Translational Research in Anatomy 31 (2023) 100247

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Translational Research in Anatomy

journal homepage: www.elsevier.com/locate/tria

Evaluation of cognitive load for a mixed reality anatomy application

Connor Michalski a, Melissa Cowan b, Jonathan Bohinsky b, Ryan Dickerson b, Jeffrey
H. Plochocki a, *
a
Department of Medical Education, USA
b
Department of Educational Technology, College of Medicine, University of Central Florida, Orlando, FL, USA

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Asynchronous learning is becoming more prevalent in medical education. Mixed reality applications
Mixed reality are interactive tools that may be used to study 3D anatomical relationships outside of the classroom. However,
Cognitive load learners may face challenges when using new technologies that are unfamiliar to them and require significant
Anatomy education
mental effort that distracts from learning. This study investigates learner cognitive load for a mixed reality (MR)
Medical education
application developed as an asynchronous resource to study heart anatomy subsequent to classroom learning.
Methods: The Cognitive Load Component questionnaire was administered to first-year medical students (n = 18)
to measure intrinsic, extrinsic, and germane cognitive load. Responses were collected after classroom and lab­
oratory instruction on heart anatomy and repeated after learners completed an MR-based learning activity
asynchronously on the same topic.
Results: Cognitive load differed between classroom and MR-based learning. Classroom learning was reported to
be more difficult and complex and required greater intrinsic cognitive load. Learners found the MR activity to be
more relevant to their studies and expressed reduced extrinsic load in comparison to classroom learning. Learners
indicated the MR application had high germane load, allowing for a greater focus on their learning, but the
volume of learning was greater in the classroom and laboratory.
Conclusions: Asynchronous MR instructional activities are a viable tool to supplement synchronous learning of 3D
structure-function relationships of the heart without overburdening cognitive resources of the learner.

1. Introduction
Medical school anatomy is traditionally taught using instructor-led
lectures and laboratories conducted in real time, also called synchro­
nous learning. Recently, many anatomists are being asked to replace a
portion of synchronous learning with activities that allow students to
learn at their own pace without real time instruction, also called asyn­
chronous learning [1,2]. Common examples of asynchronous instruction
include recorded lectures and textbook readings. However, these
teaching methods may compromise student learning if they do not
provide opportunities to study 3D anatomical relationships, which are
essential for understanding the structure and function of the human
body [3,4].
One way to address this challenge is to supplement synchronous
learning with mixed reality (MR) instructional applications. MR is a 3D
visualization platform that enables real-time interaction with computer-
generated objects that are projected onto the real world when viewed
using head-mounted displays [5]. Unlike full virtual reality that
completely simulates the real world as a virtual environment, users of
MR see the real physical world around them, but with 3D manipulable
objects inserted into it, creating an immersive and interactive experi­
ence [6,7]. Medical students who use MR technology to supplement
their traditional classroom and laboratory experiences have improved
learning outcomes, express greater confidence and understanding of
anatomical concepts, and are more motivated to learn [8–12]. Further,
they find that MR environments add value to the learning experience
and improve their understanding of complex 3D structures [13,14].
However, the complexity of new technologies like MR can pose a
challenge for learners due to increased mental effort, or cognitive load.
Cognitive load theory explains how different types of activities affect the
cognitive resources available for learning [15]. The theory distinguishes
between three types of cognitive load: intrinsic, extrinsic, and germane.
Intrinsic cognitive load is related to the difficulty of the learning task
itself, extrinsic cognitive load is caused by irrelevant distractions that do

* Corresponding author. University of Central Florida, College of Medicine, 6850 Lake Nona Blvd, Orlando, FL, 85308, USA.
E-mail address: jeffrey.plochocki@ucf.edu (J.H. Plochocki).

https://doi.org/10.1016/j.tria.2023.100247
Received 31 March 2023; Received in revised form 18 April 2023; Accepted 25 April 2023
Available online 6 May 2023
2214-854X/© 2023 The Authors. Published by Elsevier GmbH. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
C. Michalski et al. Translational Research in Anatomy 31 (2023) 100247

not support the learning goal, and germane cognitive load is mental
effort expended to integrate new information into existing knowledge.
Effective learning activities should manage intrinsic cognitive load,
minimize distractions from learning, and maximize knowledge inte­
gration [16,17].
We conducted a study to assess the mental effort exerted by first-year
medical students learning anatomy through synchronous and asyn­
chronous instruction. Measures of cognitive load experienced during
synchronous learning were collected and used as a baseline for com­
parison with the load experienced during MR-based asynchronous
learning. We tested the hypothesis that the MR activity does not
significantly distract from learning and overburden mental resources,
using synchronous learning experiences as a reference. The primary aim
was to determine if the efficacy of the MR application as an asynchro­
nous learning resource was reduced by excessive cognitive load.
2. Methods
2.1. Participants
First-year medical students enrolled at a medical school located in
the United States were recruited for the study. Participation in the study
was voluntary and anonymous. Out of 120 students in the class, 18
volunteered to participate. We sought to increase the sample size by
repeating the study in the following academic year, but changes in
faculty combined with a curricular shift in the ratio of synchronous to
asynchronous learning precluded us from conducting an equivalent
study. The limited sample size did not allow for comparisons of a control
and experiment group so the study was constructed using a repeated
measures design to assess cognitive load for the MR learning task in
conjunction with synchronous classroom and laboratory learning. A test
of power on our dataset showed that the sample size was adequate to
detect significant changes in mental effort between learning experiences
so we proceeded with a repeated measures design.
asynchronous activity that took no more than 1 h to complete. Thus,
there was a 4:1 ratio of synchronous to asynchronous instruction on
heart anatomy in the curriculum. Both the synchronous and asynchro­
nous activities were developed using the same learning objectives. The
MR activity was designed to reinforce concepts taught in the classroom
and allow for 3D virtual manipulation of the heart. The MR activity
included a 3D anatomical model that was movable, rotatable, and
scalable. The model was purchased from Cgtrader (Orlando, FL, USA)
and animated by our Educational Technology Department using Blender
(http://www.blender.org). Labels and definitions were added to the
models that could be displayed and hidden. The model could also be
animated to show chamber contraction, blood flow, and electrical con­
duction through the heart in sinus rhythm, bradycardia, and tachy­
cardia. The MR application also contained 12 flashcards that could be
accessed to test basic knowledge such as definitions and the functions of
structures. The MR activity was part of the cARdiac App designed by the
Educational Technology Department at the University of Central Florida
College of Medicine using the first-generation Microsoft HoloLens plat­
form (Fig. 1). The study received exemption status from the Institutional
Review Board.
2.3. Statistical analysis
Differences in cognitive load between synchronous classroom/labo­
ratory learning and asynchronous MR-based learning activities were
tested using a two-factor analysis of variance (ANOVA) with replication.
Differences in responses between items were assessed using independent
t tests. A Kolmogorov-Smirnov test confirmed the data were normally
distributed. Pearson’s correlations were used to evaluate the relation­
ships between survey items. Internal consistency of the responses was
measured using Cronbach’s alpha, which showed the CTC instrument
had good scale reliability (α = 0.72). Significance was set at P < 0.05.
3. Results

Means and standard errors for the CTC item responses are displayed
2.2. Study design
in Fig. 2. The ANOVA revealed a significant main effect for cognitive
load by learning activity type (F = 25.6, P < 0.01). Synchronous ac­
The cognitive load component (CTC) questionnaire used in this study
tivities were reported to require 22.6% greater mental effort in com­
was developed and validated by Naismith et al. [18]. It consisted of 6
parison to the MR activity. The ANOVA also revealed a significant
items, with two questions relating to each of the three categories of
interaction, indicating cognitive load type differed by learning activity
cognitive load: intrinsic, extrinsic, and germane (Table 1). Items were
(F = 7.69, P < 0.01). T tests showed that intrinsic load related to task
scored on a 5-point Likert scale (e.g., 1 = not at all, 2 = slightly, 3 =
complexity and difficulty were both significantly higher for the syn­
moderately, 4 = quite, 5 = extremely). Participants received synchro­
chronous activities than MR activity, as was extrinsic load related to task
nous instruction on the topic of heart anatomy and electrophysiology via
relevance (P < 0.05). Difficulty was reported to be 65.1% greater and
synchronous classroom and laboratory activities as part of an anatomy
complexity 46.9% greater with synchronous learning than MR learning,
and physiology course. Participants then completed the CTC question­
while task relevance was 11.9% lower. There was no difference in
naire related to their synchronous learning experiences. Those same
extrinsic load related to task clarity. Germaine load related to task focus
participants then completed the MR learning activity asynchronously
was 16.5% greater for the MR activity and volume learned was 25.8%
within 2 weeks of the synchronous activities and repeated the CTC
greater for the synchronous activities (P < 0.05).
questionnaire related to their asynchronous MR learning experiences.
Several of the questionnaire items were significantly correlated
The synchronous classroom activities included 2 h of didactic sessions
(Table 2). There were strong positive correlations between how learners
and 2 h of human dissection-based laboratory learning specific to heart
rated the task difficulty with task complexity (r = 0.52, P < 0.05), and
anatomy and electrophysiology. The MR activity was an independent,
volume learned (r = 0.53, P < 0.05). There was no correlation between
other item responses. The only notable negative correlations were be­
Table 1
tween focus and difficulty (r = − 0.027, P = 0.28) and task complexity (r
Cognitive load component (CLC) questionnaire.
= − 0.21, P = 0.40), but these were not significant.
Number Component Item

1 Intrinsic load
2 Intrinsic load
3 Extrinsic load
4 Extrinsic load
5 Germane
load
6 Germane
load
How difficult did you find the learning activity?
How complex did you find the learning activity?
How clear did you find the learning activity?
How relevant was the learning activity to your current
studies?
How focused were you while completing the activity?
How much did you learn from the activity?
4. Discussion
Medical school curricula are increasingly adopting asynchronous
learning to provide more flexibility and convenience for students [2].
New educational technologies such as MR offer an innovative way to
teach anatomy beyond traditional 2D resources such as textbooks,
videos, websites, and software applications displayed on computer
monitors [19,20]. MR applications are already in use at some medical

2
C. Michalski et al. Translational Research in Anatomy 31 (2023) 100247

Fig. 1. MR learning activity sample screenshot.

Fig. 2. Comparison of item responses for the CTC questionnaire. Data is shown as mean ± SE. Asterisk denotes significant difference determined with a t-test
between responses for synchronous classroom/laboratory and MR activities.

We found that the MR activities were less cognitively demanding in

Table 2
terms of task difficulty and complexity in comparison to the preceding
Correlation between questionnaire items.
synchronous classroom and laboratory learning. This may be because
Q1 Q2 Q3 Q4 Q5 Q6 one component of intrinsic cognitive load is prior knowledge level and
Q 1 1.00 expertise [21]. Previous studies have shown that intrinsic cognitive load
Q 2 0.52* 1.00 during asynchronous learning is lower for health professional students
Q 3 0.02 0.02 1.00 with prior synchronous learning experiences [22,23]. However, no such
Q 4 0.10 0.12 0.29 1.00
Q 5 − 0.27 − 0.21 0.17 − 0.09 1.00
reduction is observed when learners used a 2D medical imaging activity
Q 6 0.53* 0.36 0.37 0.29 − 0.09 1.00 to learn anatomy [24] or a computer-based simulated dissection after
lecture-based instruction on the same topic [25]. Combined, these
*Significant correlation between questionnaire items (P < 0.05).
findings suggest that 3D virtual simulations of anatomy, as with the MR
activity, can lower intrinsic cognitive load more than 2D virtual and
education institutions and have been found to enhance the student nonvirtual activities, in line with the cognitive theory for multimedia
learning experience [11]. However, the impact of MR technology as an learning [26].
asynchronous supplement to synchronous classroom and laboratory We also found a significant positive correlation between task diffi­
instruction on cognitive load is still unclear. culty and the volume of information learned during the task.

3
C. Michalski et al.
Specifically, synchronous classroom activities had a higher difficulty, a
component of intrinsic load, and also led to a larger volume of infor­
mation learned, a component of germane load, in comparison to the
asynchronous MR activity. These results indicate that most of the
learning occurs in the initial classroom experience, which learners
perceive as more challenging and complex, while the MR learning task
served primarily as a transfer of learning from the classroom environ­
ment. This sequence of high-complexity synchronous tasks followed by
asynchronous application tasks has been shown to facilitate problem
solving and additional transfers of knowledge, in accordance with
cognitive load theory and instructional design principles [27,28].
Learners rated the clarity of the MR activity similarly to synchronous
instruction despite the use of new technology, but also were able to have
greater focus while completing the MR activity. Clarity, a factor that
reduces extrinsic load, and focus, an indicator of germane load, are
optimized when the sources of information within a learning activity are
integrated, according to the split attention principle [29]. In our MR
activity, learners visualized the 3D anatomy with written explanations
of structure-function relationships shown on the display. Moreover, 3D
MR experiences that are immersive and interactive can enhance clarity
and focus, in other words, reduce extrinsic load while increasing
germane load [30]. Specifically, simple interactive controls like
movable elements, sliders, and buttons decrease extrinsic load and allow
for greater germane load, while complex controls can distract and drain
cognitive resources [31,32]. Our MR application used a simple slider
that modified the rate of heart contraction while presenting corre­
sponding changes in blood flow and electrical activity in real time ani­
mations. Of note, immersive MR activities that project virtual objects
into the real world may diminish extrinsic load, unlike fully virtual ex­
periences and 360◦ videos, which may increase load by if users find them
disorienting [33,34].
5. Limitations of the study
The study has several limitations. The questionnaire had a low
response rate of 15% from the first-year medical class. Yearly fluctua­
tions in faculty composition and anatomy curriculum preclude us from
expanding the sample size by repeating the study under equivalent
conditions with future classes. However, the sample size provided
enough statistical power to detect significant differences between vari­
ables. Another limitation is that the study may have limited generaliz­
ability. Cognitive load may be dependent on the specific design of the
MR application. Nevertheless, the study shows that it is feasible to create
an MR activity that supports anatomy instruction without adverse ef­
fects on cognitive load.
6. Conclusions
The study findings suggest that MR is a useful tool for enhancing
anatomy learning outside the classroom and laboratory without over­
loading the learners’ cognitive resources. While dissection in the gross
anatomy laboratory is essential for learning 3D anatomical relationships
and for developing professional, interpersonal, and humanistic skills
that virtual experiences may not offer [35,36], anatomy educators who
need to adopt asynchronous learning methods may consider using MR
technology to facilitate the independent study of 3D anatomical re­
lationships without distracting inexperienced learners from learning
effectively. Therefore, we suggest that MR can enhance anatomical in­
struction as part of asynchronous learning subsequent to synchronous
learning without imposing excessive cognitive load on learners.
Availability of data and material
The datasets used in the analysis are available from the corre­
sponding author upon reasonable request.
4
Translational Research in Anatomy 31 (2023) 100247
Ethical approval and consent to participate
Exempt status granted by the Authors’ Institutional Review board.
Funding statement
Not applicable.
CRediT authorship contribution statement
Connor Michalski: Conceptualization, Data curation, Formal anal­
ysis, Writing – original draft, Writing – review & editing. Melissa
Cowan: Conceptualization, Data curation, Resources, Software, Writing
– review & editing. Jonathan Bohinsky: Resources, Software, Writing –
review & editing. Ryan Dickerson: Resources, Software, Writing – re­
view & editing. Jeffrey H. Plochocki: Conceptualization, Formal
analysis, Writing – original draft, Writing – review & editing.
Declaration of competing interest
The authors report no competing interests. The authors are solely
responsible for the content and writing of this article. The datasets used
in the current study are available from the corresponding author by
request.
Acknowledgements
We give thanks to the Department of Medical Education at the Uni­
versity of Central Florida for providing funding for the project. We also
thank Dale Voorhees, Director of the Department of Educational Tech­
nology at University of Central Florida for his assistance during the
development of the MR application.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.
org/10.1016/j.tria.2023.100247.
References
[1] J.M. McBride, R.L. Drake, National survey on anatomical sciences in medical
education, Anat. Sci. Educ. 11 (1) (2018 Jan) 7–14.
[2] U. Gaur, M.A. Majumder, B. Sa, S. Sarkar, A. Williams, K. Singh, Challenges and
opportunities of preclinical medical education: COVID-19 crisis and beyond, SN
Compr. Clin. Med. 2 (11) (2020 Nov) 1992–1997.
[3] M.F. Chang, M.L. Liao, J.H. Lue, C.C. Yeh, The impact of asynchronous online
anatomy teaching and smaller learning groups in the anatomy laboratory on
medical students’ performance during the Covid-19 pandemic, Anat. Sci. Educ. 15
(3) (2022 May) 476–492.
[4] A. Ortadeveci, M.N. Ermez, S. Oz, H. Ozden, A survey study on distance anatomy
education: challenges unique to anatomy, Surg. Radiol. Anat. 44 (1) (2022 Jan)
41–47.
[5] P. Milgram, H. Takemura, A. Utsumi, F. Kishino, Augmented reality: a class of
displays on the reality-virtuality continuum, Telemanipulator Telepresence
Technol. 2351 (1995) 282–293 (International Society for Optics and Photonics).
[6] C. Moro, Z. Štromberga, A. Raikos, A. Stirling, The effectiveness of virtual and
augmented reality in health sciences and medical anatomy, Anat. Sci. Educ. 10 (6)
(2017 Nov) 549–559.
[7] B.M. Kuehn, Virtual and augmented reality put a twist on medical education,
JAMA 319 (8) (2018 Feb 27) 756–758.
[8] R. Boscolo-Berto, C. Tortorella, A. Porzionato, C. Stecco, E.E. Picardi, V. Macchi,
R. De Caro, The additional role of virtual to traditional dissection in teaching
anatomy: a randomised controlled trial, Surg. Radiol. Anat. 43 (2021 Apr)
469–479.
[9] S. Küçük, S. Kapakin, Y. Göktaş, Learning anatomy via mobile augmented reality:
effects on achievement and cognitive load, Anat. Sci. Educ. 9 (5) (2016 Oct)
411–421.
[10] C. Michalski, M. Cowan, J. Bohinsky, R. Dickerson, J. Plochocki, Mixed reality
technology influences motivation for learning in medical students, MedEdPublish 9
(155) (2020 Jul 31) 155.
[11] A.C. Stirling, C. Moro, The use of virtual, augmented and mixed reality in anatomy
education, in: Teaching Anatomy: a Practical Guide, Springer International
Publishing, Cham, 2020 Nov 21, pp. 359–366.
C. Michalski et al.
[12] A. Singal, A. Bansal, P. Chaudhary, H. Singh, A. Patra, Anatomy education of
medical and dental students during COVID-19 pandemic: a reality check, Surg.
Radiol. Anat. 43 (2021 Apr) 515–521.
[13] S. Barteit, L. Lanfermann, T. Bärnighausen, F. Neuhann, C. Beiersmann,
Augmented, mixed, and virtual reality-based head-mounted devices for medical
education: systematic review, JMIR Serious Games 9 (3) (2021 Jul 8), e29080.
[14] R. Kolecki, A. Pregowska, J. Dąbrowa, J. Skuciński, T. Pulanecki, P. Walecki, P.
M. van Dam, D. Dudek, P. Richter, K. Proniewska, Assessment of the utility of
mixed reality in medical education, Transl. Res. Anat. (2022 Jun 28), 100214.
[15] J. Sweller, J.J.G. van Merriënboer, F.G.W.C. Paas, Cognitive architecture and
instructional design, Educ. Psychol. Rev. 10 (1998) 251–296.
[16] J. Sweller, Element interactivity and intrinsic, extraneous, and germane cognitive
load, Educ. Psychol. Rev. 22 (2010 Jun) 123–138.
[17] M. Mancinetti, S. Guttormsen, C. Berendonk, Cognitive load in internal medicine:
what every clinical teacher should know about cognitive load theory, Eur. J.
Intern. Med. 60 (2019 Feb 1) 4–8.
[18] L.M. Naismith, J.J. Cheung, C. Ringsted, R.B. Cavalcanti, Limitations of subjective
cognitive load measures in simulation-based procedural training, Med. Educ. 49
(8) (2015 Aug) 805–814.
[19] C. Kamphuis, E. Barsom, M. Schijven, N. Christoph, Augmented reality in medical
education? Perspect. Med. Educ. 3 (2014) 300–311.
[20] J. Gerup, C.B. Soerensen, P. Dieckmann, Augmented reality and mixed reality for
healthcare education beyond surgery: an integrative review, Int. J. Med. Educ. 11
(2020) 1.
[21] M.P. Cook, Visual representations in science education: the influence of prior
knowledge and cognitive load theory on instructional design principles, Sci. Educ.
90 (6) (2006 Nov) 1073–1091.
[22] J. Kiesewetter, M. Sailer, V.M. Jung, R. Schönberger, E. Bauer, J.M. Zottmann,
I. Hege, H. Zimmermann, F. Fischer, M.R. Fischer, Learning clinical reasoning: how
virtual patient case format and prior knowledge interact, BMC Med. Educ. 20
(2020 Dec), 1-0.
[23] S.N. Hadie, V.P. Tan, N. Omar, N.A. Nik Mohd Alwi, H.L. Lim, K.I. Ku Marsilla,
COVID-19 disruptions in health professional education: use of cognitive load
theory on students’ comprehension, cognitive load, engagement, and motivation,
Front. Med. 8 (2021 Oct 4), 739238.
Translational Research in Anatomy 31 (2023) 100247
[24] M.K. Khalil, F. Paas, T.E. Johnson, Y.K. Su, A.F. Payer, Effects of instructional
strategies using cross sections on the recognition of anatomical structures in
correlated CT and MR images, Anat. Sci. Educ. 1 (2) (2008 Mar) 75–83.
[25] S.E. Van Nuland, K.A. Rogers, E-learning, dual-task, and cognitive load: the
anatomy of a failed experiment, Anat. Sci. Educ. 9 (2) (2016 Mar) 186–196.
[26] R.E. Mayer, Multimedia Learning, second ed., Cambridge University Press,
Cambridge, UK, 2009.
[27] J.J. Van Merrienboer, L. Kester, F. Paas, Teaching complex rather than simple
tasks: balancing intrinsic and germane load to enhance transfer of learning, Appl.
Cognit. Psychol.: Off. J. Soc. Appl. Res. Memory Cognit. 20 (3) (2006 Apr)
343–352.
[28] K.E. DeLeeuw, R.E. Mayer, A comparison of three measures of cognitive load:
evidence for separable measures of intrinsic, extraneous, and germane load,
J. Educ. Psychol. 100 (1) (2008 Feb) 223.
[29] J.J. Van Merriënboer, J. Sweller, Cognitive load theory in health professional
education: design principles and strategies, Med. Educ. 44 (1) (2010 Jan) 85–93.
[30] A. Skulmowski, K.M. Xu, Understanding cognitive load in digital and online
learning: a new perspective on extraneous cognitive load, Educ. Psychol. Rev. 34
(2022) pages171–196.
[31] H.S. Song, M. Pusic, M.W. Nick, U. Sarpel, J.L. Plass, A.L. Kalet, The cognitive
impact of interactive design features for learning complex materials in medical
education, Comput. Educ. 71 (2014 Feb 1) 198–205.
[32] J.P. Chickness, K.M. Trautman-Buckley, K. Evey, L. Labranche, Novel development
of a 3D digital mediastinum model for anatomy education, Transl. Res. Anat. 26
(2022 Mar 1), 100158.
[33] J.G. Frederiksen, S.M. Sørensen, L. Konge, M.B. Svendsen, M. Nobel-Jørgensen,
F. Bjerrum, S.A. Andersen, Cognitive load and performance in immersive virtual
reality versus conventional virtual reality simulation training of laparoscopic
surgery: a randomized trial, Surg. Endosc. 34 (2020 Mar) 1244–1252.
[34] J. Buchner, K. Buntins, M. Kerres, The impact of augmented reality on cognitive
load and performance: a systematic review, J. Comput. Assist. Learn. 38 (1) (2022
Feb) 285–303.
[35] L.J. Rizzolo, Human dissection: an approach to interweaving the traditional and
humanistic goals of medical education, Anat. Rec.: Off. Publ. Am. Assoc. Anat. 269
(6) (2002 Dec 15) 242–248.
[36] S. Hildebrandt, The role of history and ethics of anatomy in medical education,
Anat. Sci. Educ. 12 (4) (2019 Jul) 425–431.