Theory Precedes Practice: Simulation-Based Learning Enhances Long-Term Recall, but Prior Text-Based Learning Enhances Its Benefits

Simulation-Based Learning (SBL) is widely used in medical and STEM education, offering immersive, embodied, and interactive experiences. However, its implementation often introduces variability in control conditions, instructional design, and a reliance on between-subjects comparisons, making it difficult to isolate its specific contributions to learning. This study used a within-subjects randomized controlled design (N=88) to evaluate the effects of SBL on knowledge retention, retrieval efficiency, and confidence calibration. Participants, naïve to the learning content, learned two counterbalanced fictitious clinical cases via either a live-actor simulation or a structured text-based format. Retention was assessed one month later through video-based and written evaluations measuring accuracy, reaction time, and confidence. SBL led to significantly faster reaction times (Estimate = 0.066, 95% CI [0.03, 0.10], SE = 0.017, t = 3.90, p < 0.001) and higher recall accuracy (Estimate = -0.456, SE = 0.097, z = -4.71, p < 0.001, OR = 0.63, 95% CI [0.52, 0.77]) compared to text-based learning. An order effect emerged: learning first via text enhanced subsequent SBL performance, whereas the reverse sequence impaired text-based retention (Estimate = –0.837, SE = 0.343, z = –2.44, p = 0.015; OR = 0.43, 95% CI [0.22, 0.85]). Mental imagery ability influenced retrieval accuracy, with higher imagery scores predicting greater accuracy overall (Estimate = 0.266, SE = 0.114, z = 2.34, p = 0.019; OR = 1.30, 95% CI [1.04, 1.63]). A significant interaction between imagery ability and modality showed that this effect was more pronounced in the text-based condition (Estimate = -0.186, SE = 0.058, z = -3.22, p = 0.001; OR = 0.83, 95% CI [0.74, 0.93]). Confidence ratings further highlighted SBL’s advantages, with participants in the SBL condition being three times more likely to report absolute confidence (Estimate = –1.14, SE = 0.08, z = –13.68, p < 0.001; OR = 0.32, 95% CI [0.27, 0.38]). Moreover, in the SBL condition, confidence was more closely aligned with actual accuracy. This study provides empirical evidence supporting the benefits of SBL over traditional text-based learning for the acquisition and long-term retention of clinical knowledge. While SBL enhances learning, our results suggest that structured, text-based methods can also yield strong retention outcomes, particularly for item identification and sequential recall. These findings clarify the role of SBL’s immersive, embodied, and interactive elements in shaping learning while highlighting the impact of instructional sequencing and individual differences in imagery ability. Additionally, they underscore the potential benefit of SBL in aligning self-confidence with accuracy. By isolating specific SBL features, this study refines our understanding of its effects on knowledge acquisition, retrieval, and self-confidence alignment. This refined understanding allows for better-informed design of SBL interventions and offers insights that can be applied to non-SBL learning environments.