick R, et al. Objective structured assessment of technical skill (OSATS) for surgical residents. Br J Surg 1997;84(2):273–278.Google Scholar
  32. 32.
    Ilgen JS, Ma IWY, Hatala R, Cook DA. A systematic review of validity evidence for checklists versus global rating scales in simulation-based assessment. Med Educ 2015;49(2):161–173. Google Scholar
  33. 33.
    Bloch R. G_String_IV. Hamilton, ON; 2017. Available at: Accessed 6 January 2019.
  34. 34.
    Leppink J. On causality and mechanisms in medical education research: an example of path analysis. Perspect Med Educ 2015;4(2):66–72. Google Scholar
  35. 35.
    Rucker DD, Preacher KJ, Tormala ZL, Petty RE. Mediation Analysis in Social Psychology: Current Practices and New Recommendations: Mediation Analysis in Social Psychology. Soc Personal Psychol Compass 2011;5(6):359–371. Google Scholar
  36. 36.
    Hayes AF. Introduction to Mediation, Moderation, and Conditional Process Analysis: A Regression-Based Approach. New York: The Guilford Press; 2013.Google Scholar
  37. 37.
    Motola I, Devine LA, Chung HS, Sullivan JE, Issenberg SB. Simulation in healthcare education: A best evidence practical guide. AMEE Guide No. 82. Med Teach. 2013;35(10):e1511-e1530. Google Scholar
  38. 38.
    Cook DA, Brydges R, Hamstra SJ, et al. Comparative Effectiveness of Technology-Enhanced Simulation Versus Other Instructional Methods: A Systematic Review and Meta-Analysis. Simul Healthc 2012;7(5):308–320. Google Scholar
  39. 39.
    Van Merriënboer JJG, Sweller J. Cognitive load theory in health professional education: design principles and strategies: Cognitive load theory. Med Educ 2010;44(1):85–93. Google Scholar
  40. 40.
    Eva KW, Neville AJ, Norman GR. Exploring the etiology of content specificity: factors influencing analogic transfer and problem solving. Acad Med 1998;73(10 Suppl):S1–5.Google Scholar
  41. 41.
    Norman G. Teaching basic science to optimize transfer. Med Teach 2009;31(9):807–811. Google Scholar
  42. 42.
    Goldszmidt M, Minda JP, Devantier SL, Skye AL, Woods NN. Expanding the basic science debate: the role of physics knowledge in interpreting clinical findings. Adv Health Sci Educ 2012;17(4):547–555. Google Scholar
  43. 43.
    Bandiera G, Kupern A, Mylopoulos M, et al. Back from basics: integration of science and practice in medical education. Med Educ 2017;52(1):78–85. Google Scholar
  44. 44.
    Eva KW, Brady C, Pearson M, Seto K. The pedagogical value of testing: how far does it extend? Adv Health Sci Educ 2018:1–14.

Copyright information

© Society of General Internal Medicine 2019

Authors and Affiliations

  • Jeffrey J. H. Cheung
    • 1
    • 2
    Email author
  • Kulamakan M. Kulasegaram
    • 1
    • 3
  • Nicole N. Woods
    • 1
    • 3
  • Ryan Brydges
    • 1
    • 2
    • 4
  1. 1.The Wilson Centre, University Health Network and University of TorontoTorontoCanada
  2. 2.Allan Waters Family Simulation CentreSt. Michael’s HospitalTorontoCanada
  3. 3.Department of Family and Community MedicineUniversity of TorontoTorontoCanada
  4. 4.Department of MedicineUniversity of TorontoTorontoCanada

Personalised recommendations