The evolution of cognitive load theory and its application to medical education
Open accessAbstract
Cognitive Load Theory (CLT) has started to find more applications in medical education research. Unfortunately, misconceptions such as lower cognitive load always being beneficial to learning and the continued use of dated concepts and methods can result in improper applications of CLT principles in medical education design and research. This review outlines how CLT has evolved and presents a synthesis of current-day CLT principles in a holistic model for medical education design. This model distinguishes three dimensions: task fidelity: from literature (lowest) through simulated patients to real patients (highest); task complexity: the number of information elements; and instructional support: from worked examples (highest) through completion tasks to autonomous task performance (lowest). These three dimensions together constitute three steps to proficient learning: (I) start with high support on low-fidelity low-complexity tasks and gradually fade that support as learners become more proficient; (II) repeat I for low-fidelity but higher-complexity tasks; and (III) repeat I and II in that order at subsequent levels of fidelity. The numbers of fidelity levels and complexity levels within fidelity levels needed depend on the aims of the course, curriculum or individual learning trajectory. This paper concludes with suggestions for future research based on this model.
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An assessment after out-of-class instruction is an excellent way to evaluate student comprehension and facilitate mastery learning techniques.
“An assessment after the out-of-class instruction is an excellent way to evaluate student comprehension of a topic and facilitate the use of mastery learning techniques (22).”
From Applying learning theories and instructional design models for effective instruction (2016) · cites this paper as [22]
In “Three strategies for optimizing intrinsic cognitive load” (page unavailable), the paper says that appropriate assessment can improve and facilitate learning. It does not specifically recommend assessment after out-of-class instruction, say that such an assessment evaluates topic comprehension, or connect it to mastery learning techniques. (LLM, conf=0.84)
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Self-citationMenichetti, J., Lie, H. C., Mellblom, A. V., Brembo, E. A., Eide, H., Gulbrandsen, P., Heyn, L. G., Saltveit, K. H., Strømme, H., Sundling, V., et al. (2021) · Patient Education and Counseling · doi:10.1016/j.pec.2021.01.019 · Cited by 36 · see citing works
Hanway, P., Akehurst, L., Vernham, Z., & Hope, L. (2020) · Legal and Criminological Psychology · doi:10.1111/lcrp.12182 · Cited by 35 · see citing works
Measurement and Management of Cognitive Load in Surgical Education: A Narrative Review
Tokuno, J., Carver, T. E., & Fried, G. M. (2022) · Journal of surgical education · doi:10.1016/j.jsurg.2022.10.001 · Cited by 34 · see citing works
Gross, M., Wright, M. C., & Anderson, O. (2017) · Anatomical Sciences Education · doi:10.1002/ase.1684 · Cited by 37 · see citing works
The Impact of Cognitive Load Theory on the Effectiveness of Microlearning Modules
Lopez, S. (2024) · European Journal of Education and Pedagogy · doi:10.24018/ejedu.2024.5.2.799 · Cited by 33 · see citing works
Biro, M., Kim, I., Huynh, A., Fu, P., Mann, M., & Popkin, D. L. (2019) · Journal of the American Academy of Dermatology · doi:10.1016/j.jaad.2019.05.085 · Cited by 32 · see citing works
Papanagnou, D., Klein, M. R., Zhang, X. C., Cameron, K. A., Doty, A. M. B., McCarthy, D. M., Rising, K. L., & Salzman, D. H. (2021) · Advances in Simulation · doi:10.1186/s41077-021-00176-y · Cited by 33 · see citing works
Pointing and tracing enhance computer-based learning
Ginns, P., & King, V. (2021) · Educational Technology Research and Development · doi:10.1007/s11423-021-09997-0 · Cited by 31 · see citing works
Exploring the effect of improved learning performance: A mobile augmented reality learning system
Wang, W., Lin, Y., & Lu, H.-E. (2022) · Education and Information Technologies · doi:10.1007/s10639-022-11487-6 · Cited by 34 · see citing works
The Use of Anatomical Dissection Videos in Medical Education
Greene, S. J. (2019) · Anatomical Sciences Education · doi:10.1002/ase.1860 · Cited by 30 · see citing works
Ginns, P., Hu, F., & Bobis, J. (2020) · Applied Cognitive Psychology · doi:10.1002/acp.3732 · Cited by 27 · see citing works
Mental Effort, Workload, Time on Task, and Certainty: Beyond Linear Models
Leppink, J., & Pérez-Fuster, P. (2019) · Educational Psychology Review · doi:10.1007/s10648-018-09460-2 · Cited by 26 · see citing works
Self-citationEvidence for validity for the Cognitive Load Inventory for Handoffs
Young, J. Q., John, M., Thakker, K., Friedman, K. A., Sugarman, R., Sewell, J. L., & O’Sullivan, P. (2020) · Medical Education · doi:10.1111/medu.14292 · Cited by 26 · see citing works
Going beyond performance scores
Sridhar, P. K., Chan, S., & Nanayakkara, S. C. (2018) · ACM International Conference on Interaction Design and Children (IDC) · doi:10.1145/3202185.3202739 · Cited by 26 · see citing works
Faster, slower or real time? Perceptual-cognitive skills training with variable video speeds
Put, K., Wagemans, J. P., Pizzera, A., WILLIAMS, A. M., Spitz, J., Savelsbergh, G. J. P., & Helsen, W. F. (2016) · Psychology of sport and exercise · doi:10.1016/j.psychsport.2016.03.007 · Cited by 25 · see citing works
The effects of a theory‐based summary writing tool on students' summary writing
Chew, C. S., Idris, N. B., Loh, E. F., Wu, W. V., Chua, Y. P., & Bimba, A. T. (2019) · Journal of Computer Assisted Learning · doi:10.1111/jcal.12349 · Cited by 23 · see citing works
Trainee perception of cognitive load during observed faculty staff teaching of procedural skills
Sewell, J. L., Young, J. Q., Boscardin, C., ten Cate, O., & O’Sullivan, P. (2019) · Medical Education · doi:10.1111/medu.13914 · Cited by 23 · see citing works
Correlates of Cognitive Load in Surrogate Decision Makers of the Critically III
Pignatiello, G. A., & Hickman, R. L. (2018) · Western Journal of Nursing Research · doi:10.1177/0193945918807898 · Cited by 22 · see citing works
The ‘Teacher Research Group’ as a collaborative model of professional learning
Jones, L. (2021) · Educational Action Research · doi:10.1080/09650792.2021.1960577 · Cited by 22 · see citing works
Enhancing instructor credibility and immediacy in online multimedia designs
Ramlatchan, M., & Watson, G. S. (2019) · Educational Technology Research and Development · doi:10.1007/s11423-019-09714-y · Cited by 22 · see citing works
Cognitive Load and Learning in the Study of Multiple Documents
Cerdán, R., Candel, C., & Leppink, J. (2018) · Frontiers in Education · doi:10.3389/feduc.2018.00059 · Cited by 23 · see citing works
Self-citationLing, Y., Zhu, P., & Yu, J. (2021) · Educational Technology Research and Development · doi:10.1007/s11423-021-10050-3 · Cited by 21 · see citing works
Revisiting the debate on germane cognitive load versus germane resources
Greenberg, K., & Zheng, R. Z. (2022) · Journal of Cognitive Psychology · doi:10.1080/20445911.2022.2159416 · Cited by 25 · see citing works
Toma, L., & Vahrenhold, J. (2018) · ACM Conference on International Computing Education Research (ICER) · doi:10.1145/3230977.3230980 · Cited by 22 · see citing works
The Impact of Emotion on Learners’ Application of Basic Science Principles to Novel Problems
McConnell, M., Monteiro, S., Pottruff, M. M., Neville, A. J., Norman, G. R., Eva, K. W., & Kulasegaram, K. M. (2016) · Academic Medicine · doi:10.1097/acm.0000000000001360 · Cited by 21 · see citing works
Khan, S. M. F. A., & Shehawy, Y. M. (2025) · Technologies · doi:10.3390/technologies13080374 · Cited by 28 · see citing works
Clark, B. W., Niessen, T. M., Apfel, A., Luckin, J., Lee, Y. J., Desai, S. V., & Garibaldi, B. T. (2021) · The American Journal of Medicine · doi:10.1016/j.amjmed.2021.11.021 · Cited by 22 · see citing works
Aptyka, H., Fiedler, D., & Großschedl, J. (2022) · Evolution Education and Outreach · doi:10.1186/s12052-022-00163-5 · Cited by 25 · see citing works
The role of cognitive load in university students' comprehension of multiple documents
Hahnel, C., Schoor, C., Kroehne, U., Goldhammer, F., Mahlow, N., & Artelt, C. (2019) · Zeitschrift für Pädagogische Psychologie · doi:10.1024/1010-0652/a000238 · Cited by 22 · see citing works
Dorsett, M., Panchal, A. R., Stephens, C. T., Farcas, A., Leggio, W., Galton, C., Tripp, R., & Grawey, T. (2022) · Prehospital Emergency Care · doi:10.1080/10903127.2021.1977877 · Cited by 20 · see citing works
Lin, Y., & Wang, W. (2025) · Journal of Educational Computing Research · doi:10.1177/07356331241313128 · Cited by 18 · see citing works
Ward round simulation in final year medical students: Does it promote students learning?
Behrens-Pérez, C., Dolmans, D. H. J. M., Leppink, J., Gormley, G., & Driessen, E. W. (2017) · Medical Teacher · doi:10.1080/0142159x.2017.1397616 · Cited by 18 · see citing works
Self-citationPeña‐Ayala, A., & Cárdenas-Robledo, L. A. (2019) · Computers in Human Behavior · doi:10.1016/j.chb.2019.03.036 · Cited by 17 · see citing works
Finger pointing to self‐manage cognitive load in learning from split‐attention examples
Zhang, S., de Koning, B. B., & PAAS, F. G. W. C. (2022) · Applied Cognitive Psychology · doi:10.1002/acp.3961 · Cited by 18 · see citing works
Decorative animations impair recall and are a source of extraneous cognitive load
Pink, A., & Newton, P. M. (2020) · AJP Advances in Physiology Education · doi:10.1152/advan.00102.2019 · Cited by 16 · see citing works
The puzzle of experience vs. memory: Peak-end theory and strategic gamification design in M-commerce
Li, M., Jiang, Z. J., & Ma, G. (2022) · Information & Management · doi:10.1016/j.im.2022.103749 · Cited by 16 · see citing works
Matthew, G. (2020) · Research in Learning Technology · doi:10.25304/rlt.v28.2340 · Cited by 16 · see citing works
Notfallmedizinische Ausbildung durch Simulation
Schaumberg, A., Schröder, T., & Sander, M. (2017) · Der Anaesthesist · doi:10.1007/s00101-017-0264-x · Cited by 16 · see citing works
Revisiting cognitive load theory: second thoughts and unaddressed questions
Leppink, J. (2020) · Scientia Medica · doi:10.15448/1980-6108.2020.1.36918 · Cited by 17 · see citing works
Self-citationEvaluation of students’ clinical performance post-simulation training
Bowman, A. L., Reid, D., Harreveld, B., & Lawson, C. (2020) · Radiography · doi:10.1016/j.radi.2020.10.002 · Cited by 15 · see citing works
Cramer, N., Zuckerbraun, N. S., Puller, J., Furtado, A. D., Deb, A., Dorfsman, M. L., Siripong, N., Christie, M., & Tavarez, M. M. (2021) · Pediatric Emergency Care · doi:10.1097/pec.0000000000002371 · Cited by 15 · see citing works
Extraneous Load, Patient Census, and Patient Acuity Correlate With Cognitive Load During ICU Rounds
Held, N., Neumeier, A. T., Amass, T. H., Harry, E. M., Pomponio, R., Peterson, R., Huie, T. J., & Moss, M. (2024) · CHEST Journal · doi:10.1016/j.chest.2023.12.029 · Cited by 15 · see citing works
Cognitive Load Assessment Scales in Simulation
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How Learners Use Their Hands for Learning: an Eye-Tracking Study
Park, B., Korbach, A., Ginns, P., & Brünken, R. (2023) · Educational Psychology Review · doi:10.1007/s10648-023-09833-2 · Cited by 16 · see citing works
A model to teach concomitant patient communication during psychomotor skill development
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Video Tutorials in the Traditional Classroom: The Effects on Different Types of Cognitive Load
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Cognitive Load, Anxiety, and Performance During a Simulated Subarachnoid Block
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How system functionality improves the effectiveness of collaborative learning
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Bakhaya, S., Lehnbom, E. C., Filho, C., Ma, K., & Svensberg, K. (2025) · Currents in Pharmacy Teaching and Learning · doi:10.1016/j.cptl.2025.102503 · Cited by 11 · see citing works
Skulmowski, A. (2023) · Mind Brain and Education · doi:10.1111/mbe.12369 · Cited by 11 · see citing works
Framework and Schema are False Synonyms: Defining Terms to Improve Learning
Dreicer, J. J., Parsons, A. S., Joudi, T. F., Stern, S., Olson, A. P. J., & Rencic, J. J. (2023) · Perspectives on Medical Education · doi:10.5334/pme.947 · Cited by 11 · see citing works
- Authors
- Leppink, J., & Van den Heuvel, A.
- Affiliations
- Maastricht University (NL)
- Corresponding author
- Leppink, Jimmie
- ORCID
- Leppink, Jimmie
- Venue
- Perspectives on Medical Education
- Publisher
- Ubiquity Press, Ltd.
- Published
- 2015-05-28
- Volume
- 4
- Issue
- 3
- Pages
- 119-127
- ISSN
- 2212-2761 (ISSN-L)
- 2212-277X
- PMC
- PMC4456454
- OpenAlex
- W1499793228
- Cited by
- 299
- References
- 62
- Citations by year
- 2026: 40 · 2025: 28 · 2024: 20 · 2023: 29 · 2022: 35 · 2021: 35 · 2020: 31 · 2019: 28 · 2018: 21 · 2017: 13 · 2016: 17 · 2015: 2
- FWCI
- 18.95
- Type
- journal article
- Language
- en
- Open access
- diamond
- doi.org
- Licence
- Locations
- Perspectives on Medical Education (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Research Publications (Maastricht University) (publishedVersion, cc-by)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion)
- Research Publications (Maastricht University) (submittedVersion, other-oa)
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Innovations in Medical Education
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Visual and Cognitive Learning Processes
- Health Sciences › Medicine › Family Practice › Clinical Reasoning and Diagnostic Skills
- Keywords
- cognitive load theory, medical education, instructional design, task complexity, pedagogical support, worked examples, standardized patients
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