Using cognitive load theory to evaluate and improve preparatory materials and study time for the flipped classroom
Open accessAbstract
Background: Preclinical medical education is content-dense and time-constrained. Flipped classroom approaches promote durable learning, but challenges with unsatisfactory student preparation and high workload remain. Cognitive load theory defines instructional design as “efficient” if learners can master the presented concepts without cognitive overload. We created a PReparatory Evaluation Process (PREP) to systematically assess and measure improvement in the cognitive-load efficiency of preparatory materials and impact on study time (time-efficiency). Methods: We conducted this study in a flipped, multidisciplinary course for ~ 170 first year students at Harvard Medical School using a naturalistic post-test design. For each flipped session (n = 97), we assessed cognitive load and preparatory study time by administering a 3-item PREP survey embedded within a short subject-matter quiz students completed before class. Over three years (2017–2019), we evaluated cognitive load- and time- based efficiency to guide iterative revisions of the materials by content experts. The ability of PREP to detect changes to the instructional design (sensitivity) was validated through a manual audit of the materials. Results: The average survey response rate was ≥ 94%. Content expertise was not required to interpret PREP data. Initially students did not necessarily allocate the most study time to the most difficult content. Over time, the iterative changes in instructional design increased the cognitive load- and time-based efficiency of preparatory materials with large effect sizes ( p < .01). Furthermore, this increased the overall alignment of cognitive load with study time: students allocated more time to difficult content away from more familiar, less difficult content without increasing workload overall. Conclusions: Cognitive load and time constraints are important parameters to consider when designing curricula. The PREP process is learner-centered, grounded in educational theory, and works independently of content knowledge. It can provide rich and actionable insights into instructional design of flipped classes not captured by traditional satisfaction-based evaluations.
The claims and statistics of this paper haven’t been checked yet.
Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.
Integrity signals
Registry
Cites
Statistics
Claims the paper makes
The claims and statistics of this paper haven’t been checked yet.
Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
The effects of different teaching methods on students' cognitive load have been described in other settings.
“The effects of different teaching methods on students’ cognitive load have been described in other settings [5, 20–24].”
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 [20]
Self-check
Percentages, sums and reported differences re-computed from the paper’s own numbers.
The self-check needs the paper’s full text.
Cites
Cognitive Architecture and Instructional Design
Sweller, J., van Merrienboer, J. J. G., & Paas, F. G. W. C. (1998) · Educational Psychology Review · doi:10.1023/a:1022193728205 · Cited by 6,023 · see citing works
Sweller, J., Ayres, P., & Kalyuga, S. (2011) · Springer eBooks · doi:10.1007/978-1-4419-1428-6_446 · Cited by 5,538 · see citing works
Cognitive Load Measurement as a Means to Advance Cognitive Load Theory
Paas, F., Tuovinen, J. E., Tabbers, H., & Van Gerven, P. W. M. (2003) · Educational Psychologist · doi:10.1207/s15326985ep3801_8 · Cited by 2,527 · see citing works
Cognitive Architecture and Instructional Design: 20 Years Later
Sweller, J., van Merriënboer, J. J. G., & Paas, F. (2019) · Educational Psychology Review · doi:10.1007/s10648-019-09465-5 · Cited by 2,337 · cited 11× · see citing works
“CLT defines instruction as “efficient,” when it provides the learner with sufficient guidance to successfully process novel information without overloading the limited capacity of working memory [23, 24].”
BackgroundMethodInfluentialThe use of flipped classrooms in higher education: A scoping review
O'Flaherty, J., & Phillips, C. (2015) · The Internet and Higher Education · doi:10.1016/j.iheduc.2015.02.002 · Cited by 2,152 · see citing works
Cognitive Theory of Multimedia Learning
Mayer, R. E. (2014) · The Cambridge Handbook of Multimedia Learning · doi:10.1017/cbo9781139547369.005 · Cited by 1,976 · see citing works
Cognitive load theory in health professional education: design principles and strategies
Van Merriënboer, J. J. G., & Sweller, J. (2010) · Medical Education · doi:10.1111/j.1365-2923.2009.03498.x · Cited by 1,511 · cited 2× · see citing works
“to the line can also be expressed as efficiency metric E = (y – x)/√2 [23]”
BackgroundThe flipped classroom: A review of its advantages and challenges
Akçayır, G., & Akçayır, M. (2018) · Computers & Education · doi:10.1016/j.compedu.2018.07.021 · Cited by 1,491 · see citing works
Self-Regulated Learning: Beliefs, Techniques, and Illusions
Bjork, R. A., Dunlosky, J., & Kornell, N. (2013) · Annual Review of Psychology · doi:10.1146/annurev-psych-113011-143823 · Cited by 1,468 · see citing works
Flipped classroom improves student learning in health professions education: a meta-analysis
HEW, K. F., & LO, C. K. (2018) · BMC Medical Education · doi:10.1186/s12909-018-1144-z · Cited by 1,207 · see citing works
Cognitive Load Theory: Implications for medical education: AMEE Guide No. 86
Young, J. Q., Van Merrienboer, J., Durning, S., & Ten Cate, O. (2014) · Medical Teacher · doi:10.3109/0142159x.2014.889290 · Cited by 935 · see citing works
Irby, D. M., Cooke, M., & OʼBrien, B. C. (2010) · Academic Medicine · doi:10.1097/acm.0b013e3181c88449 · Cited by 924 · see citing works
Paas, F. G. W. C., & Van Merriënboer, J. J. G. (1993) · Human Factors: The Journal of the Human Factors and Ergonomics Society · doi:10.1177/001872089303500412 · Cited by 921 · see citing works
Efficiency in learning: Evidence-based guidelines to manage cognitive load
Clark, R. C., Nguyen, F., Sweller, J., & Baddeley, M. (2006) · Performance Improvement · doi:10.1002/pfi.4930450920 · Cited by 820 · see citing works
A systematic review of the effectiveness of flipped classrooms in medical education
Chen, F., Lui, A. M., & Martinelli, S. M. (2017) · Medical Education · doi:10.1111/medu.13272 · Cited by 780 · see citing works
Measurement of Cognitive Load in Instructional Research
Paas, F. G. W. C., van Merriënboer, J. J. G., & Adam, J. J. (1994) · Perceptual and Motor Skills · doi:10.2466/pms.1994.79.1.419 · Cited by 731 · see citing works
Instructional Efficiency: Revisiting the Original Construct in Educational Research
van Gog, T., & Paas, F. (2008) · Educational Psychologist · doi:10.1080/00461520701756248 · Cited by 473 · see citing works
Higher education dominance and siloed knowledge: a systematic review of flipped classroom research
Lundin, M., Bergviken Rensfeldt, A., Hillman, T., Lantz-Andersson, A., & Peterson, L. (2018) · International Journal of Educational Technology in Higher Education · doi:10.1186/s41239-018-0101-6 · Cited by 227 · see citing works
Investigating Strategies for Pre-Class Content Learning in a Flipped Classroom
Jensen, J. L., Holt, E. A., Sowards, J. B., Ogden, T. H., & West, R. E. (2018) · Journal of Science Education and Technology · doi:10.1007/s10956-018-9740-6 · Cited by 217 · see citing works
Student experiences across multiple flipped courses in a single curriculum
Khanova, J., Roth, M. T., Rodgers, J. E., & McLaughlin, J. E. (2015) · Medical Education · doi:10.1111/medu.12807 · Cited by 209 · see citing works
From Theory to Practice: The Application of Cognitive Load Theory to the Practice of Medicine
Szulewski, A., Howes, D., van Merriënboer, J. J. G., & Sweller, J. (2021) · Academic Medicine · doi:10.1097/acm.0000000000003524 · Cited by 171 · see citing works
Oudbier, J., Spaai, G. W. G., Timmermans, K., & Boerboom, T. (2022) · BMC Medical Education · doi:10.1186/s12909-021-03052-5 · Cited by 167 · see citing works
Ogrinc, G. S., Davies, L., Goodman, D., Batalden, P. B., Davidoff, F., & Stevens, D. (2015) · Journal of the American College of Surgeons · doi:10.1016/j.jamcollsurg.2015.07.456 · Cited by 164 · see citing works
Active Learning Strategies to Improve Progression from Knowledge to Action
Torralba, K. D., & Doo, L. D. (2019) · Rheumatic Disease Clinics of North America · doi:10.1016/j.rdc.2019.09.001 · Cited by 119 · see citing works
El Sadik, A., & Al Abdulmonem, W. (2021) · Anatomical Sciences Education · doi:10.1002/ase.2015 · Cited by 106 · see citing works
A preliminary framework to guide implementation of The Flipped Classroom Method in nursing education
Barbour, C. M., & Schuessler, J. B. (2018) · Nurse Education in Practice · doi:10.1016/j.nepr.2018.11.001 · Cited by 98 · see citing works
Measuring physician cognitive load: validity evidence for a physiologic and a psychometric tool
Szulewski, A., Gegenfurtner, A., Howes, D. W., Sivilotti, M. L. A., & van Merriënboer, J. J. G. (2017) · Advances in Health Sciences Education · doi:10.1007/s10459-016-9725-2 · Cited by 94 · see citing works
Youhasan, P., Chen, Y., Lyndon, M., & Henning, M. (2021) · BMC Nursing · doi:10.1186/s12912-021-00555-w · Cited by 90 · see citing works
Schiekirka-Schwake, S., & Raupach, T. (2015) · BMC Medical Education · doi:10.1186/s12909-015-0311-8 · Cited by 75 · see citing works
Schwartzstein, R. M., Dienstag, J. L., King, R. W., Chang, B. S., Flanagan, J. G., Besche, H. C., Hoenig, M. P., Miloslavsky, E. M., Atkins, K. M., Puig, A., et al. (2020) · Academic Medicine · doi:10.1097/acm.0000000000003270 · Cited by 70 · see citing works
Self-citationThe lecture-free curriculum: Setting the stage for life-long learning: AMEE Guide No. 135
Parmelee, D. X., Roman, B. J. B., Overman, I., & Alizadeh, M. (2020) · Medical Teacher · doi:10.1080/0142159x.2020.1789083 · Cited by 48 · see citing works
Post-Carnegie II curricular reform: a north American survey of emerging trends & challenges
Pock, A. R., Durning, S. J., Gilliland, W. R., et al. (2019) · BMC Medical Education · doi:10.1186/s12909-019-1680-1 · Cited by 46 · see citing works
How Do Medical Students Prepare for Flipped Classrooms?
Bouwmeester, R. A. M., de Kleijn, R. A. M., ten Cate, O., et al. (2015) · Medical Science Educator · doi:10.1007/s40670-015-0184-9 · Cited by 44 · see citing works
Elzainy, A., & Sadik, A. E. (2022) · Annals of Anatomy - Anatomischer Anzeiger · doi:10.1016/j.aanat.2022.151952 · Cited by 34 · see citing works
Exploring flipped classrooms in undergraduate nursing and health science: A systematic review
Banks, L., & Kay, R. H. (2022) · Nurse Education in Practice · doi:10.1016/j.nepr.2022.103417 · Cited by 34 · see citing works
Harvey, L. (2022) · Quality in Higher Education · doi:10.1080/13538322.2022.2050477 · Cited by 26 · see citing works
Effective and Time-Efficient Implementation of a Flipped-Classroom in Preclinical Medical Education
Marshall, A. M., & Conroy, Z. (2022) · Medical Science Educator · doi:10.1007/s40670-022-01572-3 · Cited by 20 · see citing works
Learning Alone or Learning Together: Is It Time to Reevaluate Teacher and Learner Responsibilities?
Prober, C. G., & Norden, J. G. (2020) · Academic Medicine · doi:10.1097/acm.0000000000003741 · Cited by 19 · see citing works
Blind spots in medical education: how can we envision new possibilities?
Tackett, S. A., Steinert, Y., Whitehead, C. R., Reed, D. A., & Wright, S. M. (2022) · Perspectives on Medical Education · doi:10.1007/s40037-022-00730-y · Cited by 19 · see citing works
Fleming, P., Heath, O. J., Goodridge, A., et al. (2015) · BMC Medical Education · doi:10.1186/s12909-015-0387-1 · Cited by 18 · see citing works
A new application of the temporal contiguity effect in designing narrated slideshows
Liu, T., Lin, Y.-C., & PAAS, F. G. W. C. (2022) · Educational Technology Research and Development · doi:10.1007/s11423-021-10076-7 · Cited by 11 · see citing works
Guo, L. (2022) · Reading Psychology · doi:10.1080/02702711.2022.2156949 · Cited by 9 · see citing works
Zhong, L. (2022) · Interactive Learning Environments · doi:10.1080/10494820.2022.2157840 · Cited by 5 · see citing works
Flagged first, then by citations
Research works printed but not linked: 1
- [40]Lenhard W, Lenhard A. Computation of effect sizes. Retrieved from http://www.psychometrica.de/effect_size.html. Psychoterica. 2016; 10.13140/RG.2.17823.92329. · DOI
Cited by
Sorted by citations
Gärtner, R., Peters, H., & Holzhausen, Y. (2025) · BMC Medical Education · doi:10.1186/s12909-025-08083-w · Cited by 2 · see citing works
- Authors
- Fischer, K., Sullivan, A. M., Cohen, A. P., King, R. W., Cockrill, B. A., & Besche, H. C.
- Affiliations
- Brigham and Women's Hospital (US)
- Beth Israel Deaconess Medical Center (US)
- Harvard University (US)
- Corresponding author
- Besche, Henrike C.
- ORCID
- Venue
- BMC Medical Education
- Published
- 2023-05-17
- Volume
- 23
- Issue
- 1
- Pages
- 345-345
- ISSN
- 1472-6920 (ISSN-L)
- PMC
- PMC10193725
- OpenAlex
- W4377011360
- Cited by
- 28
- References
- 43
- Citations by year
- 2026: 11 · 2025: 14 · 2024: 3
- FWCI
- 20.71
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Locations
- BMC Medical Education (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Topics
- Social Sciences › Education › Innovative Teaching Methods
- 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
- Keywords
- cognitive load theory, flipped classroom, study time, instructional design, preclinical education, curriculum evaluation, student workload, student-centered assessment
- MeSH terms
- Cognition, Curriculum, Education, Medical, Humans, Learning, Surveys and Questionnaires, Problem-Based Learning
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 ›
Are you an author, or do you see a problem with this page? Request a review
