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Simul Healthc. 2014 Apr;9(2):85-93. doi: 10.1097/SIH.0b013e3182a90304.

Training induces cognitive bias: the case of a simulation-based emergency airway curriculum.

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From the Department of Anesthesiology (C.S.P., L.S., B.F.L.), and Simulation Technology and Immersive Learning (C.S.P., L.S.), Center for Education in Medicine, Northwestern University-Feinberg School of Medicine, Chicago, IL; Department of Statistics (B.M.), School of Dentistry, University of Belgrade; and Department of Anesthesiology Clinical Center of Serbia (B.M.), Belgrade, Serbia; and Institute of Cognitive Neuroscience (I.E.D.), University College London (UCL), and Cognitive Consultants International (CCI), London, UK.



Training-induced cognitive bias may affect performance. Using a simulation-based emergency airway curriculum, we tested the hypothesis that curriculum design would induce bias and affect decision making.


Twenty-three novice anesthesiology residents were randomized into 2 groups. The primary outcome measure was the initiation of supraglottic airway and cricothyroidotomy techniques in a simulated cannot-ventilate, cannot-intubate scenario during 3 evaluation sessions. Secondary outcomes were response times for device initiation. After a baseline evaluation and didactic lecture, residents received an initial practical training in either surgical cricothyroidotomy (CRIC group) or supraglottic airway (SGA group). After the midtest, the groups switched to receive the alternate training.


From baseline to midtest, the SGA group increased initiation of supraglottic airway but not cricothyroidotomy. The CRIC group increased initiation of cricothyroidotomy but not supraglottic airway. After completion of training in both techniques, the SGA group increased initiation of both supraglottic airway and cricothyroidotomy. In contrast, the CRIC group increased initiation of cricothyroidotomy but failed to change practice in supraglottic airway. Final test response times showed that the CRIC group was slower to initiate supraglottic airway and faster to initiate cricothyroidotomy.


Practical training in only 1 technique caused bias in both groups despite a preceding didactic lecture. The chief finding was an asymmetrical effect of training sequence even after training in both techniques. Initial training in cricothyroidotomy caused bias that did not correct despite subsequent supraglottic airway training. Educators must be alert to the risk of inducing cognitive bias when designing curricula.

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