1. Improving Procedural Teaching by Understanding Features Associated with Cognitive Load
Justin L. Sewell MD, MPH
Christy K. Boscardin, PhD
John Q. Young, MD, MPP
Olle ten Cate, PhD
Patricia S. O’Sullivan, EdD

2. Procedural skills training is a balancing act!
Learners
Teachers, patients, system

3. Learners
Autonomy
Feedback
Deliberate practice
Case volume

4. Case volume Teachers, patients, system Safety Quality Efficiency
Patient-provider relationship
Efficiency
Quality
Safety

5. Learners Teachers, patients, system Patient-provider relationship
Efficiency
Quality
Safety
Autonomy
Feedback
Deliberate practice
Case volume

6. Procedural skills training in HPE
Complexity of cognitive and psychomotor demands  high risk of cognitive overload
HOWEVER, empirical evidence for contributors to cognitive load during procedural skills training is limited
Better understanding of such contributors could lead to:
Curricular innovations 
Improved learning 
Better patient outcomes???

7. Capacity for sensory input
Cognitive Load Theory
Capacity for sensory input
Long-term memory
Working memory ∞ ∞
Sweller J. Cogn Sci 1988.
Figure adapted from Young JQ. Med Teach 2014.

8. Types of cognitive load
Intrinsic load
Task complexity Learner knowledge and experience
Optimize
Extraneous load
Learning environment
Instructional design
Minimize
Learner effort and metacognitive skills
Germane load
Maximize

9. Cognitive load & working memory
Working memory overloaded – no space for germane load
Extraneous load
Intrinsic load
Space available for germane load
Extraneous load
Intrinsic load
Germane load
Adapted from Young JQ. Med Teach 2014.

10. Colonoscopy Complex and requires >300 cases to attain competence
Preferred method for colorectal cancer screening
“Middle of the road procedure”  implications for spectrum of procedural skills

11. What affects cognitive load during procedural skills training?

12. Methods
Post-colonoscopy survey distributed to 1,061 fellows in academic year
Outcome: three cognitive load types
Predictors: procedural learning features
Anticipated relationships predicted between each feature and each type of cognitive load
Multivariable linear regression model developed for each type of cognitive load

13. Outcome: cognitive load types Cognitive Load Inventory for Colonoscopy (CLIC)
Estimate of IL, EL, GL
Germane items
Intrinsic items
Extraneous items
Psychometric instrument
Multiple items averaged to estimate degree of intrinsic, extraneous and germane load
Validity evidence presented
Self-report instrument administered post-colonoscopy
0-10 scale, strongly disagree  strongly agree
Sewell JL et al. Med Educ 2016;50(6):682-92, AERA 2016

14. Also supervisor takeover
Predictors
Year in training
Prior experience
Sleep
Fatigue
Cognitive load
Learner
Patient/ task
Setting
Super-visor
Prep quality
Tolerance
Anesthesia
Gender
No. of maneuvers
Also supervisor takeover
Junior versus senior
Engagement
Confidence
Queue order
No. people in room
On call
Paged

15. Results – response rate
477 (45.0%) of 1,061 invited fellows participated
154 (95.1%) of 162 programs represented

16. Number of fellows per year in training

17. Prior colonoscopy experience

18. Intrinsic load model Feature Category Coefficient (95% CI)
P-value
Year 2 fellow (vs year 1)
Learner
-0.60 (-1.09,-0.14)
-0.17
0.01
Year 3 or 4 fellow (vs year 1)
-0.82 (-1.38,-0.26)
-0.23
0.004
Prior colonoscopy experience
-0.20 (-0.31,-0.09)
-0.24
<0.001
Fatigue
0.01 (0.008,0.02)
0.21
Tolerated procedure well
Patient/task
-0.67 ( )
-0.16
No. ancillary maneuvers
0.31 (0.18,0.44)
0.19
Supervisor took over
Multiple
0.51 (0.24,0.77)
0.16
Hours of sleep
0.11 (-0.07,0.29)
0.05
0.22
Good bowel prep (vs excellent)
0.14 (-0.17,0.44)
0.04
0.38
Fair or poor bowel prep (vs excellent)
0.17 (-0.26,0.59)
0.44

19. Extraneous load model Feature Category Coefficient (95% CI)
P-value
Fatigue
Learner
0.01 (0.005,0.02)
0.18
0.001
Queue order
Setting
0.07 (0.01,0.13)
0.10
0.03
Somewhat or very disengaged (vs very engaged)
Supervisor
0.33 (0.02,0.64)
0.11
0.04
Less than very confident
0.49 (0.13,0.86)
0.13
0.009
Supervisor took over
Multiple
0.86 (0.49,1.23)
0.24
<0.001
Year 2 fellow (vs year 1)
-0.36 (-0.84,0.12)
-0.12
0.14
Year 3 or 4 fellow (vs year 1)
-0.32 (-0.89,0.26)
-0.10
0.28
Prior colonoscopy experience
-0.04 (-0.16,0.07)
-0.06
0.46
Hours of sleep
0.17 (-0.01,0.35)
0.07
No. people in room
0.04 (-0.09,0.18)
0.52
Paged
0.16 (-0.19,0.51)
0.37
On call
-0.23 (-0.68,0.21)
-0.05
0.30
Somewhat engaged (vs very engaged)
0.45 (-0.03, 0.94)
Neither engaged nor disengaged (vs very engaged)
0.15 (-0.34,0.64)
0.55

20. Germane load model Feature Category Coefficient (95% CI) β-coefficient
P-value
Somewhat engaged (vs very engaged)
Supervisor
-0.91 (-1.83,0.001)
-0.10
0.05
Neither engaged nor disengaged (vs very engaged)
-1.33 (-2.24,-0.42)
-0.15
0.004
Somewhat or very disengaged (vs very engaged)
-0.85 (-1.44,-0.26)
0.005
Year 2 fellow (vs year 1)
Learner
-0.30 (-1.19,0.60)
-0.05
0.52
Year 3 or 4 fellow (vs year 1)
-0.62 (-1.70,0.46)
-0.11
0.26
Prior colonoscopy experience
-0.14 (-0.36,0.07)
0.19
Fatigue
0.01 (-0.005,0.02)
0.06
No. maneuvers performed
Patient/task
-0.06 (-0.32,0.19)
-0.02
0.62
Paged
Setting
0.28 (-0.36,0.98)
0.04
0.39
On call
-0.25 (-1.08,0.58)
-0.03
0.55
Queue order
0.03 (-0.09,0.14)
0.02
0.65
Less than very confident
0.58 (-0.10,1.27)
0.08
0.10
Supervisor took over
Multiple
-0.43 (-1.16,0.30)
-0.06
0.25
Intrinsic load
---
0.28 (0.08,0.48)
0.17
0.006
Extraneous load
0.25 (0.60,0.45)
0.14
0.01

21. In other words… Intrinsic load Extraneous load Germane load
: fatigue, number of maneuvers, supervisor took over
: year in training, prior colonoscopy experience, good patient tolerance
Extraneous load
: fatigue, queue order, supervisor takeover
: more engaged supervisor, more confident supervisor
Germane load
: more engaged supervisor, intrinsic load, extraneous load

22. Implications for instructional design
To optimize IL:
Select (partial) task for learner’s competence and prior experience
Take over quickly when early learner is struggling
To minimize EL:
Monitor for fatigue
Consider target number of procedures per session
Remain engaged and communicate confidence
To maximize GL:
Remain engaged with learner and procedure
Adjust support based on learner’s experience and procedural complexity

23. Limitations Some features specific to colonoscopy
CLIC measures learner perceptions of cognitive load
No measures of learning
Associations, not causation

24. Summary
Learners
Teachers, patients, system
Patient-provider relationship
Efficiency
Quality
Safety
Feedback
Autonomy
Deliberate practice
Case volume
Different sets of features are associated with the three types of cognitive load among colonoscopy learners
Classes of features studied are generalizable and adaptable
Findings can inform future education interventions to help balance the scales during procedural skills training