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Learning Challenges, Teaching Strategies, and Cognitive Load: Insights From the Experience of Seasoned Endoscopy
Justin L Sewell1, Judith L Bowen, Olle Ten Cate
1J.L. Sewell is associate professor, Division of Gastroenterology, Department of Medicine, Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, California; ORCID: http://orcid.org/0000-0003-4049-2874. J.L. Bowen is professor, Department of Medical Education and Clinical Sciences, and associate dean for curriculum, Elson S. Floyd College of Medicine, Washington State University, Spokane, Washington. O. ten Cate is professor, Medical Education, University Medical Center Utrecht, Utrecht, The Netherlands, and adjunct professor, Department of Medicine University of California, San Francisco, San Francisco, California; ORCID: http://orcid.org/0000-0002-6379-8780. P.S. O'Sullivan is professor, Department of Medicine, and director of research and development in medical education, Center for Faculty Educators, University of California, San Francisco, San Francisco, California; ORCID: http://orcid.org/0000-0002-8706-4095. B. Shah is associate professor, Division of Gastroenterology, Department of Medicine, Department of Geriatrics and Palliative Medicine, Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York. C.K. Boscardin is associate professor, Department of Medicine, University of California, San Francisco, San Francisco, California.
Purpose:
Learners of medical procedures must develop, refine, and apply schemas for both cognitive and psychomotor constructs, which may strain working memory capacity. Procedures with limitations in visual and tactile information may add risk of cognitive overload. The authors sought to elucidate how experienced procedural teachers perceived learners' challenges and their own teaching strategies in the exemplar setting of gastrointestinal endoscopy.
Method:
The authors interviewed 22 experienced endoscopy teachers in the United States, Canada, and the Netherlands between May 2016 and March 2019 and performed thematic analysis using template analysis method. Interviews addressed learner challenges and teaching strategies from the teacher participants' perspectives. Cognitive load theory informed data interpretation and analysis.
Results:
Participants described taking steps to "diagnose" trainee ability and identify struggling trainees. They described learning challenges related to trainees (performance over mastery goal orientation, low self-efficacy, lack of awareness), tasks (psychomotor challenges, mental model development, tactile understanding), teachers (teacher-trainee relationship, inadequate teaching, teaching variability), and settings (internal/external distractions, systems issues). Participants described employing strategies that could match intrinsic load to learners' levels (teaching along developmental continuum, motor instruction, technical assistance/takeover), minimize extraneous load (optimize environment, systems solutions, emotional support, define expectations), and optimize germane load (promote mastery, teach schemas, stop and focus).
Conclusions:
Participants provided insight into possible challenges while learning complex medical procedures with limitations in sensory channels, as well as teaching strategies that may address these challenges at individual and systems levels. Using cognitive load theory, the authors provide recommendations for procedural teachers.
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