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The Case of Gastrointestinal Endoscopy Cognitive Load

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The Case of Gastrointestinal Endoscopy Cognitive Load Invitation A ACRITICAL CRITICAL LENS LENS to attend the public defense of my thesis COGNITIVECOGNITIVE FORFOR EXAMINING EXAMINING LOADLOAD PROCEDURALPROCEDURAL SKILLS SKILLS TRAININGTRAINING IN IN THE THE COGNITIVE THEORY:THEORY: HEALTHHEALTH PROFESSIONS PROFESSIONS LOAD THEORY: A CRITICAL LENS FOR EXAMINING PROCEDURAL SKILLS TRAINING IN THE HEALTH PROFESSIONS THE CASE OF GASTROINTESTINAL ENDOSCOPY 230 mm (final size) 240 mm (final size) 30 August 2019 | 2:30 PM Senate Hall, Academy Building THETHE CASE CASE OF OF Domplein 29, Utrecht Utrecht University Reception in the Academy Building immediately following the defense 236 mm (with bleed 3 mm) 246 mm (with bleed 3 mm) GASTROINTESTINALGASTROINTESTINAL JustinJustin LouisLouis Justin Louis Sewell ENDOSCOPYENDOSCOPY SewellSewell [email protected] 170 mm (final size) 170 mm (final size) 65 mm 173 mm (with bleed 3 mm) 173 mm (with bleed 3 mm) 71 mm 15 mm Cognitive Load Theory: A Critical Lens for Examining Procedural Skills Training in the Health Professions The Case of Gastrointestinal Endoscopy Justin Louis Sewell ISBN: 978-94-6375-352-4 Copyright © 2019 by Justin Louis Sewell, San Francisco, CA, USA All rights reserved. No part of this thesis may be reproduced, stored in retrieval systems, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise without prior permission of the author. All previously published papers were reproduced with permission from the publisher. Cover art courtesy of Mark van Wijk. Cover: Ridderprint BV, the Netherlands Printing: Ridderprint BV, the Netherlands Cognitive Load Theory: A Critical Lens for Examining Procedural Skills Training in the Health Professions The Case of Gastrointestinal Endoscopy Cognitive Load Theory: een kritisch perspectief voor onderzoek naar de training in procedurele vaardigheden bij beroepen in de gezondheidszorg, toegepast op de gastro-intestinale endoscopie (met een samenvatting in het Nederlands) PROEFSCHRIFT ter verkrijging van de graad van doctor aan de Universiteit Utrecht op gezag van de rector magnificus, prof. dr. H.R.B.M. Kummeling, ingevolge het besluit van het college voor promoties in het openbaar te verdedigen op vrijdag 30 augustus 2019 des middags te 2.30 uur door Justin Louis Sewell geboren op 14 oktober 1976 te Abilene, Texas, Verenigde Staten van Amerika Promotoren: Prof. dr. Th.J. ten Cate Prof. dr. P.S. O’Sullivan Copromotor: Dr. C.K. Boscardin Table of Contents Preface vii Chapter 1: Introduction 9 Chapter 2: Measuring cognitive load during procedural 27 skills training with colonoscopy as an exemplar Chapter 3: Learner, patient, and supervisor features 49 are associated with different types of cognitive load during procedural skills training: implications for teaching and instructional design Chapter 4: Cognitive load theory for training health 75 professionals in the workplace: A BEME review of studies among diverse professions Chapter 5: Learning challenges, teaching strategies, 161 and cognitive load: experience of seasoned endoscopy teachers Chapter 6: Trainee perception of cognitive load during 187 observed faculty teaching of procedural skills Chapter 7: Discussion 217 Summary 251 Samenvatting 257 Acknowledgments 263 Curriculum Vitae 265 PREFACE I started my gastroenterology fellowship training immediately after completing a three-year residency in a demanding Internal Medicine program that afforded residents a great deal of autonomy. I considered myself to be a talented clinician, having managed the care of hundreds of patients, many critically ill. And yet, when I was introduced to the practice of gastrointestinal (GI) endoscopy, I felt that I had returned to the drawing board. Despite a brain brimming with knowledge about the human body, I had no framework through which to conceptualize what was happening inside the bodies of my patients when I inserted an endoscopic instrument. My teachers offered advice intended to be helpful, such as “Your scope is too long,” or, “You have a loop. You need to reduce the loop and get the scope nice and straight. Feel the tension go out as you reduce.” While I understood the individual words they were saying, I did not understand what they actually meant, or how to apply their teaching. Of course, I did eventually learn what they meant, as all successful procedural learners do, but it took a great deal of time and involved a lot of frustration and heartache. I developed adequate endoscopic competence and graduated from fellowship. I walked out of the door on June 30 as a learner and returned on July 1 as a teacher! Not surprisingly, I found myself using similar words and similar teaching techniques, and, also not surprisingly, I saw on my new learners’ faces similar glazed expressions and blank stares. I witnessed similar heartache and frustration among my learners that I had experienced so recently. “Why does this have to be so difficult?” I wondered. These challenges as both learner and teacher of medical procedures directly inspired me to pursue training in teaching techniques and education research through the Teaching Scholars Program at the University of California (UCSF). During this program, I discovered cognitive load theory (CLT), a cognitive learning theory focused on the limitations of working memory. CLT seemed highly authentic to my experience as a learner and teacher of procedural skills, and I wanted to study its role in GI endoscopy training. Although Teaching Scholars introduced me to education research, I knew that I needed more intensive training to achieve my goals, and so I matriculated to the UMC Utrecht-UCSF Doctoral Program in Health Professions Education. The fruits of my training and research endeavors are detailed in this thesis, which investigates teaching and learning of procedural skills in the health professions through the lens of CLT. The following Introduction sections will introduce the reader to the framework of CLT, the challenges of procedural skills teaching and learning, and how CLT applies to this unique area of health professions education (HPE). vii viii Chapter 1 Introduction 9 COGNITIVE LOAD THEORY CLT is a cognitive learning theory based on the Atkinson-Shriffin model of memory1 (Figure 1). First described in 1968, this model proposes three types of human memory. Sensory memory includes all the stimuli that human senses can detect. In classroom learning settings, vision and hearing are the most commonly used, but in the health professions, touch, and even smell, can be important as well. Long- Sensory Working memory term memory memory Figure 1. Model of human memory. Adapted from Young JQ et al, Medical Teacher 2014;36(5):371-384. Permission obtained from Taylor & Francis Group, http://www.tandfonline.com. Because humans are constantly bombarded with sensory stimuli, we must use working memory to select which stimuli to direct our attention. In the education setting, attending to the wrong stimuli will interfere with learning. Some information is transferred from working memory to long-term memory in the form of learning schema (i.e., organized bundles of information that together explain a concept or construct), which can later be retrieved for use. Of vital importance is the significant limitation of working memory. While capacity for both sensory and long-term memory is considered infinite, working memory is extremely limited in both capacity and duration, and can manage only a few pieces of information at any given time. Prior work has suggested working memory can manage around 7 +/- 2 informational elements at any given time2, though more contemporary research suggests the capacity is probably smaller, especially when the information involves a high degree of element interactivity or when active processing of information is required3. Furthermore, information in working memory is rapidly lost if it is not practiced and transferred to long-term memory as a schema. Working memory is generally considered to be largely fixed in capacity and has even been proposed by some as a primary contributor to the construct of intelligence4. Thus, educators must ensure that their teaching does not overload the limited working memory; if this occurs, both learning and performance will suffer5. CLT was first described by Sweller in 19886 and subsequently elaborated on by others5,7-9. CLT builds on the Atkinson-Shriffin model by proposing three types of mental activities that occupy the working memory. These three types of cognitive load, intrinsic load, extraneous load and germane load, all contribute to working memory demands. Working memory bandwidth utilized to directly complete essential elements of a learning task is termed intrinsic load. Intrinsic load will be higher when learners have less experience, or when 10 tasks are more complex. If intrinsic load is too high, the learner’s working memory will become overwhelmed, whereas if the intrinsic load is too low, learning will be limited as there is nothing for the learner to learn. Therefore, intrinsic load should be matched to the learner’s experience level and zone of proximal development5,10. When learners pay attention to, or focus on, thoughts or stimuli not essential to the learning task, another type of cognitive load, extraneous load, occurs. Distractions induce extraneous load, and can be external within the learning environment (e.g., conversations not related to the learning task, mobile devices vibrating or ringing, other interruptions) or internal within the learner’s mind (e.g., negative emotions, internal distractions)5,11,12. Such distractions occupy space in working memory while they occur and for a period of time afterward. Teachers may inadvertently induce extraneous load. Classic examples are mismatches in information between sensory channels (e.g., a lecturer speaks about a topic not matching her slides) or the use of unfamiliar jargon or terminology. In either of these cases, the learner must focus working memory resources on the modality or delivery of teaching, rather on the content of teaching, which reduces capacity for completing and learning from the task. Because extraneous load always diminishes space for productive working memory activities, it should be minimized.
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