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Effective Learning in High Cognitive Load Critical Care Simulation

University of Maryland Medical Center
Baltimore, MD

Program Director: Nirav G. Shah, MD
Type of Program: Pulmonary and Critical Care Medicine
Abstract Authors: Radhika M. Shah,MD; Avelino C. Verceles, MD; Kathryn S. Robinett, MD; Michael T. McCurdy, MD; and Nirav G. Shah, MD

Simulation has consistently proven to be an effective teaching technique that has yet to be uniformly incorporated in pulmonary and critical care programs. Simulating critically ill patients requires the development of high-fidelity simulations (HFS), which may need the use of high cognitive load. This is in direct contrast to cognitive load learning theory in medical simulation, which suggests that simulation should aim to decrease cognitive load by limiting the number of learning objectives and distracting tasks (1). We hypothesize that a new approach to critical care simulation that allows for higher cognitive load can increase fidelity and will continue to improve knowledge and performance in managing rare clinical scenarios. This would provide evidence that HFS with high cognitive load should be included in pulmonary and critical care curriculums nationwide.

We conducted a prospective, cohort study with 20 critical care fellows who participated in a HFS of massive hemoptysis. Fifty percent of fellows who participated had never managed a patient with massive hemoptysis. The simulation was developed with diverse learning objectives, including CT scan interpretation, airway management, bronchoscopy, consultant communication, and endobronchial blocker placement. It also intentionally included secondary tasks to increase fidelity and cognitive load, such as answering consultant calls and setting up the bronchoscopy cart. A questionnaire consisting of a Likert scale surrounding comfort level and knowledge on management of massive hemoptysis was administered before and after the simulation, with the baseline questionnaire serving as a control. All fellows will participate in the same simulation again in 8 months and performance data will be tracked prospectively.

There was a significant increase in comfort level in managing massive hemoptysis after the HFS despite intentionally high cognitive load. There was also a significant increase in scores surrounding knowledge on management of massive hemoptysis, from an average score of 77.5 percent to 96.2 percent on the post-simulation questionnaire (p = 0.001).

This novel approach, which incorporates a critical care HFS with an intentionally high cognitive load, resulted in a significant increase in comfort and knowledge surrounding management of massive hemoptysis. We expect that knowledge, comfort, and performance measures will be retained on subsequent simulations in 8 months. Our preliminary data piloting critical care HFS with high cognitive load demonstrate that such methods are an effective learning tool, which increases fellows’ experience with rare clinical scenarios and should be incorporated in all fellowship programs.


  1. Fraser K, Ayres P, and J Sweller. Cognitive Load Theory for Design of Medical Simulations. Simul Healthc. 2015 Oct;10(5):295-30.
Last Reviewed: December 2016