Cognitive Load Theory and Creating Expert-Students
by Christopher Cimino, MD, FACMI, VP of Medical Academics, Kaplan Medical | March 10, 2021
What Are The Optimal Conditions For Learning?
The January issue of Academic Medicine has an article by Szulewski et. al. that tests some intriguing ideas about Cognitive Load Theory in trauma and medical resuscitation settings. They reference the work of Sweller, which puts forth the idea that we have a limited capacity to transfer working memory to long-term memory. When the load gets too great, learning becomes inefficient.
The limit on load is impacted by extrinsic load factors (how much information is coming at us) and intrinsic load factors (how much effort we need to process that information). Are we watching a rom-com, a who-done-it, or a lecture on string theory? As an extension of this theory, the load limit is further affected by “memory depletion” and effect. They describe memory depletion as the observed decrease in capacity seen when a person attempts to process large amounts of information for long periods of time. After a period of rest, the capacity will return to baseline. Emotionally stressful situations will also decrease the measured capacity. Szulewski finds both these factors directly applicable to the trauma and resuscitation setting where prolonged hours, vast amounts of complex information, and emotional stressors are abundant. They use this setting to describe what seem to be the coping mechanisms used by experts as compared to novices.
How might this be applied to expert versus novice learners, specifically, medical school learners? It should be reassuring to think that the stress of medical school is not as great as a trauma center. And yet, the accumulated stress for medical students can only be measured by the person experiencing it. Certainly, the amount of new information is as great or greater than that seen in a trauma center. The long hours students spend studying is also clearly a factor. This suggests that the same things that separate expert and novice trauma teams could be in play with expert and novice medical student learners: recovery, mindfulness, and focus.
There are only so many hours in the day and it is tempting to think that squeezing in one more hour of work or study will gain us that much more knowledge. My daughter once suggested that wouldn’t it be great if we didn’t have to sleep and could get “extra stuff done” during those hours? You’d finally be able to “catch up.” I pointed out that if everyone else was doing the same thing, then they would catch-up too and so no one would really be ahead. In response, she changed her proposal to be that, you (and only you) could stop time. To this, I pointed out that if you spent ⅓ of your life in this stopped time you would indeed get that much more ahead but you’d also get older (in calendar years) 50% faster. So, instead of living 90 years, you’d seem to only live 60 years as compared to everyone else. You probably accomplish much more in those 60 years, but is it really worth it?
Even without science fiction scenarios, devoting extra time to something runs into trouble. Comparing the first few minutes of a study session to the next few minutes, we would be unlikely to measure any difference in performance. Clearly, after many hours we would expect there to be a degradation of performance. To simplify the math, let’s assume after 1 hour the performance drops to zero. And let’s assume it takes an equal amount of time to recover, 1 hour. Clearly, studying for 3 hours straight is going to be less efficient than studying for 1 hour, resting for 1 hour, and then studying for another hour. The first approach gives you only 1 hour of effective studying and the second approach gives you 2 hours.
If only we could fully recover in 1 hour...
The worst-case example lets us set up the thought experiment of what reality might be like. Any scenario in which your effectiveness drops to zero is going to play out like this unless the recovery time is faster than the depletion time. That moves us a little closer to reality because it becomes clear that the difference in those times is the critical factor. Even if effectiveness never drops to zero, if the recovery time is faster than the depletion time, then you gain more by inserting those periods of rest. It seems likely that reality has to be more complicated than that. There is reason to believe that there is a threshold phenomenon―that decrease in performance is hard to measure until some threshold is reached and then it suddenly dramatically presents as a deficit. Beyond that point, it continues to degrade until total collapse is reached. Recovery is the opposite. A single hour of sleep won’t return you to feeling normal but it will still have a dramatic improvement in someone who is sleep-deprived. A 9th or 10th hour of sleep is not going to be so noticeable.
So, if depletion is an exponential decay curve with a threshold effect and recovery is an inverse exponential curve, then it follows that there is some balance of study and recovery in which recovery speed is greater than depletion speed. In other words, knowing that you need to allow time for recovery is easy. Knowing how to balance the two for maximal performance is hard. The short answer for students is: think about how you can monitor your own performance and experiment to find what the best balance is for you. In the trauma center, the answer is usually they have set shifts and they don’t take their work home with them.
At a recent pre-med panel sharing information about “A Day in the LIfe” of doctors, a student asked how doctors deal with all the stress. The panelists had a variety of answers:
“The stress becomes less as you become familiar with recurring situations.”
“The stress is a challenge that makes meeting the challenge rewarding.”
“The stress motivates you to perform better than you would without the stress.”
The panelists agreed though that the stress of death or failure was always difficult and required reflection and thought each tie it happened.
“If I ever get used to a patient dying I’ll know it is time to retire.”
How does this apply to medical school? The stress students find there is not nearly as “glorious.” It is true that some bragging occurs related to having pulled “all-nighters” or getting “top scores;” however, it seems a bit hollow. The failure of losing a patient is hard, but it is external. The failure of a poor exam score is very personal and embarrassing. Offsetting a patient’s death by recalling the number of lives saved is helpful. Recalling the number of tests passed is not nearly as reassuring.
Mindfulness and reflection play a role in helping students put things in perspective. Failure is a learning experience. As painful as it may be, there are those who dig in deep to get beyond the pain to discover deeper lessons about recognizing impending failure, learning how to ask for help, and avoid being paralyzed.
Most medical students have not known severe personal failure. Many of them graduate, get through residency, and rise to levels of higher responsibility and stress only to fail for the first time when patients and staff are depending on them. Such late-career first failures are catastrophic for all involved. So, if there is a bright spot in the experience of failure it is that to residency directors, such an applicant is battle-tested and their story may be a positive one of moving on and recognizing the warning signs. That is a rare experience for residency applicants.
The other important aspect of mindfulness in failure is to be aware of self-isolation. The embarrassment factor should not be minimized as a risk. It can be lethal. People should share their failures with people they trust. For students, this can be difficult if their choice is peers (who they are competing with) or friends and family (who may have no idea what medical school is like). Getting students to trust the Dean of Students is a conundrum.
The ability to focus on the most critical features of a problem is one of the things that can spare cognitive load. Experience, triaging, and pattern matching give experts the edge in this regard. A trauma team seeing a patient with hypotension and T-waves on the ECG might consider heart ischemia as the cause of the hypotension but more likely they will look for hemorrhage given the setting and their experience. Then again, spying low voltage might trigger them to look for hemopericardium as a mechanical cause, rather than an ischemic cause of hypotension. The novice meanwhile may be fixated in calculating the access of ischemia from the leads in which the T-waves appear which in this setting is largely irrelevant.
Students face the same problem: if their task is to “pass a test,” then the question, “what’s on the test?” becomes a high priority. In the world of expert-students, this might be the right focus, much to the annoyance of professors. This is because there is a mismatch in goals. We wish the student’s primary goal was becoming the best physician possible. And it is, but it is a broad long-range goal and the only way to succeed at such goals is to break them down into smaller, more achievable goals.
In the world of cutting-edge research, the details are all relevant to reproducibility and future research. In the world of medical student transformation into physicians, Ph.D. instructors are the novices. Tetrodotoxin is important in discussions of ion channels, but tetrodotoxin poisoning (pufferfish poisoning) is relatively rare in the world of medicine.
Most students in the first month of medical school are not expert-students yet. Even a goal like “pass the test” is too broad and needs to be broken down. Focusing on these smaller goals is the way they find focus.
What Do I Do First?
The first and most important goal students have to reach is how to prioritize. Students have pre-existing habits, and their individual strengths dictate that this is usually left as a self-evolving skill. I believe they fall into several patterns that manifest in the kinds of questions they ask themselves. Many students will shift to asking different questions at different times and not always in the order presented here.
- Can I Do This?
When a student starts scoring below the mean for the first time in their life, the question of whether they are really capable of being a doctor often surfaces. They need reassurance that this is normal and at least half their classmates are experiencing this. Also helpful is guidance in how to break down problems and attack them a step at a time.
- How Am I Doing?
A student who has accepted their current level of performance is looking for signs that they are improving. The goal-posts keep shifting as new content keeps coming at them. Being about to track their progress by discipline or organ system can give them that insight into their incremental improvements.
- How Does This Connect To Everything Else?
As a student gains confidence that they are making progress, they begin to handle more and look for ways to connect the specific topic they are focused on to content they have already mastered or that they will soon be exposed to.
- Can I make use of my best mode of learning?
- Am I ready?
No one wants to learn just to take a test. But tests remain an inevitable barrier. As students get nearer to their test date, they want to be efficient in practice and review. The extra information becomes less relevant in this content.
These different needs and tasks show that students have developed their own methods of handling cognitive load as expert-students.
I enjoy writing articles for this blog because it gives me a chance to think about education and learning issues in a deep way. I try to avoid commercialism because I think it annoys readers and distracts them from the message I am most interested in conveying. However, in this case, I can’t avoid being proud of the work my team has completed this month which goes to the heart of the cognitive load issue.
Over the course of the last year we have revamped and reorganized our Step 1 and Step 2 CK QBank explanations. Our Step 1 revision was completed this month (March 2021) and the Step 2 CK revision is on track to be finished next month (April 2021.)
The revision includes one broad change and series of focused changes. A strategy section provides that step-by-step approach to problem deconstruction. The number of different strategies that are required to answer Step 1 items is greater than most college or graduate school exams but they aren't infinite. Finding these patterns and guiding students through them can build confidence that this is not another world away from what they are used to, but one they belong in. We have added visual and video explanations to serve the needs of students who look for multiple learning modes. We crafted concise explanations for those who want to be in the most efficient practice and review mode. And all these are organized into specific sections to allow students the ability to be focused on the kind of task they wish to work on.
Kaplan’s USMLE Step 1 and Step 2 CK, PANCE, and INBDE resources now incorporate 3D BioDIgital images. To learn more or to have a Kaplan team member walk you through these visual learning resources firsthand, request a demo today.
P.S. Be sure to read “Eight Tips for Managing Cognitive Load in Your Online Teaching” for strategies you can apply to your virtual classroom.
Szulewski, Adam MD, FRCPC, MHPE, PhD; Howes, Daniel MD, FRCPC; van Merriënboer, Jeroen J.G. PhD; Sweller, John PhD. From Theory to Practice: The Application of Cognitive Load Theory to the Practice of Medicine. Academic Medicine: January 2021 - Volume 96 - Issue 1 - p 24-30. doi: 10.1097/ACM.0000000000003524
Dr. Cimino has earned a reputation internationally as an award-winning medical educator. He was the founding Assistant Dean for Educational Informatics at Albert Einstein College of Medicine and former Associate Dean for Student Affairs at New York Medical College. He is board certified in Neurology and Clinical Informatics. He served as a member of the NBME Step 1 Behavioral Science Committee and the NBME End of Life Care Task Force.