Examining the Influence of Cognitive Load in Clinical Reasoning and Its Relationship to Self-Regulated Learning

• In Event: Learner Support in Digital Learning Environments

Abstract

Objectives
This paper addresses the role that cognitive load plays in self-regulated learning (SRL) in medicine. In particular, we examine medical students as they establish a clinical diagnosis in the context of solving clinical cases in BioWorld (Author, 2009), a computer supported learning environment designed for medical students to deliberately practice (Ericsson, 2004) their diagnostic reasoning strategies while solving virtual cases. Our goal is to identify where students need scaffolding by identifying how cognitive load influences SRL (Boekaerts, 2017). Our assumption is that cognitive load is tied to case difficulty and as clinical cases get more difficult, there is an increase in experienced cognitive load. Furthermore, we are interested in a nuanced examination of how cognitive load is tied to particular phases of SRL, i.e., forethought, performance, and self-reflection. Finally, we examine how cognitive load in three SRL phases contribute to diagnostic performance, i.e., efficiency and confidence.
Methods
27 medical students volunteered for the study and solved three patient cases of varying difficulty, resulting in 81cases that were analyzed. Think alouds were collected as students solved patient cases resulting in 81 transcripts. These transcripts were segmented into meaning units and coded for cognitive load and SRL phases. Specifically, two raters coded 30% of the transcripts. We then used five types of supervised machine learning algorithms (i.e., Naïve Bayes, Decision Tree, Deep Learning, Support Vector Machines, and Rule Induction) to predict the variables of interest for the rest of the think-aloud protocols based on their linguistic features extracted by the Linguistic Inquiry and Word Count (LIWC) program (see Table 1-3) (Pennebaker, Boyd, Jordan, & Blackburn, 2015). Repeated measures ANOVAs were conducted to compare differences in cognitive load among three patient cases and across three SRL phases. We estimated the relative importance of cognitive load in three SRL phases towards diagnostic performance using the method developed by Lideman, Merenda, and Gold (1980).
Results
Students had significantly higher cognitive load in the performance phase that of forethought phase, regardless the complexity of patient cases. For the easy case of Amy, students demonstrated significantly lower cognitive load in the self-reflection phase than that of the other two phases (see Table 4). Interestingly, there was no significant difference in overall cognitive load across the three patient cases as shown in Table 5. In addition, we found that cognitive load in three SRL phases contributed differently to diagnostic efficiency and confidence (See Table 6 the details).
Significance
SRL is a mediating factor in clinical reasoning, leading to higher levels of accuracy in clinical diagnosis. Cognitive load had a specific relationship to phases of SRL. Students experienced more cognitive load in the performance phase revealing an important area for future adaptation. Scaffolding students in this phase may lead to better diagnostic reasoning. The varying effect of cognitive load on different aspects of performance also inform the design of individualized scaffoldings. Understanding the relationship between cognitive load and SRL can lead to design decisions that provide necessary adaptation based on distinct student profiles.

Authors

• Susanne P. Lajoie, McGill University

• Shan Li, McGill University

• Juan Zheng, McGill University

• Tianshu Li, McGill University

• Alejandra Ruiz-Segura, McGill University

• Kirsten Nynych, McGill University