Online Learning and Residents' Acquisition of Mechanical Ventilation Knowledge: Sequencing Matters

Game-based Education in Residency (GamER) Study Group, Traci A Wolbrink, Sandrijn M van Schaik, David A Turner, Steven J Staffa, Eleanor Keller, Donald L Boyer, Grace Chong, Jarrod Cross, Sylvia Del Castillo, Andrew Feng, R Stanley Hum, Ebor Jacob James, Amanda Johnson, Sarah Kandil, Martin Kneyber, Ramachandran Rameshkumar, Amanda Levin, Rakesh Lodha, Muralidharan JayashreeAnthony Olivero, Felix Oberender, Rahul S Panesar, Puneet A Pooni, Kyle J Rehder, Shuba Sankaranarayanan, Margaret Scheffler, Rana Sharara-Chami, Ashley L Siems, Rajakumar Padur Sivaraman, Ken Tegtmeyer, Stacey Valentine, Florencia Villois, Amelie von Saint Andre-von Arnim, Margaret Winkler, Chris Dede, Jeffrey P Burns

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OBJECTIVE: Rapid advancements in medicine and changing standards in medical education require new, efficient educational strategies. We investigated whether an online intervention could increase residents' knowledge and improve knowledge retention in mechanical ventilation when compared with a clinical rotation and whether the timing of intervention had an impact on overall knowledge gains.

DESIGN: A prospective, interventional crossover study conducted from October 2015 to December 2017.

SETTING: Multicenter study conducted in 33 PICUs across eight countries.

SUBJECTS: Pediatric categorical residents rotating through the PICU for the first time. We allocated 483 residents into two arms based on rotation date to use an online intervention either before or after the clinical rotation.

INTERVENTIONS: Residents completed an online virtual mechanical ventilation simulator either before or after a 1-month clinical rotation with a 2-month period between interventions.

MEASUREMENTS AND MAIN RESULTS: Performance on case-based, multiple-choice question tests before and after each intervention was used to quantify knowledge gains and knowledge retention. Initial knowledge gains in residents who completed the online intervention (average knowledge gain, 6.9%; SD, 18.2) were noninferior compared with those who completed 1 month of a clinical rotation (average knowledge gain, 6.1%; SD, 18.9; difference, 0.8%; 95% CI, -5.05 to 6.47; p = 0.81). Knowledge retention was greater following completion of the online intervention when compared with the clinical rotation when controlling for time (difference, 7.6%; 95% CI, 0.7-14.5; p = 0.03). When the online intervention was sequenced before (average knowledge gain, 14.6%; SD, 15.4) rather than after (average knowledge gain, 7.0%; SD, 19.1) the clinical rotation, residents had superior overall knowledge acquisition (difference, 7.6%; 95% CI, 2.01-12.97;p = 0.008).

CONCLUSIONS: Incorporating an interactive online educational intervention prior to a clinical rotation may offer a strategy to prime learners for the upcoming rotation, augmenting clinical learning in graduate medical education.

Original languageEnglish
Pages (from-to)E1-E8
Number of pages8
JournalCritical Care Medicine
Issue number1
Early online date2019
Publication statusPublished - Jan-2020


  • flipped classroom
  • graduate medical education
  • mechanical ventilation
  • online learning
  • pediatric critical care medicine
  • virtual simulation

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