Applying constructive alignment and cognitive load in teaching

Using constructive alignment to create student engagement

Family medicine encompasses topics that are relevant to all medical professionals, such as fever, cough, various types of pain (chest, abdominal, back, headaches), depression, and prevention. We structured the course around 16 such broad topics. Within each topic, we used constructive alignment to create a clear structure of learning goals that were relevant to the real-world practice of any clinician, provided a sequence of learning that supported these goals, and included an assessment that was fully aligned to the learning. This structure allows us to confirm that our students understand the concepts and are able to apply the material in meaningful, real-world contexts. It also avoided disengagement from students not intrinsically interested in family medicine.

Using cognitive load theory to moderate cognitive load and enhance learning

The way we structure ... information and think with it [changes our conceptions of the world]. Thus, education is about conceptual change, not just the acquisition of information.²

We created a foundational schema for each clinical problem by first dissecting our own approach. We then divided the schema into discrete elements, each no bigger than the working memory limit. We presented the information in a multimodal fashion requiring engagement of both the phonological loop and the visuospatial sketchpad components. We limited the overall content to a minimal amount of information that could support the foundational schema without assumed prior knowledge. We used the flipped-classroom approach and required learners to engage with and learn the material at their own pace at home before each session. During sessions, we created an elaboration sequence,⁸ first reviewing individual elements of a schema before moving to complete schema presentation, and then elaborating on the complexities that can arise in a topic, using clinical cases of escalating difficulty. We also created a schedule of spaced reinforcement to ensure long-term memory retention. Once the basics were in hand, we gave the students a comprehensive e-book to deepen their knowledge. The following provides an example of this process.

Example

Topic: Fever. A common clinical scenario encountered across all specialties.

Learning goals: Key real-life learning goals were selected through an iterative discussion among the course directors. We settled on these 7 goals for students:

• be able to define fever using various measurement methods,

• understand the sources of variability in fever measurement,

• understand the thermostat concept and the mechanism of heat loss and gain,

• separate fever from hyperthermia,

• know that hyperthermia requires cooling,

• know when to “dig deeper” in fever, and

• know how to treat fever for symptomatic relief.

This list was organized into a visual schema that was provided before class with an explanation using narrated slides (Figure 1). Presenting information in an audiovisual way engages the multimodal representation effects and has been shown to enhance learning⁵; schema-based learning has been shown to both reduce cognitive load and enhance diagnostic accuracy in medical learners,^9,10 presumably because it presents information in a way that is readily recognizable to the long-term memory systems that intrinsically use similar representations.³

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Figure 1.

Visual schema of fever

Each slide of the class preparatory material contained narration that elaborated on no more than 7 points of information to stay within the limits of one’s episodic buffer. Whenever possible, information was presented visually. Students were given a week to go over the material at their own pace to manage their own cognitive load. All precourse material contained only limited content, each tied to 1 of the stated learning goals. Key points were clearly emphasized within each slide (Figure 2).

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Figure 2.

Example of one slide in class precourse material

Students arrived at class prepared. In class, to create spaced repetition, we asked students to write out, from memory, the relevant information from the preparatory materials and draw the schema. We then engaged in simple activities like “Fever—Yes or No” based on the given temperature and the measurement method, or “Which method to use?” given a certain patient age (eg, rectal for confirmatory testing in age <2 years old). We then created an elaboration sequence of cases for discussion (Figure 3).

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Figure 3.

Example of sequence of cases

We built on this further with a spaced-repetition ladder. First, students were given a quiz with 4 questions relating to the content within a week of each session. At the start of the next session, the essential points and the schema of the previous session were reviewed. The required preparatory slides from each class were reviewed prior to each summative examination (made possible by the limited amount of content), and each question on the quiz specifically aligned to 1 of the stated learning goals. Finally, the e-book with more in-depth material on each topic allowed students to broaden and deepen their knowledge on their own time within the context of our broader spiral curriculum.