During a medical simulation, novice students have limited available working memory resources to learn new information.1 In addition, different elements of simulation-based medical education additively place a strain on students’ working memory by increasing their cognitive load, which competes with the information they are trying to learn (e.g., listening to faculty presentations + doubt and self-consciousness about their own abilities + concentration necessary to effectively utilize fine motor skills + listening and incorporating direct feedback, etc). The structure and complexity of the medical simulation adds to students’ intrinsic cognitive load; or in other words, there are certain concepts, topics, and learning elements that are inherently more difficult to learn (e.g., post-operative patient simulations can be particularly difficult for medical students because of the need to combine a multitude of skills within complex medical scenarios in a junior learner who has little to no experience with leadership or decision-making).
To be frank, there’s not much a professor can do to reduce the intrinsic cognitive load of certain surgical education topics that are notoriously difficult subject matters to teach. Especially for novice students, some medical topics are just plain difficult and require more memory resources to learn (renal physiology, types and presentation of shock, and sepsis are notorious examples). To further complicate matters, compared to other learning environments, medical simulations present a higher intrinsic load, due to the complexity of medical practices that require the simultaneous processing of different sources of information (e.g., a complex obstetric simulation that requires learners to focus on the critical needs of the mother and infant at the same time). And since these simulations are cognitively demanding for students in the first place, it is especially important for professors to avoid piling on their students’ limited mental processing abilities. One way professors can help free up memory resources to improve students’ learning is by strategically tailoring their teaching behaviors and decisions in medical simulations.
Professors can reduce or add to students’ extraneous cognitive load based on how they present information (communicating clearly or unclearly), the activities that they offer (having students complete simple versus complex activities), and the instructional design of their simulation sessions (verbally describing parts of an organ versus pointing to a part of an organ in a detailed picture). When students have high intrinsic and extraneous cognitive loads, it is difficult for them to learn because the cognitive burden imposed on them can overload their processing capabilities. When this happens, students become overwhelmed with the training session and have trouble retaining important information. Fortunately, there are effective teaching strategies that professors can use to reduce students’ extraneous load and free up more available memory resources. To reduce the cognitive load for novice student learners, professors might consider:2, 3
- Providing Worked Examples and Completion Tasks: Providing student learners with a detailed example that has already been completed will help them learn and reduce their extraneous load (e.g., during a suture workshop, provide students with a completely sutured wound as their worked example). Also, providing student learners with a part of the solution first, and then allowing them to work through this example to completion is equally effective. For instance, in the suture workshop described above, an educator could initiate a subcuticular closure and allow the student to close the remainder of the wound. By having students finish the professor’s work, the extraneous load is reduced because students can refer back to the partially worked example (how the stiches look, how far apart they are, what a good knot looks like, etc.) and complete the task, instead of doing the stiches completely on their own. This should make sense to surgeons, given the old dictum of surgical education, “see one, do one, teach one.”
- Start with Low Fidelity Simulations and Gradually Increase the Task Complexity and Learning Elements: Students’ extraneous load can be reduced by beginning with low fidelity simulations that do not contain many interacting elements. For example, initiating simulation experience early in medical student education with simple tasks (such as extracting information from a chart and writing a progress note) can improve performance in later simulations due to familiarity with the process. Then, simulations can gradually increase the interacting elements (e.g., have students extract information from a chart, followed by interviewing a simulated patient, adding verbal communication). Gradually increasing task complexity and learning elements will help students not be cognitively overloaded.
- Use Multiple Communication Channels to Teach: Extraneous load can be decreased by presenting information to students with both visual and auditory channels. Students process visual and auditory information differently, so the idea is that you can divert some information to different processing systems to share in the cognitive load instead of relying on just one system to process all of the information (quality medical education lectures often utilize extensive verbal communication with only images, figures, or bullet points on a PowerPoint presentation). The key here is to not be redundant in both channels, but instead, reinforce the content with different messages using varying channels.
- Engage students in a Task and only Reinforce Pertinent Information: Medical students learn by doing, so have them do something. They learn through practice, further practice, and then even more practice. Since professors have a wealth of medical knowledge but their pupils do not, it’s easy for educators to get off track and present information that is not specifically required for learning the topic offered in the simulation (e.g., a simulation that is supposed to be focused on the techniques of endotracheal intubation might go off the rails when one student asks detailed questions about anesthetic medication dosages and mechanism of action). Educators need to be careful to only present information related to the simulation and repeatedly reinforce these topics with practice.
These are but a few of the numerous effective teaching strategies that professors can utilize to reduce the extraneous cognitive load of their students. Simulations are difficult to learn in the first place and require a higher intrinsic load than most learning opportunities. Therefore, it is especially important that professors do their best to reduce the extraneous load for students using effective instructional techniques. By doing so, they will free up their students’ working memory resources and allow them to process information and learn about medicine in a more optimal manner.
References:
1 Fraser, K., Ma, I., Teteris, E., Baxter, H., Wright, B., & McLaughlin, K. (2012). Emotion, cognitive load and learning outcomes during simulation training. Medical Education, 46, 1055-1062. doi:10.1111/j.1365-2923.2012.04355.x
2 Reedy, G. B. (2015). Using cognitive load theory to inform simulation design and practice. Clinical Simulation in Nursing, 11, 355-360. doi:10.1016/j.ecns.2015.053.004
3 Josephsen, J. (2015). Cognitive load theory and nursing simulation: An integrative review. Clinical Simulation in Nursing, 11, 259-267. doi:10.1016/j.ecns.2015.02.004
4 Young, J. Q., van Merriënboer, J., Durning, S., & ten Cate, O. (2014). Cognitive load theory: Implications for medical education: AMEE guide no. 86. Medical Teacher, 36, 371-384. doi:10.3109/0142159X.2014.889290
Alan A Thomay MD