Heart Rate and Heart Rate Variability Correlate with Clinical Reasoning Performance and Self-Reported Measures of Cognitive Load

Lambert Schuwirth,Mark C. Haigney,Temple A. Ratcliffe,Howard D. Lee,Alexis Battista,Anthony R. Artino,Jeroen J. G. van Merrienboer,Steven J. Durning,Elexis McBee,Soroosh Solhjoo

doi:10.1038/s41598-019-50280-3

Abstract

Cognitive load is a key mediator of cognitive processing that may impact clinical reasoning performance. The purpose of this study was to gather biologic validity evidence for correlates of different types of self-reported cognitive load, and to explore the association of self-reported cognitive load and physiologic measures with clinical reasoning performance. We hypothesized that increased cognitive load would manifest evidence of elevated sympathetic tone and would be associated with lower clinical reasoning performance scores. Fifteen medical students wore Holter monitors and watched three videos depicting medical encounters before completing a post-encounter form and standard measures of cognitive load. Correlation analysis was used to investigate the relationship between cardiac measures (mean heart rate, heart rate variability and QT interval variability) and self-reported measures of cognitive load, and their association with clinical reasoning performance scores. Despite the low number of participants, strong positive correlations were found between measures of intrinsic cognitive load and heart rate variability. Performance was negatively correlated with mean heart rate, as well as single-item cognitive load measures. Our data signify a possible role for using physiologic monitoring for identifying individuals experiencing high cognitive load and those at risk for performing poorly during clinical reasoning tasks.

Highlights

Www.nature.com/scientificreports to one’s mental effort to complete a task, and it is primarily driven by element interactivity; that is, the number of cognitive elements that are simultaneously processed in working memory
Heart rate variability is commonly used as an index of autonomic nervous system activity, it remains unclear whether it is sufficiently sensitive to variations in cognitive load in education scenarios
Research conducted in other domains suggests that biological changes may precede cognitive awareness when individuals are struggling with their thought processes; for example, among professional gamblers, high sympathetic tone, as measured by skin galvanic response, was observed before these professionals could vocalize a problem with a fixed card deck[35]

Summary

Introduction

Www.nature.com/scientificreports to one’s mental effort to complete a task, and it is primarily driven by element interactivity; that is, the number of cognitive elements that are simultaneously processed in working memory. It is reasonable to assume that when excessive cognitive load occurs, the clinician does not have cognitive resources left to reflect on the balance between cognitive load and capacity Especially in those situations, self-reports are logically of limited practical value. In an exploratory study of computer-based training strategies, Paas et al.[31] found no correlation between cognitive load and one specific aspect of heart rate variability; they only looked at the spectral power in the low frequency band (i.e., spectral power of the frequency band of 0.07–0.14 Hz), did not parse out different components of cognitive load, and did not include an orthogonal measure of the impact of cognitive load on the autonomic nervous system. We sought to explore if this phenomenon is present in the context of clinical reasoning as improving physician’s awareness of when help is needed could dramatically improve care and reduce error

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