Sewell GI faculty photo
Justin L. Sewell, MD, MPH

by Dr. Justin Sewell

Do you remember learning to perform colonoscopy? Was it exciting? Challenging? Rewarding? Frustrating? Overwhelming? Chances are it was all of these! Colonoscopy remains an incredibly important task that gastroenterologists must master during training. However, despite the importance of colonoscopy and its significant cognitive and psychomotor complexity, few studies have rigorously investigated just how fellows learn to perform colonoscopy.

We sought to address this gap by studying colonoscopy learning through the lens of cognitive load theory. Cognitive load theory is an established learning theory that focuses on the limits of working memory as a bottleneck for learning. As opposed to capacity for sensory input and long-term memory, which are essentially infinite, working memory can handle only a few pieces of information at any given time. When this is exceeded, learners can neither learn nor perform. Anyone who has completed a gastroenterology fellowship can attest that the capacity of working memory can be rapidly exceeded during colonoscopy training!

In our study, we sought to measure the cognitive load that gastroenterology fellows experience while learning to perform colonoscopy. We enrolled a representative sample of nearly 500 gastroenterology fellows throughout the United States.  Participants completed a web-based survey after a colonoscopy learning encounter that measured the three types of cognitive load that they experienced as well as other covariates. Using exploratory and confirmatory factor analysis, we developed and provided validity evidence for our cognitive load measurement instrument – the Cognitive Load Inventory for Colonoscopy (CLIC). We found that fellows with greater prior colonoscopy experience had lower levels of cognitive load than fellows with less experience.

Our results support the relevance of cognitive load theory to colonoscopy training, and underscore the importance of rigorously designed educational research studies in the realm of endoscopic procedures training. We propose that the CLIC can be used to assess the cognitive load that fellows experience during colonoscopy training, in both experimental and workplace learning settings.  Our study is published in the June issue of Medical Education, and can be found HERE

Measuring cognitive load during procedural skills training with colonoscopy as an exemplar

Justin L. Sewell, MD, MPH (University of California, San Francisco); Christy K. Boscardin, PhD (UCSF); John Q. Young, MD, MPP (Hofstra Northwell School of Medicine); Olle ten Cate, PhD (UMC Utrecht, the Netherlands); Patricia S. O’Sullivan, EdD (UCSF) 

Medical Education 2016: 50: 682692 doi: 10.1111/medu.12965



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.


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.


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.


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.