Taking the difference out of attainment

Dear Editor,

Re: The cognitive load theory and differential attainment.

The multi-pronged approach to finding solutions to the issue of differential attainment, highlighted in the article by Samara Linton (1) is welcome. At the University of Nottingham where I am based, we also offer a multi-pronged approach. Our medical school, international office, student services and our student’s union, provide a network of support services built around the needs of our international students, who we highly value.  Student led activities include activities run by the various international societies, the MedSoc society and the Afro-Caribbean medical network. 

I would however also like to offer another approach which was not considered in the article by Samara Linton or the GMC report (2) published last year, “What supported your success in training” cited in the article by Samara Linton. This approach is addressing the issue of differential attainment within the framework of the cognitive load theory.

The cognitive load theory is based on the premise that during the process of learning, new information is initially stored in short term or working memory and later transferred into long term memory for storage and future retrieval. The theory proposes that while working memory is limited in both capacity and duration, allowing for maintaining and processing only a few pieces of information at any given time (3), the capacity of long-term memory is unlimited (4). With respect to instructional design or teaching, it argues that if the total cognitive load associated with learning a task or skill exceeds the capacity of the available working memory, additional information the learner is exposed to, is unavailable for long term storage and future retrieval and learning, therefore attainment and performance may be impaired.

Three types of cognitive load have been defined; intrinsic, extraneous and germane. Intrinsic cognitive load refers to the complexity or nature of the information being learnt. Extraneous cognitive load refers to factors external to the material or information being learnt which increase cognitive load. Some factors which increase extraneous cognitive load, include suboptimal instructional design or the way in which the information is presented (e.g. requiring students to look at power point slides as well as a research article during a lecture and unnecessarily having to search for information). Other examples include external distractions (e.g. noise and language of instruction (requiring knowledge of a non-native or second language to understand the information, which may be relevant to some international medical students and doctors)) or internal distractions, e.g. worries or thinking about external or personal issues (4), which is also relevant in the context of real or perceived racial bias and attainment of medical students and doctors. Germane cognitive load refers to the way in which schema or patterns obtained from prior learning and experience impact on the new material being learnt.

The cognitive load theory, advocates for instructional designs that maximise learning by reducing extraneous load, optimising germane load and managing intrinsic load. Within the context of differential attainment therefore, the cognitive load theory (especially, extraneous cognitive load) might provide a credible theoretical framework on which to explore the associations between educational attainment and racial background and identify potential solutions. In practice, some interventions to consider exploring, include the effect of promoting healthy psychological and behavioural responses to “adversity”. Although there are currently some challenges with identifying reliable measurements of extraneous cognitive load theory, a move to this approach might, in my opinion, address some of the issues highlighted in Samara Linton’s interesting article.

It is however important to be mindful of the unintentional potential contribution of articles on differential attainment to negative stereotyping. In my experience so far as clinical sub-dean, I have supported students from all backgrounds following an unsuccessful attempt at an assessment, where it was clear that internal distractions and an increased extraneous cognitive load contributed to the outcome. The approach offered in this article, therefore applies to all students, who encounter some difficulty in assessments and not just students with a specific demographic profile.

References

1. Linton S. Taking the difference out of attainment. BMJ. 2020 Feb 12;368:m438. doi: 10.1136/bmj.m438.
2. Roe V, Patterson F, Kerrin M, Edwards H. “What supported your success in training?” A qualitative exploration of the factors associated with an absence of an ethnic attainment gap in post-graduate specialty training. General Medical Council. Nov 2019. https://www.gmc-uk.org/-/media/documents/gmc-da-final-report-success-fac....
3. Young JQ, Van Merrienboer J, Durning S, Ten Cate O. Cognitive Load Theory: implications for medical education: AMEE Guide No. 86. Med Teach. 2014 May;36(5):371-84.
4. Sweller, J., van Merriënboer, J.J.G. & Paas, F. Cognitive Architecture and Instructional Design: 20 Years Later. Educ Psychol Rev. 2019; 31, 261–292