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Cognition and Learning Environment

The nature of the problems presented and the learning environment affects the processing of novel information by short-term working memory. There are three factors that affect the load placed upon short-term memory processing:

  • Intrinsic load

  • Extraneous load

  • Germane load

Intrinsic Load

Intrinsic load is defined by the number of new information elements to be processed simultaneously and by element interactivity: how closely the information elements are related to one another. For example, one could more easily process new information about pharmacologic agents within the same class of drugs if they all had similar names and mechanisms of actions, such as benzodiazepines (flurazepam, oxazepam).

Simplifying the learning task will lessen the intrinsic load. When schemas for organizing elements are developed, then the intrinsic load can be increased. Intrinsic load can be reduced by breaking down complex learning tasks into a series of simplified tasks, then combining them back into real-world problems.

A logical progression of increasing complexity in education could start with a simple paper case of a single medical problem, then a simulation with a medical record, then an encounter with a standardized patient, then a clerkship rotation.

Extraneous Load

Extraneous load is a function of the intructional procedure. The extraneous load is high for trial and error learning. This load is high when the novice learner has to search out the information needed (e.g., computer searching, or looking up terms in the dictionary). This load is high when multitasking because there is a cognitive load to shifting attention from one task to another, requiring reorientation to thinking. Thus, internet usage with surfing has a high cognitive cost. Online multitaskers tend to jump from one irrelevant item to another, without deep thinking, and do not concentrate on accomplishing a task.

Any single mode of learning (visual, auditory, kinesthetic, reading) can be overwhelmed. However, more processing can occur via multiple modes simultaneously.

Extraneous load can be decreased when specific goals are replaced by goal-free tasks. For example, instead of asking the student to provide a detailed explanation for the pathophysiology for a case of diabetic ketoacidosis, the student can be tasked to provide examples of acidosis. Students can be given a problem that has already been worked out and discuss that, rather than try to work through a problem with unknowns.

As learners acquire more working memory and schemas, they can be given more complex problems with more unknowns. At novice levels, continuous coaching is given; at expert levels, less ongoing guidance is provided.

Germane Load

Germane load is a function of working long-term memory. The greater the amount of long-term memory organized by schemas, the greater the intrinsic load can be. As learners progress, they can begin to handle more information. Then they can be placed into situations where there is variability in the learning tasks. For example, they can be given multiple acid-base problems to solve that help build and reinforce schemas. They can work an entire day in a general clinic and apply history-taking and physical diagnosis skills across variable patient presentations.

Intrinsic and extraneous cognitive loads are addititive. Even a simple learning problem can be made difficult by poor instructional design.

Attention Span

Maintaining attention to the learning task at hand is essential. Attention is inversely proportional to multitasking. Attention is focused through curiosity. Getting enough rest is important to prevent fatigue. As John Howard, the pioneer of adventure racing, observed, 'If you're not getting enough sleep, you'll be making bad decisions.' In addition, exercise supports cognition and cognitive flexibility (executive function).


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Masley S, Roetzheim R, Gualtieri T. Aerobic exercise enhances cognitive flexibility. J Clin Psychol Med Settings. 2009;16:186-193.

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