Learning Challenges, Teaching Strategies, and Cognitive Load: Insights From the Experience of Seasoned Endoscopy Teachers

Abstract

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.

Trainee perception of cognitive load during observed faculty staff teaching of procedural skills

“…This was consistent with measured cognitive load; germane and intrinsic load levels were rated as greater than extraneous load. It makes sense that some activities were used more than others, but we were surprised to observe no instances of either ‘promote mastery mindset’ or ‘stop and listen’ as these were mentioned by participants in our prior study . Participants in that study, who were purposively selected for deep education experience and insight, may have been more likely than the ‘typical’ GI endoscopy teacher to use these more reflective teaching activities.…”

“…The vast majority of teaching was oral. Although participants in our prior study described physical teaching strategies such as the use of hand gestures and manipulation of the equipment outside the patient's body, we rarely observed these; when they were used, learners often did not notice them. As procedural skills are inherently physical, it is interesting that more teaching was not enacted physically.…”

“…Very few studies have investigated the three types of cognitive load in procedural settings . Our prior work quantitatively assessed the characteristics of learners, teachers, tasks and settings that were associated with intrinsic, germane and extraneous load amongst colonoscopy learners . Naismith et al .…”

“…Previously, we characterised teaching activities reported as used by experienced endoscopy teachers when teaching GI endoscopy . Participants in that study, who were purposively sampled to maximise experience and insight into educational processes, reported using 11 specific teaching activities.…”

“…Previously, we characterised teaching activities reported as used by experienced endoscopy teachers when teaching GI endoscopy. 15 Participants in that study, who were purposively sampled to maximise experience and insight into educational processes, reported using 11 specific teaching activities. However, as participants were highly selected for their education expertise and insight, we do not know whether 'typical' endoscopy teachers use these activities, how the activities are enacted or how they affect learners' cognitive load.…”