Cognitive Load The theory of cognitive load, initially developed by John Sweller in the 1980s, suggests that any person at a given time has a finite amount of working memory. It’s the cognitive equivalent to the RAM on your computer or Internet bandwidth. Working memory is responsible for temporarily managing and processing new, as well as already stored, information. It is responsible for integrating information with what you already know, processing and organizing information in memory, disposing of information that is deemed unimportant, and retrieving information for application. This also sometimes referred to as “short term memory”. Cognitive load is divided into three fundamental elements: intrinsic, germane, and extraneous load. The intrinsic load is essentially the inherent difficulty of the material. For example, it’s easier to learn that 5+5=10 than learn how to solve a complex differential equation explaining how a fluid moves through a pipe or blood vessel. The germane load is the unconscious load that is placed on the mind to process the information and form a construct in your mind of what 5+5 is, an organized patter of the information in you brain, or how the memory or image appears to you. In psychological parlance this is called a schema. Finally, the extraneous load is created by how the information is presented. If it’s taught or presented too quickly for processing, or with images that are confusing, this load is very high. Conversely, if we present things clearly, speak at an appropriate pace, and new ideas to schema that already exist, the extraneous load goes down. On a small side note, you can actually measure cognitive load by evaluating task-­‐
involved pupillary response. As the load increases on working memory, researchers have found that there is a linear increase in pupillary dilation. This can be evaluated by carefully watching and measuring how dilated a learner’s pupil is as information is presented In order to more effectively present or teach information we need to minimize the extraneous cognitive load and optimize the information for efficient germane processing. • Plass et al. Cognitive Load Theory. New York: Cambridge University Press. 2010. • Sweller. “Cognitive load theory, learning difficulty, and instructional design.” Learning and Instruction 1994; 4(4): 295–312. • Sweller et al. “Cognitive architechture nd instructional design.” Ed Psych Review 1998; 10(3): 251-­‐296. • Paas et al. “Cognitive Load Theory and Instructional Design: Recent Developments.” Ed Psychologist 2003; 38(1): 1–4. • Kramer. “Physiological metrics of mental workload: a review of recent programs.” In Damos (Ed.) Multiple-­‐task Performance. London: Taylor and Francis Ltd. 1991. • Beatty. “Task-­‐evoked papillary responses, processing load, and the structure of processing resources.” Psych Bulletin 1982; 91: 276-­‐292. • Kahneman. Attention and Effort. Englewood Cliffs, NJ: Prentice-­‐Hall. 1973. Knowledge Time Since the 1970s, research demonstrates that the active attention span of people to focus on and process information is relative short. Some have suggested that it is as short as 15-­‐18 minutes; others have stated it’s as long as 20-­‐30 minutes. In any individual case, however, the data seem to agree that it is certainly not an hour or two. Yet, we convenient design classes and conference lectures around somewhat traditional one-­‐hour blocks. This has been demonstrated to be inefficient. Lectures, speeches, talks, or presentations designed to relay information should probably be limited to something in neighborhood of 18-­‐30 minutes. If the information you want to relay simply cannot fit into that time frame (as a lot of medical education content does), simply take a 5-­‐10 min break after 20-­‐30 minutes. Alternatively, break things up with a video or audio recording. •
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Johnstone A. H., Percival F. (1976). “Attention breaks in lectures.” Educ Chem. 13, 49–50. Szpunar et al. “Mind wandering and education: from the classroom to online learning.” Front Psychol 2013; 4. Stuart & Rutherford. “Medical student concentration during lectures.” Lancet 1978; 2(8088): 514–516. Agarwal A. “Why Are TED Talks 18 Minutes Long?” http://www.labnol.org/tech/ted-­‐talk-­‐18-­‐minutes/12755/ (Accessed March 21, 2015) Gallo. Talk Like TED: The 9 Public-­‐Speaking Secrets of the World’s Top Minds. New York: St. Martin’s Press. 2014. Baumeister & Tierney. Willpower: Rediscovering the Greatest Human Strength. Reprint edition. New York: Penguin Books. 2012. Tambini et al. “Enhanced brain correlations during rest are related to memory for recent experiences.” Neuron 2010; 65(2): 280–290. Tell a story Telling stories has been a fundamental part of human communication since (and possibly before) the evolution of our species. A growing body of data from the communication literature demonstrates that packing information in the form of a story is an effective way to communicate ideas. It gets people to identify with a situation and taps into existing memories or emotions. In fact, some research shows that when we tell stories people identify with, the speaker and the listener exhibit brain-­‐to-­‐brain coupling. This phenomenon facilitates excellent transmission of information. If it is impractical to package information within the context of a story, perhaps starting the conversation to capture attention can help. Furthermore, the most effective part of stories is that they often incorporate a lot of sensory input. We describe places, sounds, smells, and other sensory information that can create a very vivid picture in the brain. It develops a strong schema for the listener’s brain to store in his or her memory. A wide range of people and professions have used the technique of coupling information to stories, or sensory-­‐rich constructs. From medical students using tools like Picmonic® to individuals counting cards in Las Vegas casinos, learning information in this way seems to enhance memory and recall of information. • Hasson et al. “Brain-­‐to-­‐brain coupling: a mechanism for creating and sharing a social world.” Trends in Cognitive Sciences 2012; 16(2): 114–121. • Stephens et al. “Speaker–listener neural coupling underlies successful communication.” PNAS 2010; 107(32): 14425–14430. •
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Heath & Heath. Made to Stick: Why Some Ideas Survive and Others Die. 1st edition. New York: Random House. 2008. Guber. Tell to Win: Connect, Persuade, and Triumph with the Hidden Power of Story. New York: Crown Business. 2011. Sachs. Winning the Story Wars: Why Those Who Tell -­‐ and Live -­‐ the Best Stories Will Rule the Future. Unabridged edition. Grand Haven, MI: Brilliance Audio. 2012. Dinh HQ et al. “Evaluating the importance of multi-­‐sensory input on memory and the sense of presence in virtual environments.” Virtual Reality. Proceedings, IEEE in Houston, TX 13-­‐17 March 1999. Calvert & Thesen. “Multisensory integration: methodological approaches and emerging principles in the human brain.” Journal of Physiology-­‐Paris 2004; 98(1–3): 191–205. Shams & Seitz. “Benefits of multisensory learning.” Trends in Cognitive Sciences 2008; 12(11): 411–417. Calvert et al. The Handbook of Multisensory Processes. MIT Press. Subramanian et al. “Novel educational approach for medical students: improved retention rates using interactive medical software compared with traditional lecture-­‐based format.” J Surg Educ 2012; 69(4): 449–452.-­‐ Yang et al. “The Picmonic(®) Learning System: enhancing memory retention of medical sciences, using an audiovisual mnemonic Web-­‐based learning platform.” Adv Med Educ Pract 2014; 5125–132. Technical Elements The technical elements of how a presentation is made are very important. In the corporate world, investments of millions of dollars can rest on the effectively of a 5-­‐
8 minute presentation. As a result, substantial time and effort has been put into researching and refining how to effectively construct visual and auditory media. In fact, some individuals have made a very successful career out consulting on the subject. The moral of the story is keep it clear, concise, and simple. Use less text, or at least only the text you need to get a main point across. When you do use text make sure the font style, size, and contrast on conduce to easy visual processing. Don’t overload an audience: try to keep things to one main idea per slide or visual image. After all, six slides (in a computer-­‐based software) cost the same as one slide. For an excellent, concise synopsis of these design concepts view the YouTube video referenced below: “Brain Friendly Teaching” by Dr. Petra Lewis. • Duarte. Slide:ology: The Art and Science of Creating Great Presentations. 1 edition. Sebastopol, CA: O’Reilly Media. 2008. • Duarte. Resonate: Present Visual Stories that Transform Audiences. 1 edition. Hoboken, N.J: John Wiley and Sons. 2010. •
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Reynolds. Presentation Zen: Simple Ideas on Presentation Design and Delivery. 2 edition. Berkeley, CA: New Riders. 2012. Reynolds. Presentation Zen Design: Simple Design Principles and Techniques to Enhance Your Presentations. 2 edition. New Riders. 2014. Mayer et al. “When less is more: meaningful learning from visual and verbal summaries of science textbook lessons.” J Ed Psych 1996; 88: 63-­‐73. Mayer et al. “Cognitive constraints on multimedia learning: When presenting more material results in less understanding.” J Ed Psych 2001; 93: 187-­‐198. Moreno & Mayer. “Cognitive principles of multimedia learning: The role of modality and contiguity.” J Ed Psych 1999; 91 358-­‐368. Mousavi “Reducing cognitive load by mixing auditory and visual presentation modes.” J Ed Psych; 87: 319-­‐334. Miller. “The magic number seven, plus or minus two: Some limits on our capacity for processing information.” Psych Review; 63: 81-­‐97. Lewis. “Brain Friendly Teaching. “ https://www.youtube.com/watch?feature=youtu.be&v=XuJA-­‐UM4yzE (Accessed 21 March 2015). Tandle J. “Presentation Zen-­‐ Eye Gazing for PowerPoint Presentation Design in PowerPoint 2007-­‐2013.” 14 October 2011. https://wordpress.training-­‐
nyc.com/general/presentation-­‐zen-­‐eye-­‐gazing-­‐for-­‐powerpoint-­‐presentation-­‐
design/ (Accessed 20 March 2015). Tie ideas together We know that dopamine is a very important excitatory neurotransmitter in tracts of nervous tissue in the brain associated with many functions. Two of these functions are learning and memory formation. When we connect seemly disparate pieces of information or present novel material that suddenly makes things “click”, it makes people feel good. Academic adventurers actually get a neurochemical reward for those “ah ha” moments. This can be seen by increase neurotransmission and dopamine release from neurons in cerebral structures collectively referred to as the brain’s reward center. These moments are also associated with a rise in dopamine levels in other cortical areas of the brain associated with memory. So, by presenting new information and tying concepts together, we enhance learning and information retention. • Burns. “Dopamine and Learning: What The Brain’s Reward Center Can Teach Educators.” http://www.scilearn.com/blog/dopamine-­‐learning-­‐brains-­‐
reward-­‐center-­‐teach-­‐educators (Accessed 21 March 2015). • Harley. “Norepinephrine and Dopamine as Learning Signals.” Neural Plasticity 2004; 11(3-­‐4): 191–204. • Kulisevsky. “Role of Dopamine in Learning and Memory.” Drugs & Aging 2012; 16(5): 365–379. • Arias-­‐Carrión & Pŏppel. “Dopamine, learning, and reward-­‐seeking behavior.” Acta Neurobiol Exp (Wars) 2007; 67(4): 481–488. •
Medina. Brain Rules: 12 Principles for Surviving and Thriving at Work, Home, and School. Seattle, Wash.: Pear Press. Testing and recall Quizzing and testing may be one of the most uncomfortable aspects of learning, but as it turns out it is one of the most important. Having to retrieve and apply information, as opposed to just seeing the information again, is far superior when it comes to making the information stick in your mind. It consolidates, reconsolidates and generally strengthens the mental coding, or “memory traces,” made when you learn something. This effect is further enhanced if the quizzing or testing is spread out over a period of time. For example, it would be best if you are forced to recall information during a presentation, after a presentation, days after the presentation, an a week or two after the presentation. • Karpicke J. “Science Learning Easier When Students Put Down Textbooks and Actively Recall Information.” Science 2011. https://www.nsf.gov/news/news_summ.jsp?cntn_id=118432 (Accessed 21 March 2015) • Roediger & Karpicle “The power of testing memory: Basic research and implications for educational practice.” Perspectives on Psychological Science 2006; 1: 181-­‐210. • Brown et al. Make it Stick: The Science of Successful Learning. Cambridge, MA: Harvard University Press. 2014. • Pyc & Rawson. “Why Testing Improves Memory: Mediator Effectiveness Hypothesis.” Science 2010; 330(6002): 335–335. • Karpicke & Roediger. “The Critical Importance of Retrieval for Learning.” Science 2008; 319(5865): 966–968. Cognition When I refer to “cognition” I am referring to the conscious mental activities that involve the activity of thought, comprehending a situation, remembering pieces of information, synthesizing that information into a cogent plan and making clinical decisions. Until recently, it was believed that this skill or ability was essentially immutable. Today, research in the field of neurobiology has demonstrated this is not the case. Neuroplasticity refers to the functional and structural changes in neural pathways, from the molecular to tissue levels, that can occur throughout the brain. Investigating this concept has been very important in rehabilitation of brain injuries as well as treatment of conditions such as dementia and Alzheimer’s disease. Since the mid 1990s neuroscientist have been aware that training in a particular skill and improvement in that skill are associated with structural changes the brain. In 2009 researchers realized that training and enhancing cognitive capacity in one area of the brain, such as play playing an instrument, may actually improve other skills, such is listening carefully to spoken words amidst background noise. Some recent evidence suggests that practicing decision-­‐making in simulation can enhance decision making capabilities. In a presentation at the annual meeting of the Society of Academic Emergency Medicine in 2012, Dr. Sudhir Balgia presented research findings from his efforts at the Henry Ford Health System that suggested training residents in simulation lab actually improved their capacity to make time-­‐
sensitive clinical decision during a real resuscitation. In addition, a presented at the annual meeting of the Society for Medical Decision Making, suggested that for junior trainees, simulation training to improve rapid decision-­‐making under short-­‐term time constraints could be effective. Dr. Susanne Jaeggi, a professor of Cognitive Neuroscience at UC Irvine, has published evidence that suggests training in certain cognitive tasks can in increase an individual’s general fluid intelligence. Fluid intelligence is essentially ability to think and logically develop solutions to novel problems, independent of acquired knowledge. This prospective, controlled, randomized trial was perhaps most promising because it showed that very demanding memory training produced substantial improvements in scores on fluid intelligence tests. The idea that you can improve fluid intelligence with training holds substantial promise for air medical crews. The implication is that we could perhaps develop training to improve a crew member’s ability to solve complex clinical problems and make better treatment decisions. Although there are various tools commercially available that claim to improve brain function, such as Luminosity®, none have been explored in the clinical setting. This may be an important next step. • Cramer et al. “Harnessing neuroplasticity for clinical applications.” Brain 2011; 134(6): 1591–1609. • Fernandez & Goldberg. The Sharp Brains Guide to Brain Fitness: 18 Interviews with Scientists, Practical Advice, and Product Reviews, to Keep Your Brain Sharp. 1 edition. San Francisco, CA: SharpBrains, Incorporated. • Papbery-­‐Clark et al. “Biological bases for the musician advantage for speech-­‐
in-­‐noise.” Poster presentation at the annual meeting of the Society for Neuroscience. Neuroscience 2009. • Willis et al. “Ten-­‐Year Effects of the Advanced Cognitive Training for Independent and Vital Elderly Cognitive Training Trial on Cognition and Everyday Functioning in Older Adults.” JAMA 2014; 62(1): 16–24. • Willis et al. “Long-­‐term effects of cognitive training on everyday functional outcomes in older adults.” JAMA 2006; 296(23): 2805–2814. • Benjamin et al. “Using Simulation Based Training Methods for Improved Warfighter Decision Making.” In: Dylan et al. (Eds) Foundations of Augmented Cognition, Lecture Notes in Computer Science. Springer: Berlin & Heidelberg. •
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2013. http://link.springer.com/chapter/10.1007/978-­‐3-­‐642-­‐39454-­‐6_2 (Accessed 29 March 2015). Balgia. “Simulation training improves critical decision-­‐making skills of ER residents.” Society for Academic Emergency Medicine Annual Meeting. Chicago, IL. 2011. Lecture. http://www.eurekalert.org/pub_releases/2012-­‐
05/hfhs-­‐sti051112.php (Accessed 29 March 2015). McKell. “Simulation training to improve clinical decision-­‐making by surgical residents.” 36th Annual Meeting of the Society for Medical Decision Making. 2014. https://smdm.confex.com/smdm/2014fl/webprogram/Paper8614.html (Accessed 29 March 2015). Gross & Rebok. “Memory training and strategy use in older adults: Results from the ACTIVE study.” Psych and Aging 2011; 26(3): 503–517. Gross et al. “Cognitive Predictors of Everyday Functioning in Older Adults: Results From the ACTIVE Cognitive Intervention Trial.” J Gerontol B Psychol Sci Soc Sci 2011; 66B(5): 557–566. Cramer et al. “Harnessing neuroplasticity for clinical applications.” Brain 2011; 134(6): 1591–1609. Au et al. “Improving fluid intelligence with training on working memory: a meta-­‐analysis.” Psychon Bull Rev 2014; 22(2): 366–377. Jaeggi et al. “Improving fluid intelligence with training on working memory.” Proc Natl Acad Sci USA 2008; 105(19): 6829–6833. Jaeggi et al. “Short-­‐ and long-­‐term benefits of cognitive training.” PNAS 2011; 108(25): 10081–10086. Skill Much research has been done on acquisition of skills expertise. Attempts have been made to elucidate how people become proficient and ultimately master individual tasks in a given career field. One message seems to repeat itself: practice is absolutely necessary. Although scientists that study proclaimed “experts” in different fields seem to disagree on precisely how much skills practice is needed, this basic premise of practice still pervades the literature. Furthermore, it is important to practice with conscious attention to the task and in a very deliberate, structured manner. I would also argue that a key aspect to skills acquisition is to practice these skills until they become deeply ingrained into what many people refer to as “muscle memory.” This process essentially constitutes taking a task that we have to actively think about and turning it into a habit: a regular tendency or practice that we don’t consciously have to think about. Researchers have shown that as something becomes a habit, the activity of parts of the brain involved in conscious thought and memory actually go down. So, the importance of turning technical skills into deeply ingrained neuromuscular programs is important because it decreases the load on the brain when you have to process a lot of information rapidly. In order to develop effective neuromotor programs, deliberate repetition is required. In my opinion, I think we often skip over the step-­‐wise building of basic motor skills acquisition on low-­‐fidelity training tools and manikins because paramedic and nurse trainees in the transport world find it “boring” or “too simple.” For example, airway practice and training often starts on a low-­‐fidelity manikin. The question often comes up, “what do you get sticking a plastic tube into a plastic manikin?” My answer is pretty strait forward: a motor program. Sure, the manikin is not as realistic as intubating a human being. However, the idea is to build an effective motor program that builds a strong foundation for effective skills execution. An example of this is Dr. Richard Levitan’s idea regarding “incrementalization”: breaking down airway procedures into small individual skills and engaging in deliberate, repeated practice. • Gladwell. Outliers: The Story of Success. Reprint edition. New York: Back Bay Books. • Ericsson et al. “The making of an expert.” Harvard Business Rev 2007; 85(7-­‐
8): 114–121, 193. • Ericsson et al. “Giftedness and evidence for reproducibly superior performance: an account based on the expert performance framework.” High Ability Studies 2007; 18(1): 3–56. •
Macnamara et al. “Deliberate Practice and Performance in Music, Games, Sports, Education, and
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Elbert et al. “Increased cortical representation of the fingers of the left hand in string players.” Science 1995; 270(5234): 305–307. Pascual-­‐Leone. “The brain that plays music and is changed by it.” Ann N Y Acad Sci 2001; 930315–329. Tracy et al. “Regional brain activation associated with different performance patterns during learning of a complex motor skill.” Cereb Cortex 2003; 13(9): 904–910. Anders et al. “The role of deliberate practice in the acquisition of expert performance.” Psych Review 1993; 100(3): 363–406. Graybeil. “Overview of habits, rituals, and the evaluative brain.” Annual Review of Neuroscience 2008; 31: 359-­‐387. Barnes et al. “Activity of striatal neurons reflects dynamic encoding and recoding of procedural memories.” Nature 2005; 437: 1158-­‐1161. Graybiel. “Network-­‐level neuroplasticity in coritco-­‐basal ganglia pathways.” Parkinsonism and Related Disorders 2004; 10: 293-­‐296. Graybiel. “The Basal Ganglia and Chunking of Action Repertoires.” Neurobiology of Learning and Memory 1998; 70(1–2): 119–136. Graybiel et al. “The basal ganglia and adaptive motor control.” Science 1994; 265(5180): 1826–1831. Yin & Knowlton. “The role of the basal ganglia in habit formation.” Nat Rev Neurosci 2006; 7(6): 464–476. •
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Bayley et al. “Robust habit learning in the absence of awareness and independent of the medial temporal lobe.” Nature 2005; 436(7050): 550–
553. Levitan R “Airway Management 2014” Lecture. (Accessed and produced with permission 21 March 2015). Lamb. “Could simulated emergency procedures practiced in a static environment improve the clinical performance of a Critical Care Air Support Team (CCAST)? A literature review.” Intensive Crit Care Nurs 2007; 23(1): 33–42. Shapiro et al. “Simulation based teamwork training for emergency department staff: does it improve clinical team performance when added to an existing didactic teamwork curriculum?” Qual Saf Health Care 2004; 13(6): 417–421. Share Your Passion Pathos is an appeal to an audiences’ emotions. While this talk primarily focused on Logos, or the data and logic, behind brain friendly teaching, it is important to recognize the undeniably important role of passion when it comes to transmitting information and ideas. Carmine Gallo discusses the importance of passion in terms of presenting information in his book Talk Like TED. In fact, there is important evidence from the world of behavioral science and cognitive psychology demonstrates that passion can have a powerful influence over how people learn and remember information. Passion and other “positive emotions” expressed by a presenter can be transmitted to an audience and improve their mood. This can lead to changes in brain chemistry that promote more attentive listening, make what you are saying more memorable and change the way people perceive a topic in a positive way. •
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Gallo. Talk Like TED: The 9 Public-­‐Speaking Secrets of the World’s Top Minds. New York: St. Martin’s Press. 2014. Mitteness et al. “Angel investor characteristics that determine whether perceived passion leads to higher evaluations of funding potential.” Journal of Business Venturing 2012; 27(5): 592–606. Bono & Ilies. “Charisma, positive emotions and mood contagion.” The Leadership Quarterly 2006; 17(4): 317–334. Cardon et al. “The Nature and Experience of Entrepreneurial Passion.” Acad Manage Rev 2009; 34(3): 511–532. Friedman & Martin. The Longevity Project: Surprising Discoveries for Health and Long Life from the Landmark Eight-­‐Decade S tudy. 1 edition. New York, N.Y.: Plume. 2012