The Cognitive Load of Inpatient Consults: Development of the Consult Cognitive Load Instrument and Initial Validity Evidence

How Many Is Too Many? Using Cognitive Load Theory to Determine the Maximum Safe Number of Inpatient Consultations for Trainees

PURPOSE

Cognitive load, specifically extraneous load (EL) reflective of distractions, may provide evidence of a lack of focus, potentially making additional work unsafe. The assessment of trainees performing inpatient consultations provides a helpful model for examining this question. The goal of this study was to provide useful information to clinical and educational leaders to optimize inpatient consultation services and rotations and mitigate potential patient safety risk.

METHOD

In 2019, using the Consult Cognitive Load instrument, the authors obtained EL data from inpatient consultations performed by internal medicine fellows and psychiatry residents across 5 University of California hospitals. In 2023, the authors constructed a Wright map to compare the participants' EL data with the number of prior initial consultations performed during the shift.

RESULTS

Of 326 trainees contacted, 139 (43%) completed the EL survey items. The Wright map shows that trainees were estimated to agree that interruptions were already distracting at the first consultation of the shift. After 4 consultations, trainees were estimated to strongly agree that interruptions were distracting, and to agree that emotions, extraneous information, and technology were distracting.

CONCLUSIONS

The authors propose a quantitative, empirically driven, mean safety limit of 4 new inpatient consultations per shift for trainees to avoid cognitive overload, thereby potentially supporting patient safety. Clinical and educational leaders can adjust this limit to fit the unique needs of their practice setting. A similar approach using cognitive load and item response theory could be used to conduct patient safety research in other domains.

Using Item-Response Theory to Improve Interpretation of the Trans Woman Voice Questionnaire

OBJECTIVE

The Trans Woman Voice Questionnaire (TWVQ) is commonly used to quantify self-perceptions of voice for trans women seeking gender-affirming voice care, but the interpretation of TWVQ scores remains challenging. The objective of this study was to use item-response theory (IRT) to evaluate the relationship between TWVQ items and persons on a common scale and identify improvements to increase the meaningfulness of TWVQ scores.

METHODS

A retrospective review of TWVQ scores from trans women patients between 2018-2020 was performed. Rasch-family models were used to generate item-person maps positioning respondent location and item difficulty estimates on a logit scale, which was then converted into a scaled score using linear transformations.

RESULTS

TWVQ responses from 86 patients were analyzed. Initial item-person maps demonstrated that the middle response categories ("sometimes" and "often") performed inconsistently across items (poor threshold banding); interpretability improved when these ratings were scored as one category. The models were rerun using revised scoring, which retained high reliability (0.93) and supported a unidimensional construct. Updated item-person maps revealed four scaled score zones (≤54, >54 to ≤101, >101 to ≤140, and >140) that each corresponded to an increasing pattern of item thresholds (probability of selecting one response category vs. others). These ranges can be interpreted as minimal, low, moderate, and high, respectively.

CONCLUSIONS

Empiric data from Rasch analysis supports new interval scoring for the TWVQ that advances the clinical and research utility of the instrument and lays the foundation for future improvements in clinical care and outcomes assessment.

LEVEL OF EVIDENCE

NA Laryngoscope, 2022.

Moving From Theory to Practice in Oncology Education When Virtual Is Your Reality

Evidence-based education is crucial for meeting the evolving needs of learners in the oncology workforce, given the growing demand for well-trained providers and the rapidly changing complexities of cancer care. With the onset of the severe acute respiratory syndrome coronavirus 2 pandemic, innovative means of delivering educational content in a virtual setting have become a necessary reality. Knowledge of learning science can be translated into concrete, pragmatic methods for using evidence-based education in a virtual world and affords important opportunities for innovation and inclusion across a broad network of educators and learners. We offer key insights and tools to promote attention to and agility with teaching in virtual settings to meet the needs of contemporary educators and learners.

The Cognitive Load of Inpatient Consults: A Convergent Parallel Mixed Methods Study Using the Consult Cognitive Load Instrument

PURPOSE

Consultation is crucial for patient care and a primary responsibility of fellows. Understanding the cognitive load associated with the complex skill of consultation would enhance fellow learning. The authors aimed to determine themes describing the fellow experience during inpatient consults specifically, align these themes with Consult Cognitive Load (CCL) scores, and identify strategies to manage cognitive load to enhance fellow education and performance, and, consequently, patient care.

METHOD

The authors studied 16 fellows using mixed methods. Fellows who accepted an invitation completed an inpatient consult followed by the CCL, a measure of cognitive load during consults, and an interview. Three authors conducted a thematic analysis. Member checks and triangulation supported theme trustworthiness. Subsequently, 3 authors rated the extent and cognitive demand of each theme expressed in each transcript. The authors measured interrater reliability and used Spearman correlation to describe the association of these ratings with CCL scores. The authors examined themes to identify strategies that educators might use.

RESULTS

Analysis revealed 4 themes: "nature and scope," which conceptually aligned with intrinsic load (IL); "leveraging resources," which had elements of both IL and extraneous load (EL); "extraneous factors," which aligned with EL; and "drivers," which aligned with germane load (GL). Interrater reliability for extent and demand ratings ranged from 0.57 to 0.79. The correlation between "nature and scope" and IL was 0.37, "extraneous factors" and EL 0.71, and "drivers" and GL 0.32. "Leveraging resources" did not correlate with IL (0.06) or EL (-0.09). Potential strategies based on themes included offering level-appropriate assistance to match IL, focusing the fellow's attention to reduce EL, and providing succinct teaching to promote GL.

CONCLUSIONS

This study provided deep insight into the fellow consult experience and suggested strategies for educators to guide consult learning. The theme "leveraging resources" merits further exploration.