title: Measuring cognitive load during procedural skills training with colonoscopy as an exemplar.
abstract: OBJECTIVE
  Few studies have investigated cognitive factors affecting learning of procedural skills in medical education. Cognitive load theory, which focuses on working memory, is highly relevant, but methods for measuring cognitive load during procedural training are not well understood. Using colonoscopy as an exemplar, we used cognitive load theory to develop a self-report instrument to measure three types of cognitive load (intrinsic, extraneous and germane load) and to provide evidence for instrument validity.
  
  
  METHODS
  We developed the instrument (the Cognitive Load Inventory for Colonoscopy [CLIC]) using a multi-step process. It included 19 items measuring three types of cognitive load, three global rating items and demographics. We then conducted a cross-sectional survey that was administered electronically to 1061 gastroenterology trainees in the USA. Participants completed the CLIC following a colonoscopy. The two study phases (exploratory and confirmatory) each lasted for 10 weeks during the 2014-2015 academic year. Exploratory factor analysis determined the most parsimonious factor structure; confirmatory factor analysis assessed model fit. Composite measures of intrinsic, extraneous and germane load were compared across years of training and with global rating items.
  
  
  RESULTS
  A total of 477 (45.0%) invitees participated (116 in the exploratory study and 361 in the confirmatory study) in 154 (95.1%) training programmes. Demographics were similar to national data from the USA. The most parsimonious factor structure included three factors reflecting the three types of cognitive load. Confirmatory factor analysis verified that a three-factor model was the best fit. Intrinsic, extraneous and germane load items had high internal consistency (Cronbach's alpha 0.90, 0.87 and 0.96, respectively) and correlated as expected with year in training and global assessment of cognitive load.
  
  
  CONCLUSIONS
  The CLIC measures three types of cognitive load during colonoscopy training. Evidence of validity is provided. Although CLIC items relate to colonoscopy, the development process we detail can be used to adapt the instrument for use in other learning settings in medical education.
authors.affiliation: Department of Medicine, University of California San Francisco, San Francisco, California, USA.
authors.forename: Justin L
authors.initials: JL
authors.lastname: Sewell
authors.affiliation: Department of Medicine, University of California San Francisco, San Francisco, California, USA.
authors.forename: Christy K
authors.initials: CK
authors.lastname: Boscardin
authors.affiliation: Department of Psychiatry, Hofstra North Shore-LIJ School of Medicine, Hempstead, New York, USA.
authors.forename: John Q
authors.initials: JQ
authors.lastname: Young
authors.affiliation: Department of Medicine, University of California San Francisco, San Francisco, California, USA.|Center for Research and Development of Education, UMC Utrecht, Utrecht, the Netherlands.
authors.forename: Olle
authors.initials: O
authors.lastname: Ten Cate
authors.affiliation: Department of Medicine, University of California San Francisco, San Francisco, California, USA.
authors.forename: Patricia S
authors.initials: PS
authors.lastname: O'Sullivan
mesh_terms: D000328:Adult; D002983:Clinical Competence / Q000592:standards*; D003071:Cognition / Q000502:physiology*; D003113:Colonoscopy / Q000193:education*; D004503:Education, Medical, Graduate; D005260:Female; D005762:Gastroenterology / Q000193:education*; D006801:Humans; D007858:Learning; D008297:Male; D010549:Personal Satisfaction; D011594:Psychometrics; D011597:Psychomotor Performance; D012495:San Francisco; D013337:Students, Medical / Q000523:psychology; D011795:Surveys and Questionnaires