Adam Szulewski

Introduction: The medical pause is a theoretical framework describing how brief interruptions in clinical activities can optimize cognitive load through reflection and relaxation. However, little is known about what occurs during instructor-prompted and learner-led pauses in simulation-based training. This study investigates whether reflection or relaxation predominates during the specific pauses and how these activities influence cognitive load and performance. Methods: Fifty-two medical students (13 teams) participated in an emergency medicine team simulation, assigned either to a pause group or a control group. A mixed-methods design was employed, combining semi-structured focus group interviews with quantitative assessments of cognitive load and performance. Results: Three themes emerged: (1) dynamic fluctuations of cognitive load at the individual level, (2) perceived usefulness of pausing, and (3) the central role of team leadership. Reflecting the dynamic nature, no significant quantitative differences were found between groups at the individual level. However, Bayesian analysis provided anecdotal evidence that leaders in the pause group experienced higher germane load, suggesting greater reflective engagement during pauses. Discussion: These findings indicate that the pauses may foster reflection, particularly among leaders. The study discusses the limitations of one-time quantitative measures in complex simulations and recommends adopting team-based rather than individual-level analyses of cognitive load and performance in future research.

Objectives Managing critically ill patients requires specific skills, yet little is known about how teaching occurs during real-time resuscitations. This scoping review aimed to summarize and map how teaching during real-time resuscitation has been described and conceptualized in the literature, to inform emergency physician clinician-educators and to identify gaps in this area. Methods We searched 6 databases from inception to April 2025 and hand-searched abstracts from 10 conferences held in the past 7 years. Backward and forward citation searches were performed. Eligible studies described a teaching interaction involving a medical learner (any level) and an actual critically ill patient in a hospital-based setting. No restrictions were applied based on publication type. Included eligible empirical studies were appraised using the Mixed Methods Assessment Tool. Using descriptive qualitative content analysis, we inductively and iteratively developed categories through team discussion to organize how teaching during resuscitation has been reported in the literature. Results A total of 25,530 titles and abstracts were screened. Full-text review of 242 articles yielded 13 included records, with 8 additional identified through reference screening, forward searching, and conference material review. Resuscitations most commonly occurred in the emergency department (n = 8) or the intensive care unit (n = 4). Learners were primarily residents (n = 17) or fellows (n = 7). Appraisal of 10 empirical studies showed heterogeneous quality. Twenty-three teaching strategies were described. Three categories emerged from the analysis: (1) teaching adapted to learners’ level of involvement during the resuscitation, (2) supervisor practices, and (3) ethical considerations shaping teaching during resuscitation. Conclusion This scoping review summarizes and maps how teaching during real-time resuscitation has been described and conceptualized in the literature. It highlights reported strategies that emergency physicians may consider adapting in clinical practice while also underscoring the paucity of empirical work in this underexplored area.

We present a novel multimodal dataset for Cognitive Load Assessment in REal-time (CLARE). The dataset contains physiological and Gaze data from 24 participants with self-reported cognitive load scores as ground-truth labels. The dataset includes four modalities: Electrocardiography (ECG), Electrodermal Activity (EDA), Electroencephalogram (EEG), and Gaze tracking. Each participant completed four nine-minute sessions using the MATB-II software, a computer-based mental workload task. The sessions were divided into one-minute segments of varying complexity to induce different levels of cognitive load. During the experiment, participants reported their cognitive load every 10 seconds. For the dataset, we also provide benchmark binary classification results with machine learning and deep learning models on two different evaluation schemes, namely, 10-fold and leave-one-subject-out (LOSO) cross-validation. Benchmark results show that for 10-fold evaluation, the Transformer based deep learning model achieves the best classification performance with ECG, EDA, and Gaze. In contrast, for LOSO, the best performance is achieved by the deep learning model with ECG, EDA, and EEG.

Introduction: Debriefing after simulation facilitates reflective thinking and learning. Eye-tracking augmented debriefing (ETAD) may provide advantages over traditional debriefing (TD) by leveraging video replay with first-person perspective. This multisite randomized controlled trial compared the impact of ETAD with TD (without eye-tracking and without video) after simulation on 4 outcomes: (1) resident metacognitive awareness (the primary outcome), (2) cognitive load (CL) of residents and debriefers, (3) alignment of resident self-assessment and debriefer assessment scores, and (4) resident and debriefer perceptions of the debriefing experience. Method: Fifty-four emergency medicine residents from 2 institutions were randomized to the experimental (ETAD) or the control (TD) arm. Residents completed 2 simulation stations followed by debriefing. Before station 1 and after station 2, residents completed a Metacognition Awareness Inventory (MAI). After each station, debriefers and residents rated their CL and completed an assessment of performance. After the stations, residents were interviewed and debriefers participated in a focus group. Results: There were no statistically significant differences in mean MAI change, resident CL, or assessment alignment between residents and debriefers. Debriefer CL was lower in the experimental arm. Interviews identified 4 themes: (1) reflections related to debriefing approach, (2) eye-tracking as a metacognitive sensitizer, (3) translation of metacognition to practice, and (4) ETAD as a strategy to manage CL. Residents reported that eye tracking improved the specificity of feedback. Debriefers relied less on notes, leveraged video timestamps, appreciated the structure of the eye-tracking video, and found the video useful when debriefing poor performers. Conclusions: There were no significant quantitative differences in MAI or resident CL scores; qualitative findings suggest that residents appreciated the benefits of the eye-tracking video review. Debriefers expended less CL and reported less perceived mental effort with the new technology. Future research should leverage longitudinal experimental designs to further understand the impact of eye-tracking facilitated debriefing.

As an early adopter of competency-based medical education (CBME) our postgraduate institution was uniquely positioned to analyze implementation experience data across programs, while keeping institutional factors constant. We described participants' experiences related to CBME implementation across programs derived from early program evaluation efforts within our setting. This evaluation focused on eight residency programs at a medium-sized academic institution in Canada. Participants (n = 175) included program leaders, faculty, and residents. The study consisted of 3 phases: (1) describing intended implementation; (2) documenting enacted implementation; and (3) comparing intended with enacted implementation to inform adaptations. Each program's findings were summarized in technical reports which were then analyzed thematically. Cross program data were organized by themes. Six themes were identified. All groups emphasized the need for ongoing refinement of CBME resulting from shared tensions such as increased assessment burden. However, there were some disparate CBME-related experiences between programs such as the experience with entrustable professional activities, the interpretation of retrospective entrustment anchors, and quality of feedback. We detected several cross-program successes and important challenges related to CBME. Our experience can inform other programs engaging in implementation and evaluation of CBME.

Residents and faculty have described a burden of assessment related to the implementation of competency-based medical education (CBME), which may undermine its benefits. Although this concerning signal has been identified, little has been done to identify adaptations to address this problem. Grounded in an analysis of an early Canadian pan-institutional CBME adopter’s experience, this article describes postgraduate programs’ adaptations related to the challenges of assessment in CBME. From June 2019–September 2022, 8 residency programs underwent a standardized Rapid Evaluation guided by the Core Components Framework (CCF). Sixty interviews and 18 focus groups were held with invested partners. Transcripts were analyzed abductively using CCF, and ideal implementation was compared with enacted implementation. These findings were then shared back with program leaders, adaptations were subsequently developed, and technical reports were generated for each program. Researchers reviewed the technical reports to identify themes related to the burden of assessment with a subsequent focus on identifying adaptations across programs. Three themes were identified: (1) disparate mental models of assessment processes in CBME, (2) challenges in workplace-based assessment processes, and (3) challenges in performance review and decision making. Theme 1 included entrustment interpretation and lack of shared mindset for performance standards. Adaptations included revising entrustment scales, faculty development, and formalizing resident membership. Theme 2 involved direct observation, timeliness of assessment completion, and feedback quality. Adaptations included alternative assessment strategies beyond entrustable professional activity forms and proactive assessment planning. Theme 3 related to resident data monitoring and competence committee decision making. Adaptations included adding resident representatives to the competence committee and assessment platform enhancements. These adaptations represent responses to the concerning signal of significant burden of assessment within CBME being experienced broadly. The authors hope other programs may learn from their institution’s experience and navigate the CBME-related assessment burden their invested partners may be facing.

Background: In the emergency department (ED), chest radiographs (CXRs) provide essential information for clinical diagnostic reasoning. Errors in interpretation by emergency physicians can lead to negative patient outcomes. To aid in teaching this important skill, an understanding of cognitive processes and cognitive load (CL) in CXR interpretation in emergency medicine (EM) personnel is warranted.Methods: This study adopted a concurrent mixed‐methods research design. Participant groups included medical students (M), junior (J) and senior (S) EM residents, and attending emergency physicians (P) in the ED at an academic hospital. To elucidate cognitive processes, a real‐time cognitive task analysis during CXR interpretation was performed. Interviews were audio recorded, transcribed verbatim, and analyzed thematically. The interview was followed by a questionnaire, where participants rated their CL, stress, and confidence level.Results: Levels of CL (M vs. S and M vs. P, p = 0.002; J vs. S, p = 0.004; J vs. P, p = 0.005) and stress (J vs. P, p = 0.002) decreased, while confidence levels increased (M vs. S, p = 0.006; J vs. S, p ≤ 0.001; J vs. P, p = 0.003) as experience level increased. Qualitative analysis of interviews revealed four themes: checking behavior, information reduction, pattern recognition versus systematic viewing, and recognizing scope of practice. Experts commonly utilized checking behavior (e.g., comparison to prior radiographs) and deprioritized task irrelevant data. Experts used a general overview technique as their initial approach as opposed to a systematic viewing approach, and they more readily recognized an EM physicians’ scope of practice in this task.Conclusion: This study characterized differences in cognition that led to increased CL, stress, and lower level of confidence in EM learners during CXR interpretation and provided insight into expertise development in this important skill.

Background: Patient resuscitation can be overwhelming for junior postgraduate medical residents due to its inherent complexity and high-stakes environment. Emotional states of unpleasant hyperarousal burden cognitive resources, contributing to cognitive overload and performance decline. Our objective is to characterize the associations between pre-scenario emotional state and junior residents’ cognitive load and performance in a simulated-resuscitation, to provide evidence for informed curricular development. Methods: PGY-1 residents self-rated their emotional state before four simulated-resuscitation scenarios, and their cognitive load after. Faculty assessed performance with entrustment scores. Factor analysis identified the principal components of emotional state data. Linear regression models examined the relationship between pre-scenario emotional components, cognitive load, and performance scores. Results: 47/47 medical and surgical residents (100%) participated and completed Emotional State (99.5%) and Cognitive Load (98.9%) surveys. Positive invigoration and negative tranquility were the principal components. Pre-scenario tranquility was negatively associated with cognitive load (b= -0.23, p < 0.0001), and cognitive load was negatively associated with performance scores (b= -0.27, p < 0.0001). Pre-scenario invigoration was negatively associated with cognitive load (b=-0.18,p = 0.0001), and positively associated with performance scores (b= 0.08, p = 0.0193). Conclusion: Amongst junior residents participating in simulated resuscitation scenarios, pre-scenario agitation (negative tranquility) is associated with increased cognitive load, which itself is associated with lower performance scores. These findings suggest residency programs should consider developing curriculum aimed at modulating residents’ emotional agitation and reducing residents’ cognitive burden to improve resuscitation performance.

Background: Emergency physicians often experience a high cognitive load (CL) due to the inherent nature of working in acute care settings. CL has traditionally been measured in educational studies but has not been well studied in the clinical environment.Methods: Emergency medicine attending physicians and residents working in an academic urgent care center completed psychometric questionnaires while on shift to measure overall CL, intrinsic cognitive load (ICL), extraneous cognitive load (ECL), and acute stress. Data regarding the patient load, patient acuity, and the number of patients in the waiting room were also collected. Correlational analysis and simple linear regression were used to evaluate predictors of CL on shift.Results: Forty‐two questionnaires were completed (26 by attending physicians, 16 by residents). Attending physicians carried a significantly higher patient load compared to residents (p < 0.001). No differences in mean overall CL, ICL, ECL, and acute stress were observed between attending physicians and residents. Bivariate analysis demonstrated associations between ICL, ECL, acute stress, and overall CL in attending physicians. In residents, acute stress was the only variable associated with overall CL and the number of high‐acuity patients was associated with ICL.Conclusions: Factors influencing reported CL during clinical work are different between attending emergency physicians and residents. Further study to appreciate the impact of these differences is required and may help educators elucidate strategies to better manage CL, thereby improving clinical performance and potentially improving patient care.

Purpose: Competency‐based medical education (CBME) has prompted widespread implementation of workplace‐based assessment (WBA) tools using entrustment anchors. This study aimed to identify factors that influence faculty's rating choices immediately following assessment and explore their experiences using WBAs with entrustment anchors, specifically the Ottawa Surgical Competency Operating Room Evaluation scale. Method: A convenience sample of 50 semi‐structured interviews with Emergency Medicine (EM) physicians from a single Canadian hospital were conducted between July and August 2019. All interviews occurred within two hours of faculty completing a WBA of a trainee. Faculty were asked what they considered when rating the trainee's performance and whether they considered an alternate rating. Two team members independently analysed interview transcripts using conventional content analysis with line‐by‐line coding to identify themes. Results: Interviews captured interactions between 70% (26/37) of full‐time EM faculty and 86% (19/22) of EM trainees. Faculty most commonly identified the amount of guidance the trainee required as influencing their rating. Other variables such as clinical context, trainee experience, past experiences with the trainee, perceived competence and confidence were also identified. While most faculty did not struggle to assign ratings, some had difficulty interpreting the language of entrustment anchors, being unsure whether their assessment should be retrospective or prospective in nature, and if/how the assessment should change whether they were ‘in the room’ or not. Conclusions: By going to the frontline during WBA encounters, this study captured authentic and honest reflections from physicians immediately engaged in assessment using entrustment anchors. While many of the factors identified are consistent with previous retrospective work, we highlight how some faculty consider factors outside the prescribed approach and struggle with the language of entrustment anchors. These results further our understanding of ‘in‐the‐moment’ assessments using entrustment anchors and may facilitate effective faculty development regarding WBA in CBME.