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Acad Med. 2017 Nov;92(11):1622-1631. doi: 10.1097/ACM.0000000000001690.

Learner, Patient, and Supervisor Features Are Associated With Different Types of Cognitive Load During Procedural Skills Training: Implications for Teaching and Instructional Design.

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J.L. Sewell is assistant professor of medicine, Department of Medicine, Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, California. C.K. Boscardin is associate professor of medicine, Department of Medicine, University of California, San Francisco, San Francisco, California. J.Q. Young is professor and vice chair for education, Department of Psychiatry, Hofstra Northwell School of Medicine, Glen Oaks, New York. O. ten Cate is professor of medical education and director, Center for Research and Development of Education, University Medical Center Utrecht, Utrecht, The Netherlands, and adjunct professor of medicine, Department of Medicine, University of California, San Francisco, San Francisco, California. P.S. O'Sullivan is professor of medicine, Department of Medicine, and director of research and development in medical education, Center for Faculty Educators, University of California, San Francisco, San Francisco, California.



Cognitive load theory, focusing on limits of the working memory, is relevant to medical education; however, factors associated with cognitive load during procedural skills training are not well characterized. The authors sought to determine how features of learners, patients/tasks, settings, and supervisors were associated with three types of cognitive load among learners performing a specific procedure, colonoscopy, to identify implications for procedural teaching.


Data were collected through an electronically administered survey sent to 1,061 U.S. gastroenterology fellows during the 2014-2015 academic year; 477 (45.0%) participated. Participants completed the survey immediately following a colonoscopy. Using multivariable linear regression analyses, the authors identified sets of features associated with intrinsic, extraneous, and germane loads.


Features associated with intrinsic load included learners (prior experience and year in training negatively associated, fatigue positively associated) and patient/tasks (procedural complexity positively associated, better patient tolerance negatively associated). Features associated with extraneous load included learners (fatigue positively associated), setting (queue order positively associated), and supervisors (supervisor engagement and confidence negatively associated). Only one feature, supervisor engagement, was (positively) associated with germane load.


These data support practical recommendations for teaching procedural skills through the lens of cognitive load theory. To optimize intrinsic load, level of experience and competence of learners should be balanced with procedural complexity; part-task approaches and scaffolding may be beneficial. To reduce extraneous load, teachers should remain engaged, and factors within the procedural setting that may interfere with learning should be minimized. To optimize germane load, teachers should remain engaged.

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