Practice Perfect 729
Working with Cognitive Overload

One of the major challenges of being an educator of students and residents is understanding where our learners are situated along the learning spectrum. It’s probably obvious for me to state that a 4th year podiatry student is on a different level from a 3rd year resident. But it can be a challenge to figure out exactly where that difference becomes significant in affecting performance and deconstructing the errors in trainee actions that require help.

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One of the main factors involved with challenges to new learners is the concept of cognitive load – or more to the point, cognitive overload. As a very simple review, memory is thought to be constructed in short term (or working memory) and long-term types. We use working memory for momentary tasks and then move that information into long term memory.1

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It is known that because this short-term memory system is limited in capacity, it is easy for novice learners with less experience in a certain domain to lose information if it comes in too quickly or in too much volume. This is the concept of cognitive overload. The irony is that long-term memory is almost unlimited in capacity while short-term memory is tiny. Think of this as pouring a gallon of water into an ocean but pouring that water through a thimble-sized strainer. Slow going!

Long-term memory is almost unlimited in capacity while short-term memory is tiny

Cognitive load can be influenced by the environment, how the learner interacts with that environment, and the abilities of the learner himself. A simple example to demonstrate this is the use of music in the operating room with new surgeons.2 It has been found that listening to music during surgery decreases the quality of performance of novice surgeons while having little effect on experienced surgeons. The extra environmental inputs use up the young surgeon’s working memory, increasing cognitive load, and reducing their ability to perform on the highly complex task of surgery. It is for this reason that I typically turn off the music in the OR when I’m working with a first-year resident and leave it on with more experienced ones.

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Here are some suggestions to help your new learners prepare for the complexities of surgery while minimizing the downfalls of cognitive overload.

  1. Realize that as an expert surgeon you may not be an expert teacher - As such, the aspects of your work that are automated and intuitive may not be conscious to you and will not be broken up into manageable parts by your learning novice surgeon . As a result, my suggestion is to first be very patient with your learner; they’re not going to be as fast or efficient as you and may not always understand what you’re doing. Second, consider taking over the case at the point of highest complexity, and then returning the knife when things calm down.
  2. Determine proper knowledge before discussing case details - I separated this one out from its close cousin that follows in number 3 because it is an imperative first step before discussing the details of a case. Ask your learning surgeon to tell you what they know about the patient, the pathology, and indications for the procedure. They should be able to discuss pertinent anatomy and at-risk structures. Remember to modulate your expectations based on the situation. For example, if the resident didn’t have a chance to meet the patient before the procedure, then their knowledge of the patient would reasonably be less comprehensive than if they met the patient in the clinic. If the resident is not able to recall the required knowledge to perform the surgery, then they can’t possibly properly do the surgery.
  3. Prepare your learner before the case4 - This one takes forethought and some effort. For optimal learning, it would be beneficial for your learner to simulate the surgery beforehand (on a cadaver is best but most of the time not possible). It is then more realistic to have the student or resident talk you through how the procedure would be done – with a focus on the details. Make sure they have a strong image of what is going to occur during the procedure itself. Talk over important decision-making points and areas of potential complications. Have them repeat the narrative if they at first seem disorganized. In some cases, just before the surgery, I have also asked my resident to go to a different scrub sink alone and visualize the surgery in their minds while scrubbing their hands. This type of visualization and mental rehearsal should decrease their cognitive load during the procedure.
  4. Monitor the learner carefully during the procedure - Experienced surgeons have a knowledge of what to expect and rapidly adjust to changing situations during the case.5 Novice learners will not have this subconscious knowledge, so will react differently to variances or unexpected situations and may not be able to anticipate complications or needs. It’s important, then, for the preceptor to maintain a vigilant awareness of the entire surgical situation – this “situational awareness” will allow the surgeon to maintain control and flow during the case. A simple rule of thumb I find useful is to watch for “pauses and pokes”. Imagine a resident starting a bunionectomy. They make an incision of proper depth. The skin spreads in its expected manner, but the resident pauses, staring at the incision. They poke around in a disorganized manner. These are signs they have reached the limit of their procedural knowledge and need guidance.
  5. Ask questions - Self-assessment during the surgical procedure is an ongoing process for the experienced surgeon. For example, after drawing an incision line, the surgeon will quickly evaluate the line asking themselves, “Is the incision in the proper location?” “Is the size adequate for proper exposure?” These are often almost subconscious for experts but are far from it for the novice. Don’t think your trainee is on your same level and avoid asking these types of questions. Some teachers like to let their learner take the reins and possibly encounter trouble due to an unperceived mistake which they have to work out. However, the stakes are higher in surgery, so to prevent this type of error, it is helpful to ask questions to make sure your trainee is evaluating the surgical process as it proceeds. I like to use this method because it consistently provides feedback about the resident’s thought process (decreasing my anxiety) while allowing the case to continue to move along.

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Perhaps the most important aspect of working with the new learner in surgery is to realize cognitive overload is the norm and not the exception, but it can be overcome with preparation, forethought, and patience. 

Best wishes.

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
  1. Kirschner PA (ed). Cognitive load theory: Implications of cognitive load theory on the design of learning. [Editorial]. Learning and Instruction. 12(1):1-10.
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  2. Pluyter JR, Buzink SN, Rutkowski AF, Jakimowicz JJ. Do absorption and realistic distraction influence performance of component task surgical procedure? Surg Endosc. 2010 Apr;24(4):902-097.
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  3. Sullivan ME, Ortega A, Wasserberg N, Kaufman H, Nyquist J, Clark R. Assessing the teaching of procedural skills: can cognitive task analysis add to our traditional teaching methods? Am J Surg. 2008 Jan;195(1):20-23.
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  4. Wiggins-Dohlvik K, Stewart RM, Babbitt RJ, Gelfond J, Zarzabal LA, Willis RE. Surgeons' performance during critical situations: competence, confidence, and composure. Am J Surg. 2009 Dec;198(6):817-23.
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  5. Crebbin W, Beasley SW, Watters DA. Clinical decision making: how surgeons do it. ANZ J Surg. 2013 Jun;83(6):422-428.
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