Physiologic measurements of cognitive load in clinical reasoning

Dolores R. Mullikin; Ryan P. Flanagan; Jerusalem Merkebu; Steven J. Durning; Michael Soh

doi:10.1515/dx-2023-0143

Article

Physiologic measurements of cognitive load in clinical reasoning

Dolores R. Mullikin , Ryan P. Flanagan , Jerusalem Merkebu , Steven J. Durning and Michael Soh

Published/Copyright: January 29, 2024

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From the journal Diagnosis Volume 11 Issue 2

Abstract

Objectives

Cognitive load is postulated to be a significant factor in clinical reasoning performance. Monitoring physiologic measures, such as heart rate variability (HRV) may serve as a way to monitor changes in cognitive load. The pathophysiology of why HRV has a relationship to cognitive load is unclear, but it may be related to blood pressure changes that occur in a response to mental stress.

Methods

Fourteen residents and ten attendings from Internal Medicine wore Holter monitors and watched a video depicting a medical encounter before completing a post encounter form used to evaluate their clinical reasoning and standard psychometric measures of cognitive load. Blood pressure was obtained before and after the encounter. Correlation analysis was used to investigate the relationship between HRV, blood pressure, self-reported cognitive load measures, clinical reasoning performance scores, and experience level.

Results

Strong positive correlations were found between increasing HRV and increasing mean arterial pressure (MAP) (p=0.01, Cohen’s d=1.41). There was a strong positive correlation with increasing MAP and increasing cognitive load (Pearson correlation 0.763; 95 % CI [; 95 % CI [−0.364, 0.983]). Clinical reasoning performance was negatively correlated with increasing MAP (Pearson correlation −0.446; 95 % CI [−0.720, −0.052]). Subjects with increased HRV, MAP and cognitive load were more likely to be a resident (Pearson correlation −0.845; 95 % CI [−0.990, 0.147]).

Conclusions

Evaluating HRV and MAP can help us to understand cognitive load and its implications on trainee and physician clinical reasoning performance, with the intent to utilize this information to improve patient care.

Keywords: clinical reasoning; cognitive load; diagnostic errors

Corresponding Author: Dolores R. Mullikin, MD, Pediatric Assistant Clerkship Director USUHS, Department of Pediatrics, Uniformed Services University of Health Sciences, Bethesda, USA, E-mail: Dolores.mullikin@usuhs.edu.

Acknowledgments

We acknowledge Saroosh Solhjoo and Mark Haigney for laying the groundwork for this study.

Research ethics: This study was deemed exempt by the IRB at Uniformed Services University of Health Sciences.
Informed consent: Informed consent was obtained from all participants prior to this study.
Author contributions: Dolores R Mullikin developed the theoretical framework, analyzed the data and wrote the manuscript. Ryan P Flanagan analyzed the cardiac data. Jerusalem Merkebu developed the theoretical framework. Steven J. Durning designed and conducted the simulations. Michael Soh oversaw the development and design and performed the statistical analysis. All authors reviewed and approved the final manuscript.
Competing interests: The authors state no conflict of interest.
Research funding: None declared.
Data availability: The data that support the findings of this study are available upon request from the corresponding author DM, upon reasonable request.
Disclaimer: The views expressed in this paper reflect the opinions of the authors only and not necessarily those of the United States Army, Uniformed Services University, Henry M. Jackson Foundation, or the Department of Defense.

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Received: 2023-10-12

Accepted: 2024-01-08

Published Online: 2024-01-29

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Articles in the same Issue

https://doi.org/10.1515/dx-2023-0143

Keywords for this article

clinical reasoning; cognitive load; diagnostic errors