How do attending physicians describe cognitive overload among their workplace learners?

Physiologic measurements of cognitive load in clinical reasoning

OBJECTIVES

Cognitive load is postulated to be a significant factor in clinical reasoning performance. Monitoring physiologic measures, such as heart rate variability (HRV) may serve as a way to monitor changes in cognitive load. The pathophysiology of why HRV has a relationship to cognitive load is unclear, but it may be related to blood pressure changes that occur in a response to mental stress.

METHODS

Fourteen residents and ten attendings from Internal Medicine wore Holter monitors and watched a video depicting a medical encounter before completing a post encounter form used to evaluate their clinical reasoning and standard psychometric measures of cognitive load. Blood pressure was obtained before and after the encounter. Correlation analysis was used to investigate the relationship between HRV, blood pressure, self-reported cognitive load measures, clinical reasoning performance scores, and experience level.

RESULTS

Strong positive correlations were found between increasing HRV and increasing mean arterial pressure (MAP) (p=0.01, Cohen's d=1.41). There was a strong positive correlation with increasing MAP and increasing cognitive load (Pearson correlation 0.763; 95 % CI [; 95 % CI [-0.364, 0.983]). Clinical reasoning performance was negatively correlated with increasing MAP (Pearson correlation -0.446; 95 % CI [-0.720, -0.052]). Subjects with increased HRV, MAP and cognitive load were more likely to be a resident (Pearson correlation -0.845; 95 % CI [-0.990, 0.147]).

CONCLUSIONS

Evaluating HRV and MAP can help us to understand cognitive load and its implications on trainee and physician clinical reasoning performance, with the intent to utilize this information to improve patient care.

The Decline of Basic Ophthalmology in General Medical Education: A Scoping Review and Recommended Potential Solutions

OBJECTIVE

This literature review aims to explore research and conceptual pieces on the state of ophthalmology education and suggest potential ways to address current challenges.

METHODS

A search was conducted in PubMed, ERIC, Web of Science, and Google Scholar with combinations of the following search terms: "ophthalmology education," "undergraduate medical education," "medical student," "United States," and "Canada." Eliminating irrelevant articles yielded 47 articles. Three were excluded because of region and focus, leaving 44. After examining the citations, we generated an additional 22 texts for review, totaling 66 articles.

RESULTS

Four primary themes were identified: (1) challenges to ophthalmological education in the U.S. and Canada, (2) potential remedies for optimizing ophthalmology curriculum, (3) technology in ophthalmology education, and (4) innovative ophthalmology teaching approaches. Major challenges included the lack of a standardized curriculum and inadequate clinical exposure and skills training. A number of remedies were proposed, such as standardizing curriculum and furthering faculty involvement, utilizing technology as time-effective learning aids, and employing innovative teaching approaches such as service learning.

CONCLUSION

In light of challenges in ophthalmology education, curriculum designers should consider Cognitive Load Theory (CLT) to assist students to remember meaningful exposures to ophthalmology knowledge and techniques. Based on CLT, we suggest two potential approaches to incorporating ophthalmology curriculum. The first is to embrace interdisciplinary collaborations and place ophthalmology knowledge in varied contexts to facilitate schema construction. The second is to incorporate ophthalmology diagnostics requirements into OSCEs and utilize simulation models for students to gradually increase the fidelity of tasks and devote cognitive resources fully to learning.

Impact of training in the supervision of clinical reasoning in the pediatric emergency department on residents' perception of the on-call experience

BACKGROUND

In 2021, the prevalence of signs of burnout among medical residents was reported to be 67%. Being on call is particularly stressful for residents, notably due to their lack of medical experience. When they are on call, several factors contribute to a mismatch between the residents' theoretical knowledge and the operationalization of that knowledge in a clinical reasoning process. Using the script and cognitive load theories as a basis, we hypothesized that training clinician-teachers in the supervision of clinical reasoning could improve residents' perception of the experience of being on call.

METHODS

We performed a longitudinal, exploratory, controlled study with a cohort of medical residents who were on call in the pediatric emergency department during the semester from 1 November 2021 to 30 April 2022. During the night, the residents on call in the pediatric emergency department completed validated questionnaires investigating (1) mental effort, (2) cognitive weariness, (3) state anxiety, (4) feeling of self-efficacy, and (5) well-being. We compared the questionnaires of residents supervised by pediatricians trained in the supervision of clinical reasoning (supervision group) with those of residents in a control group, supervised by pediatricians with no specific pedagogical training.

RESULTS

A total of 284 questionnaires (174 supervision group, 110 controls) were collected from 38 residents in three pediatric emergency departments. The results confirm that being on call is difficult for residents. Compared to the control group, residents in the supervision group had lower cognitive weariness scores (mean 3.0 ± 1.1 vs. 3.5 ± 1.3). There was no significant difference between groups for any of the other dimensions of the on-call experience. In the supervision group, mental effort was significantly lower at the end of the study semester (5 [5-6] when on call in month 6 of the semester vs. 6 [5-7] when on call in months 1-5 of the semester; p = 0.01) and was greater for more senior residents (7 [6-8] for those in the 4th or higher semester of residency vs. 6 [5-7] for residents in their 1st, 2nd, or 3rd semester of residency; β = 0.92 ± 0.40; p = 0.02).

CONCLUSION

Beyond the positive effects for residents, this study illustrates the feasibility of implementing training for clinicians in the supervision of clinical reasoning.

Reducing Student Workload Through Curricular Efficiency

OBJECTIVE

This integrative review will examine the current literature assessing student workload, outcomes of increased workload and cognitive load, and approaches to evaluate and reduce student workload. Recommendations to better inform curriculum planning efforts will be presented along with a call to action to address the dilemma of student workload and curricular efficiency efforts.

FINDINGS

Literature supports that perceptions of heavy workload can influence students' approach to learning and lead to the adoption of surface learning rather than a deep approach that involves higher-order processing and critical thinking. Additionally, ongoing evidence suggests that workload expansion affects student well-being and potential burnout in professional programs, and specifically that students perceive workload as directly related to their well-being and satisfaction. Intentional planning by faculty and programs can address this issue through streamlining classroom content, reducing lecture time, and modifying preclass work to allow for efficient learning. Even if the curriculum is lecture-based, workload perceptions can be affected by developing clearer guidance to set expectations for learners, intentionality in classroom design, and creating opportunities for student engagement.

SUMMARY

Cognitive overload is multifactorial and complicated, given the increased standards of professional education accreditation and licensure requirements. As the Academy deliberately considers methods to improve curricular efficiency, there is an opportunity to focus on curriculum delivery with an appropriate balance of breadth and depth of instruction to ensure effective assessment and cognitive load.

Cognitive Load Assessment Scales in Simulation: Validity Evidence for a Novel Measure of Cognitive Load Types

INTRODUCTION

Cognitive load (CL) theory provides a framework to inform simulation instructional design. Reliable measures of CL types (intrinsic [IL], extraneous [EL], and germane load [GL]) in simulation are lacking. We developed the novel Cognitive Load Assessment Scales in Simulation (CLAS-Sim) and report validity evidence using Kane's framework.

METHODS

This quasi-experimental study tested the effect of a segmented/pause-and-debrief or standard/end-of-case-debrief intervention on pediatric residents' performance and self-rated CL in 2 complex- and simple-case simulations. After each simulation, participants completed 22 items measuring CL types. Three validity inferences were examined: scoring (instrument development and principal component analysis); generalization (internal consistency reliability of CL-component items across cases); and extrapolation [CLAS-Sim correlations with the single-item Paas scale, which measures overall CL; differences in primary task performance (high vs low); and discriminant validity of IL under different instructional-design conditions].

RESULTS

Seventy-four residents completed both simulations and postcase CLAS-Sim measures. The principal component analysis yielded 3 components: 4-item IL, 4-item EL, and 3-item GL scales (Cronbach's α, 0.68-0.77). The Paas scores correlated with CLAS-Sim IL and total CL scores in both cases ( rs range, 0.39-0.70; P ≤ 0.001). High complex-case performers reported lower IL and total CL (analyses of variance, each P < 0.001). In multivariate analyses of variance, CLAS-Sim IL, GL, and total CL varied across both cases by arm (each P ≤ 0.018); the segmented-debrief arm reported lower IL than the standard-debrief arm in both cases (each P ≤ 0.01).

CONCLUSIONS

The CLAS-Sim demonstrates preliminary validity evidence for distinguishing 3 CL types but requires further study to evaluate the impact of simulation-design elements on CL and learning.

Enhancing robotic efficiency through the eyes of robotic surgeons: sub-analysis of the expertise in perception during robotic surgery (ExPeRtS) study

BACKGROUND

Robotic technology affords surgeons many novel and useful features, but two stereotypes continue to prevail: robotic surgery is expensive and inefficient. To identify educational opportunities and improve operative efficiency, we analyzed expert commentary on videos of robotic surgery.

METHODS

Expert robotic surgeons, identified through high case volumes and contributions to the surgical literature, reviewed eight anonymous video clips portraying key portions of two robotic general surgery procedures. While watching, surgeons commented on what they saw on the screen. All interactions with participants were in person, recorded, transcribed, and subsequently analyzed. Using content analysis, researchers double-coded each transcript applying a consensus developed codebook.

RESULTS

Seventeen surgeons participated. The average participant was male (82.4%), 47 (SD = 6.6) years old, had 13.2 (SD = 8.23) years of teaching experience, worked in urban academic hospitals (64.7%) and had performed 643 (SD = 467) robotic operations at the time of interviews. Emphasis on efficiency (or lack thereof) surfaced across three main themes: overall case progression, robotic capabilities, and instrumentation. Experts verbally rewarded purposeful and "ergonomically sound" movements while language reflecting impatience with repetitive and indecisive movements was attributed to presumed inexperience. Efficient robotic capabilities included enhanced visualization, additional robotic arms to improve exposure, and wristed instruments. Finally, experts discussed instrument selection with regards to energy modality, safety features, cost, and versatility.

CONCLUSION

This study highlights three areas for improved efficiency: case progression, robotic capabilities, and instrumentation. Development of education materials within these themes could help surgical educators overcome one of robotic technology's persistent challenges.

Chatbot‐mediated learning of cardiac auscultation

Previous research suggested cardiac auscultation is underdeveloped in physicians-in-training. Developing proficiency requires wide exposure to signs, practice and feedback, which may not regularly occur in clinical environments. Our novel pilot study using a mixed-methods approach (n = 9) suggests chatbot-mediated learning of cardiac auscultation is accessible and possesses unique advantages, including immediate feedback, helping in the management of cognitive overload and facilitating deliberate practice.

Pre-Clinical Medical Students' Use of Motivational and Cognitive Study Strategies During Anatomy Learning: A Three-Year Cross-Sectional Survey

Medical students' motivation and study strategies are crucial in determining academic performance. This study aimed to assess the motivation and learning strategies of medical students as well as their association with performance in anatomy examinations. The Motivated Strategies for Learning Questionnaire, two focus group discussions, and students' current anatomy cumulative grade point average (cGPA) were used. Generally, the medical students strongly felt that anatomy is fundamental to the practice of medicine and surgery. This result was consistent with high task value scores of 5.99 ± 1.25. They were also driven by extrinsic goal orientation (5.59 ± 1.42) and intrinsic goal orientation (5.08 ± 1.26). Most medical students typically relied on elaboration (5.35 ± 1.25) ahead of other cognitive strategies namely rehearsal (5.30 ± 1.11), organization (5.15 ± 1.34), and lowest-rated critical thinking (4.77 ± 1.19). The students also relied on resource management strategies, effort regulation (5.15 ± 1.20) and time and study environment regulation (5.03 ± 1.03) more than the moderately scored peer learning (4.95 ± 1.50) and help-seeking (4.95 ± 1.09). In the focus group discussions, students reported that they often narrate or explain to each other what they would have read and understood from anatomy lectures, tutorials, and textbooks. They also bemoaned the lack of institutional support for stress burdens. The motivation and learning strategies subscales were not correlated with anatomy cGPA. Males were driven by extrinsic goals and experienced significantly higher levels of test anxiety than females (P < 0.05). Knowing the motivation and learning strategies students employ early in the medical curriculum can be leveraged to promote self-directed learning and academic achievement.

A behavioural study of obedience in health professional students

Interprofessional Education and Collaborative Practice (IPECP) is a field of study suggested to improve team functioning and patient safety. However, even interprofessional teams are susceptible to group pressures which may inhibit speaking up (positive deviance). Obedience is one group pressure that can inhibit positive deviance leading to negative patient outcomes. To examine the influence of obedience to authority in an interprofessional setting, an experimental simulated clinical scenario was conducted with Respiratory Therapy (RT) (n = 40) and Advanced Care Paramedic (ACP) (n = 20) students. In an airway management scenario, it was necessary for students to challenge an authority, a senior anesthesiologist, to prevent patient harm. In a 2 × 2 design cognitive load and an interventional writing task designed to increase positive deviance were tested. The effect of individual characteristics, including Moral Foundations, and displacement of responsibility were also examined. There was a significant effect for profession and cognitive load: RT students demonstrated lower levels of positive deviance in the low cognitive load scenario than students in other conditions. The writing task did not have a significant effect on RT or ACP students' behaviour. The influence of Moral Foundations differed from expectations, In Group Loyalty was selected as a negative predictor of positive deviance while Respect for Authority was not. Displacement of responsibility was influential for some participants thought not for all. Other individual variables were identified for further investigation. Observational analysis of the simulation videos was conducted to obtain further insight into student behaviour in a compliance scenario. Individual differences, including experience, should be considered when providing education and training for positive deviance. Simulation provides an ideal setting to use compliance scenarios to train for positive deviance and for experimentation to study interprofessional team behaviour.

Sharing the Bandwidth in Cognitively Overloaded Teams and Systems: Mechanistic Insights from a Walk on the Wild Side of Clinical Reasoning

IssuePrevious work from the diagnostic error literature has provided indirect evidence that faulty clinical reasoning may be the most frequent cause of error when attaching a diagnostic label. The precise mechanisms underlying diagnostic error are unclear and continue to be subject to considerable theory informed debate in the clinical reasoning literature. Evidence: We take a theoretical approach to merging these two worlds of literature by first zooming out using distributed cognition as a social cognitive lens (macro theory) to develop a view of the process and outcome of clinical reasoning occurring in the wild - defined as the integrated clinical workplace - the natural habitat of clinicians working within teams. We then zoom in using the novel combination of cognitive load theory and distributed cognition to provide additional theoretical insights into the potential mechanisms of error. Implications: Through the lenses of distributed cognition and cognitive load theory, we can begin to prospectively investigate how cognitive overload is represented and shared within interprofessional teams over time and space and how this influences clinical reasoning performance and leads to error. We believe that this work will help teams manage cognitive load and prevent error.

Dual Process Theory and Cognitive Load: How Intensivists Make Diagnoses

Improving clinical reasoning in order to reduce frequency of diagnostic errors is an important area of study. The authors discuss dual process theory as a model of clinical reasoning and explore the role that cognitive load plays in clinical reasoning in the intensive care unit environment.