Cognitive load in hospital medicine: Implications for teachers, learners, and programs

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Practicing medicine is cognitively demanding. One must recall and integrate vast knowledge into care, often in fast-paced, chaotic environments. As humans, our ability to form long-term memories is influenced by the demands, or “load,” placed upon our cognition at any point in time. Cognitive Load Theory characterizes these demands and reveals how their interplay and balance influence our ability to form long-term memories and, ultimately, expertise.¹ Said simply, our brains can only work so hard—and if we are overwhelmed, we do not learn effectively. This is why the days we are pushed beyond our capacity end up a blur and contribute less to learning.

Memory can be divided into three systems: sensory, working, and long-term. Sensory memory allows us to take in vast amounts of sensory information, but it is short lived. Working memory, which has limited capacity, organizes this information and helps store it in long-term memory. Although long-term memory can hold much more than sensory memory, it's working memory that is the bottleneck. Research shows that working memory can typically manage only 7 (±2) items at a time.² According to Cognitive Load Theory, working memory is a limiting factor in learning and identifies three types of cognitive load that impact working memory: intrinsic, extraneous, and germane.

Cognitive Load Theory has important implications for learning in the clinical learning environment. A scoping review concluded, in part, that high levels of intrinsic load negatively impact the performance of trainees and that aspects of healthcare work environments negatively impact capacity for learning.¹ Medicine is complicated (high intrinsic load) and learned and practiced in complex environments (high extraneous load), leading to inefficient and suboptimal long-term memory formation. We explore these cognitive load categories and provide examples of how teachers, learners, and systems can use cognitive load to optimize learning in the hospital (Table 1).

INTRINSIC COGNITIVE LOAD

Intrinsic cognitive load refers to the “cognitive demands imposed by accomplishing the essential components of a learning task.”¹ Thus, intrinsic load is primarily driven by the task's difficulty as it relates to one's expertise or lack thereof.⁴ Recognizing factors that optimize intrinsic load can improve learning. Optimization does not always mean decreasing intrinsic load—some degree of difficulty is desirable and necessary for learning.

One way to optimize intrinsic load is to continually assess whether patient care (e.g., learning) tasks are appropriate for each learner's experience level. This approach requires reliably “diagnosing” the level of the learner, choosing patient care tasks that match experience and learning needs, and adjusting workload based on the expertise of each learner. We believe this is something that good educators do instinctively. For example, entrusting an intern to place a central line requires a complex calculus factoring in the time of year, the overall clinical workload, and observations of that intern across patient encounters. Understanding how Cognitive Load Theory informs this intuition can help us apply it more broadly, making other complex adjustments easier.

Intrinsic load also informs how complex tasks can be broken down into simpler components learned in sequence or through partial task completion.^5-7 For example, if a faculty member is teaching a new intern how to perform a central venous line insertion, it may be more effective to talk through the procedure step by step and then have the intern complete only a predetermined portion.^6, 7 The complexity of learning can increase over time as the learner demonstrates competency. Competency driving complexity of learning can be applied to cognitive tasks as well. For instance, standardized checklists have improved diagnostic accuracy without increasing cognitive load or causing expertise reversal during specific tasks.^8, 9 Helping simplify complex cognitive tasks, such as protocols for the management of diabetic ketoacidosis, may lessen intrinsic load by decreasing orders needed while facilitating better learning about the topic conceptually.

In addition, the intrinsic load of a cognitive task (e.g., diagnostic reasoning) may be optimized by having learners apply frameworks to organize their approach and reorganize their knowledge, thereby forming their schema.¹⁰ Schemas are highly efficient structures for organizing knowledge about conditions and their relation to one another, which experts consciously (and unconsciously) use to diagnose and manage efficiently.¹¹ Guiding learners to common frameworks (e.g., diagnostic categories of prerenal, intrinsic, and postrenal causes of acute kidney injury) allows them to enrich their pre-existing schema and develop new, related ones (e.g., linking initial diagnostic tests and treatments to AKI categories).

Educators should also consider learner fatigue and the environment's role in increasing intrinsic cognitive load. Fatigue has been associated with increases in intrinsic and extraneous load, and complexity in the clinical environment may also increase intrinsic load.^6, 12 Open communication and intentional monitoring for learner fatigue and factors increasing intrinsic load, such as carrying too many patients too early, can lead to opportunities to improve quality learning.¹

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