What is Cognitive Load and How to Manage It for Clinicians?

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Tom Haederle

Federal rules restrict an airline pilot to a flight maximum of eight hours if he or she is piloting the aircraft solo. This is because the human brain operates at peak performance for only so long. Minds and bodies tire and require rest. One term for handling highly technical and information heavy tasks is cognitive load, a measure for the mental effort required for processing whatever you're dealing with at the time.

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Tom Haederle

Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. Clinicians bring all of their skill, expertise and mental firepower to bear on great patient care. But there are many aspects of care today that can derail or compete for their attention. In this Safety Speaker Series podcast, we explore ways to ease the cognitive load that many physicians and other caregivers face to allow them to focus on the most important job of treating patients.

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Tom Haederle

As today's guest, a retired professor of psychiatry at the University of Rochester Medical Center puts it. Brainpower is a finite resource. We have to budget the expertise like we would money and allocate it in the right places.

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Elisa Arespacochaga

Thanks, Tom. I’m Elisa Arespacochaga, vice president of clinical affairs and workforce, and today I'm really excited to be joined by Dr. Michael Privitera, a professor emeritus at the University of Rochester Medical Center who is a leading researcher on the intersection of health care quality and safety with well-being. And a good friend. Today's podcast is part of AHA's Patient Safety Initiatives Safety Speaks series.

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Elisa Arespacochaga

So, Mike, to get us started, tell me just a little bit about you and how you came to this work.

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Michael Privitera, M.D.

Sure. Absolutely. Elisa, good to see you. Basically, from the point of view, I've seen many changes in health care and how we tend to get overwhelmed with the information explosion that we have and a lot of expectations, but without the adequate resources really to deal with them and the overload, basically. So trying to look for a science that would help us with give us language.

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Michael Privitera, M.D.

That's kind of how I came across human factors and ergonomics. And one of the things you talk about today is cognitive load.

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Elisa Arespacochaga

Well, let's get into it. Let's start with that. Can you explain to me, because I didn't understand it before I heard you explain it. What do you mean by cognitive load and why is it particularly relevant for clinicians? You're a retired physician now. But why is this so important, particularly for our clinical colleagues?

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Michael Privitera, M.D.

Sure. Cognitive load is basically it's kind of a measurement of mental effort that's required in processing whatever it is you're dealing with at the time. So it could be very simple to very complex. If you're in medicine and nursing it tends to get very complex sometimes. So that would have a higher cognitive load than something that's very simple to deal with.

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Michael Privitera, M.D.

And this all gets processed through a part of our brain called the working memory. And we only have kind of a short time to deal with it. So our working memory only gives us about 15 to 30s to actually process something. So we easily can get over the limit to overload. And we've found workarounds around this, but that's why it becomes so important

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Michael Privitera, M.D.

so we don't make a mistake. If your profession has really high cognitive load per se, it's your higher risk for burnout. In a particular task, if the cognitive load is measured to be too high, the research shows that you're more likely for medical error. So it's very important.

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Elisa Arespacochaga

So can you tell me a little bit about sort of the cognitive load. Can you dive in a little bit about how it works and what it really measures?

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Michael Privitera, M.D.

Sure. It's where I think human factors and understanding cognitive load can really help us out of the current predicament we're in with ever increasing expectations and basically technology really exploding and making it harder for us humans to adapt. Right? The good news about cognitive load is there's the essential part, which is the intrinsic cognitive load. And it's basically the inherent difficulty.

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Michael Privitera, M.D.

And how we present something really makes a difference about how much of that brainpower we're using. So this research originally started in education. Doctor John Weller in Australia was understanding the three parts of cognitive load and talked about intrinsic. Germane is how much brain power is being used to make the mental model in your mind of what it is you're dealing with, so you can store it into your long term memory.

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Michael Privitera, M.D.

Or if you come across a pattern, you just heard a patient's history, well, that sounds like congestive heart failure. And you're kind of downloading from the long term memory back into working memory. And then you say, oh my gosh, that's a diagnosis here. So then, extraneous cognitive load is where we have lots of opportunity. That's basically the waste that we could get rid of.

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Michael Privitera, M.D.

What is it that we could remove by better design and sometimes a lot of conflicting pieces of information or too much information, or we're trying to synthesize all these expectations. There's extraneous cognitive load, and it kind of pulls our brainpower away from the task at hand that we either have to learn or do. So that's where our opportunity is.

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Michael Privitera, M.D.

We can really work by understanding how to get rid of this extraneous cognitive load and actually be able to see this invisible thing that's getting in our way.

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Elisa Arespacochaga

You've mentioned human factors and ergonomics a couple times. Can you just dig in a little bit more on that as well? I want to make sure folks understand. What does that even mean?

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Michael Privitera, M.D.

Human factors and ergonomics is a science really. It's embraced in many other professions, but not enough in health care. That's kind of our problem. So in other words, astronauts, pilots, even if you're into simultaneous translating at the United Nations, they consider how much you're having to deal with cognitively. And they have mandatory breaks. But in health care, it's kind of like we're not seeing the human limitation even though you're boarded in one, two or three things, if you stay up all night or you have excessive cognitive load, you might make the error in that board

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Michael Privitera, M.D.

certification times 2 or 3 doesn't really protect you enough. It helps a little bit, but you're still in the human club is the point here. We're not addressing the human club part of all this.

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Elisa Arespacochaga

Absolutely, absolutely. Every time I've tried to translate between English and Spanish, I'm very tired at the end and I cannot do simultaneous translating so.

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Chris DeRienzo, M.D.

Thank you for tuning in to this episode of Safety Speaks, the podcast series dedicated to patient safety, brought to you by the American Hospital Association. I'm Dr. Chris DeRienzo, the chief physician executive and a champion of the Patient Safety Initiative. AHA's Patient Safety Initiative is a collaborative, data driven effort that lifts up the voices of individual hospitals and health systems into the national patient safety conversation.

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Chris DeRienzo, M.D.

e information and to join the: 1500

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Chris DeRienzo, M.D.

Remember, together we can make health care safer for everyone.

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Elisa Arespacochaga

Let's talk a little bit about some of the primary factors that really contribute to that high cognitive load in health care. Obviously, you talked a little bit about some of the challenges there. As a clinician, you're trying to bring disparate information together, but can you talk a little bit about how we sort of get in our own way I guess, in terms of driving up that cognitive load in health care environments?

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Michael Privitera, M.D.

Really excellent point. And I hope that just kind of helps people to start to really see that this actually is a problem. It may be invisible to us, but it's a real problem that affects us safety, well-being, quality and our ability to sustain our career, actually. It comes from a lot of sources in in basically high volume too. -uch of it is well-meaning, but it can be excessive and non-strategic, and sometimes it comes in the form of what we think might be patient safety initiatives or regulations.

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Michael Privitera, M.D.

And they might, the way they're designed backfire in purpose. A good example that comes to mind a lot in electronic medical record that we deal with is the best practice alert or pop up. You realize it's guaranteed to derail what you're thinking about at the time, but yet it's woven in as a guardrail or protective factor, or to remind you not to forget about something.

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Michael Privitera, M.D.

But if you don't know where that clinician is in their thinking process, their cognitive flow, they might be at the point that after they've seen their patient, they're in differential diagnosis. Well, they have these symptoms. What might it be? If you derail somebody right there they have anywhere from about a 20 to 40% chance that they might not get back to the material thinking about, plus the loss.

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Michael Privitera, M.D.

So in other words, what we're doing well-intended, but it can take up extra brainpower to get back on track. And you may actually lose info on healthcare. We have multiple regulators. We have multiple sources of authority or the payers. You have to do this, that and the other to get paid. So we have multiple sources and trying to reconcile those different things.

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Michael Privitera, M.D.

Sometimes if they're directly passed down, coming through the C-suite directly to the clinicians that have to do something, that's a lot of brain power you're trying to reconcile. And it takes away from patient care implication. I guess the whole message here is this is a finite resource, and the more we know about it, we have to budget the expertise of their brain power like we would money and allocate it in the right places strategically.

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Michael Privitera, M.D.

So that's the hope of this science. The more we know about it, we can understand how we have to strategically allocate.

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Elisa Arespacochaga

I'm fascinated by this, and so much I think about how much I get when someone interrupts me when I'm in the middle of writing something, or at the end, the amount of time it takes you to get back to where you were. I don't think I had actually ever thought about that. But yeah, if you're constantly being assaulted by pop-ups, whether they're best practice alerts or emails, it can disrupt your thinking.

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Elisa Arespacochaga

So let's talk about some strategies that are helpful. We sort of, you know, define where the challenge is. What are those effective ways of managing cognitive load with the health care workforce, so that we can appropriately budget that very finite resource of their ability to think through a problem?

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Michael Privitera, M.D.

That's a really great question. And a lot of this is in process in the work. So it's probably going to keep evolving over time. But we have one mantra to think about. Don't make them think more than they necessarily have to. If you can keep that in mind. Extra stuff if you can get to the point, concise, whatever.

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Michael Privitera, M.D.

But standardization helps if you allow a certain wiggle room for, you know, the exceptions that are needed, what we call aligned autonomy. It's still following the strategic plan of the institution, but a little bit of room for specific things. Come on learning some of the points, like consolidating information together. The concept is called split attention. So split attention is the greater the amount of time between two pieces of information or in space. Either one that makes it harder to see those two pieces of information is related, and being able to put it into your long term memory that they're related.

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Michael Privitera, M.D.

So put things together that are related: process coupling is another example of that. If there's two types of processes, try to get them closer together. That saves cognitive load. Some of the things we do naturally like dashboards help us cross comparative charts so we can work within that. 15 to 30s of working memory redundancy. We talk about in engineering is having two systems.

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Michael Privitera, M.D.

That's like in the airlines industry, a backup set of breaks for the plane if the one set doesn't work, gets redundancy. But in information redundancy can backfire. So trying to keep it to one source of information where possible. Satisficing is a term that's from economics. It's basically satisfactory and sufficient to do the job. But in everyday things, think of satisficing.

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Michael Privitera, M.D.

Is it good enough to do the job? It's a decision making strategy.

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Elisa Arespacochaga

I understand. Yeah, it's one that I struggle with understanding a way to, you know, do is it good enough to do what needs to be done, and where are the places where that extra energy can help, where it's really needed? What you're saying is really being very strategic and thinking about ways to really tighten down on where that finite resource is being used.

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Michael Privitera, M.D.

Yeah.

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Elisa Arespacochaga

Seems like it, you know, can last forever, but clearly it can't. I know one of our earliest interactions was one of your great papers on executive function and how quickly that deteriorates when you are tired or you're having a bad day or you don't feel you have control.

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Michael Privitera, M.D.

Oh, yeah, it does. It does. If you think about how some things are designed, like if a CEO, for example, might have somebody that's your first contact to get in towards his or her office. And so it protects their brain function for thinking of high level decisions. So if we can do that for the everyday person, what are the things that we can get off their plate so they can think for the most critical thing, especially if they're thinking about health care?

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Elisa Arepacochaga

Yeah

Michael Privitera, M.D.

Are we having enough protection of the lesser needed types of things? Take that off their plate so they have that function for the high level and executive function goes, if we're highly stressed. Yeah. It's one of the last things to develop in evolution for us as humans. So it's sensitive to setbacks easily. That's the irony. We're not bulletproof is the point.

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Elisa Arespacochaga

Yeah absolutely. So let's talk about an example where some of these interventions that you just laid out actually lead to improvement. I know you've done this work, in your role at University of Rochester. How is this making measurable improvement in clinician well-being and patient safety?

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Michael Privitera, M.D.

Well, in terms of some of the examples, you know, it's like the well-meaning aspects of, mandatory education, for example, it was all meant for improving patient safety and quality. But since they're coming from different authorities, they added up in ways and trying to reconcile the different needs, understanding the quantity, no resource provided for doing them. For example, you had to do them and finding time for them somehow.

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Michael Privitera, M.D.

All those things, when we took this on as our wellness committee, first thing we did is just list them all, put them all together and all the sources they came from. And then we shared that together with Quality and Safety Office and Education office. And immediately the first week when they looked at everything, 20% were taken right off.

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Michael Privitera, M.D.

we use a well-being index in: 2018

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Michael Privitera, M.D.

I love the term that you've told me about Elisa. This was back in the days when it wasn't cool to work on burnout, and I was in that stage and boy, was it uphill. The culture is strong. Yeah, and also the feeling that there's no limit to the brain power and the fact that they're tired and they're up all night shouldn't affect your quality and safety.

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Michael Privitera, M.D.

Where I don't know where we got that image from, but it part of it is our medical culture, especially as things have expanded. We really are having a hard time doing that safely nowadays. And if you think about the 14% reduction, we already know the research and how that converts to patient safety and the economic benefits. The study and surgeons high burnout was associated with a 200% increase risk of medical error.

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Michael Privitera, M.D.

So the benefits of the reduction are clear just by looking to correlations with the research.

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Elisa Arespacochaga

Absolutely. So, you know, when you brought this and you did this work, what role did leadership and what role can they play in addressing some of these challenges. So the leaders who are listening, what can they do to really engage in this?

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Michael Privitera, M.D.

Okay. Great questions. And part of what I've been doing for the last 14 years or so is trying to extract from human factors engineering, putting it into words that might make more sense to a layperson because we're not engineers in health care. That's been the process. So basically, realizing so many things from disparate authorities come through the C-suite, the CEO, chief financial officer, chief operations, etc. and realizing that is the opportunity for how we implement. How do we implement mandatories, how do we implement requirements?

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Michael Privitera, M.D.

It usually gets dispersed to many different offices. The whole idea from the human factors point of view is trying to get an idea of what are all the expectations going out? And that's we're connecting well-being with quality work, you start to see that these are all interacting. If you understand what's happening to our brain, there's no doubt all this overloaded is affecting patient safety and quality.

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Michael Privitera, M.D.

Plus, it's the unspoken reason why people keep leaving. So basically, trying to get an idea of acknowledging that this cognitive load is a real thing. And the more we start to understand it, try to understand it in leadership positions, some of the basics of what this means in terms of cognitive load. A great work that has been really instrumental in me understanding what to do in health care organizations is by William Passmore.

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Michael Privitera, M.D.

ve. That's a book he wrote in: 1988

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Michael Privitera, M.D.

You know, people know how to take care of the patient. They can't make it happen through the tech or other things like that. So realizing these are real things, the more we know about it. Taking on halo bias is another. Halo bias is something because it might have a term patient safety or quality associated with it, we don't push back on the science.

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Michael Privitera, M.D.

It already gets in the door because it's got that term. My point is, when you see if they're coming and there's so many of them, maybe it's not quality or safety anymore. Maybe it's actually doing the reverse and it's causing a problem because it's all totaled together. Understand how and where the impact is being felt. So that's feedback systems - try to get feedback systems from front lines back to leadership, frontline leadership.

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Michael Privitera, M.D.

The way we're structured now, there's a communication flow: national state, industry leadership and requirements go through the C-suite down to clinicians. It's mostly a one-way communication. We don't have a feedback system to send a really critical. So the more we can do about getting more regular surveys, the psychosocial safety that's needed for being able to speak up if there's an issue is critical.

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Michael Privitera, M.D.

So that culture is really important. So actually health care leaders have a big key in improvement. And they can really do a lot more than they know right now. So the more that we understand about human factors, I really believe it's a way out of our struggles.

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Elisa Arespacochaga

Oh, absolutely. I couldn't agree more with some of the things you said. I think the building those feedback loops give you so much opportunity to understand because you don't know until you walk in someone's shoes to some extent, or get their feedback what it is to be them and to do their job. And we keep adding...in healthcare, we tend to be a little bad at taking things away.

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Elisa Arespacochaga

Yeah. And de-implementing. I know that's one of Krasinski's favorite words and I love to use it, but how do we de-implement some of the things that we've put in place? Oh, Mike, you have been really just such a shining light on this issue. I know you're - at least for me - you were the person who explained it to me and helped me understand it.

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Elisa Arespacochaga

And I just want to thank you so much for sharing your expertise, your experiences, all of the work that you've done over the last 14 years, trying to figure out how to make us a kinder, gentler, and safer place to work and continuing to do it even though you're, you know, enjoying a well-deserved vacation. But thank you again for joining me and sharing just a little bit about the work that you've done.

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Elisa Arespacochaga

If your organization has not signed up with the AHA Patient Safety Initiative, I absolutely encourage you to join us. You can gain a wealth of information and resources and collaborative opportunities and get to talk to people as awesome as Mike. So please sign up on the AHA Patient Safety Initiative web page. Thank you for listening and I hope you have a wonderful day.

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Elisa Arespacochaga

Thanks again Mike.

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Michael Privitera, M.D.

Thank you Elisa for your continuing support.

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Tom Haederle

Thanks for listening to Advancing Health. Please subscribe and write us five stars on Apple Podcasts, Spotify or wherever you get your podcasts.