Understanding the Cognitive Load of Cross-Cover Care: The Resident's Perspective

Background Cross-cover is a cognitively complex, understudied aspect of graduate medical education. Understanding it through cognitive load theory can reveal areas of excessive cognitive load that can hinder reasoning and learning. Objective To characterize perceived cross-cover challenges by residents using a cognitive load lens. Methods An anonymous electronic survey was sent to 329 residents in internal medicine, internal medicine-pediatrics, pediatrics, general surgery, and neurology at a single academic institution in 2023. They were asked to characterize the frequency and perceived likelihood of associated adverse events of cross-cover challenges on 5-point Likert scales. These challenges were categorized by cognitive load type (intrinsic, extraneous, or germane). An impact score (range 1 to 25) was calculated by multiplying the frequency rating by the perceived likelihood of an adverse event. Differences between intern (postgraduate year [PGY] 1) and senior (PGY-2+) residents were examined. Results Response rate was 48% (n=158). Challenges related to extraneous load were the most impactful barrier to cross-cover care, including (average [±SD]): hospital short staffed (13.5 [±5.7]), receiving unnecessary notifications (12.9 [6.4]), and competing responsibilities (12.1 [5.6]). The impact of challenges characterized by intrinsic and germane loads varied between resident level, with higher impact for PGY-1 residents. These include lack of medical knowledge, lack of knowledge of hospital processes, delay calling attending overnight, and delay calling consultants overnight. Conclusions Cross-cover challenges related to extraneous load emerged as the most impactful barrier to effective cross-cover care, with PGY-1 residents experiencing a higher burden from intrinsic and germane loads than PGY-2+ residents.