Measuring cognitive load during procedural skills training with colonoscopy as an exemplar
Abstract
Objectives: 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.
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A 4-point Likert scale was used to measure the categories of cognitive load instead of the 11-point Likert scale previously reported by Sewell and colleagues, and the use of this larger scale may have led to more nuanced measurement results.
“In this study, a 4-point Likert scale was used to measure the categories of cognitive load instead of the 11-point Likert scale previously reported by Sewell and colleagues [27]. The use of this larger scale may have led to more nuanced measurement results.”
From Teaching a single manual therapy technique at a time reduces cognitive load in physiotherapy students: a randomized controlled educational study (2025) · cites this paper as [27]
The subdimensions of cognitive load were assessed using an adaptation of the Cognitive Load Inventory for Colonoscopy (CLIC) questionnaire, which was developed and validated by Sewell and colleagues for colonoscopy training.
“To capture the subdimension of cognitive load, it was built upon the Cognitive Load Inventory for Colonoscopy (CLIC) questionnaire, which was developed and validated by Sewell and colleagues for colonoscopy training [27].”
From Teaching a single manual therapy technique at a time reduces cognitive load in physiotherapy students: a randomized controlled educational study (2025) · cites this paper as [27]
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- Authors
- Sewell, J. L., Boscardin, C. K., Young, J. Q., ten Cate, O., & O'Sullivan, P. S.
- Affiliations
- University of California, San Francisco (US)
- Hofstra University (US)
- Department of Medicine University of California San Francisco San Francisco California USA
- Corresponding author
- Sewell, Justin L
- Venue
- Medical Education
- Publisher
- Wiley
- Published
- 2016-05-11
- Volume
- 50
- Issue
- 6
- Pages
- 682-692
- ISSN
- 0308-0110 (ISSN-L)
- 1365-2923
- OpenAlex
- W2385731273
- Cited by
- 64
- References
- 33
- Citations by year
- 2026: 3 · 2025: 5 · 2024: 4 · 2023: 7 · 2022: 5 · 2021: 10 · 2020: 6 · 2019: 8 · 2018: 5 · 2017: 4 · 2016: 4 · 2012: 1
- FWCI
- 6.94
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Medical Education (publishedVersion)
- PubMed (publishedVersion)
- Funders
- Jacobsohn Endowment for Excellence at the University of California San Francisco
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Innovations in Medical Education
- Health Sciences › Medicine › Surgery › Surgical Simulation and Training
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Visual and Cognitive Learning Processes
- Keywords
- cognitive load, colonoscopy training, procedural training, cognitive load theory, intrinsic cognitive load, extraneous load, germane load, self-report instrument development, gastroenterology trainees, working memory, assessment validity
- MeSH terms
- Adult, Clinical Competence, Cognition, Colonoscopy, Education, Medical, Graduate, Female, Gastroenterology, Humans, Learning, Male, Personal Satisfaction, Psychometrics, Psychomotor Performance, Surveys and Questionnaires, San Francisco, Students, Medical
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
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