Enhanced Learning and Retention of Medical Knowledge Using the Mobile Flash card Application Anki

Gamification and Serious Games in Orthopedic Education: A Systematic Review

Gamification and serious games have successfully been used in surgical specialties to improve technical skills related to systematic procedures. However, the use of gamified education material has remained limited in orthopedic residency training. The objective of this systematic review is to summarize the current use, development, and future directions of gamification for developing orthopedic skills. A comprehensive literature search was performed on Ovid MEDLINE, Web of Science, and Scopus between January 1, 2012, and the search date of July 1, 2023. After screening 1,915 papers, a total of four publications that utilized elements of gamification in acquiring and/or improving orthopedic skills were included. Three studies showed a positive correlation between video gaming experience and orthopedic skill performance, acquisition, or both. One study showed a positive response from residents when training sessions were hosted in a competitive, but friendly environment with direct observation from their attendings. Gamified learning has the potential to improve orthopedic education, but its current use is largely unexplored. A competitive or rewarding environment promotes engagement and active learning. To enable the highest and most efficient level of training, future development should be geared toward virtual reality simulators that incorporate haptic feedback to better simulate other orthopedic-based tasks.

Effectiveness of spaced repetition for clinical problem solving amongst undergraduate medical students studying paediatrics in Pakistan

BACKGROUND

Studies using spaced repetition for teaching and learning in undergraduate clinical rotations such as paediatrics are limited, even more so in the South Asian region. Therefore, this study aimed to identify the effectiveness of utilizing spaced repetition compared to traditional learning methods among undergraduate medical students during their paediatric rotation at a medical university in Pakistan.

METHODS

Bahria University Medical and Dental College (BUMDC) conducted quasii-experimental research in Karachi. Four topics were identified from the Year 5 Pediatrics curriculum to be used in the study, using which the study content was developed along with 50 multiple choice questions (MCQs) for assessment. All BUMDC Year 5 medical students rotating in Pediatrics were included and randomly allocated to the control or intervention group. In the control group, they provided the students with traditional study methods consisting of books and lectures to learn topics. In the intervention group, we created an Anki flashcard deck of the same topics to enable learning via spaced repetition. The researchers conducted a pretest and post test assessment of the 50 MCQs in both groups at the beginning and after the four-week study interval. The data were analysed using SPSS 19.

RESULTS

A total of 115 BUMDC medical students agreed to participate in the study; 70 (59.1%) were in the intervention group, and 45 (41.7%) were in the control group. The pretest mean score of the control group was 27.96 ± 3.70, and the posttest mean score was 27.22 ± 5.02, with no statistically significant difference at the 95% confidence level. The mean score of the pretest for the intervention group was 27.93 ± 4.53, and that of the posttest was 30.8 ± 4.56, with a statistically significant difference at the 95% confidence level. The intervention showed a significant effect size of 0.8.

CONCLUSION

The use of spaced repetitions resulted in significantly greater scores for medical students studying paediatrics than for those using more traditional methods of learning, compromising medical books and lectures. Considering that medical students need to retain a vast amount of information, using spaced repetition through flashcards can be a more effective learning tool that is more cost-efficient and time-efficient than traditional learning methods.

Effectiveness of spaced repetition learning using a mobile flashcard application among dental students: A randomized controlled trial

BACKGROUND

Dental education in India predominantly relies on traditional lecture-based learning (LBL), which may hinder student engagement and learning outcomes. To address these limitations, innovative learning methodologies, such as spaced repetition learning (SRL), are imperative. SRL prioritizes active recall and can enhance long-term knowledge retention. This study aims to assess the effectiveness of SRL delivered through a mobile flashcard application, in enhancing knowledge retention among dental undergraduates.

METHODS

This single-blind randomized controlled trial (CTRI/2023/10/059347), conducted in Belagavi, India, involved 90 dental students who were equally distributed into control (LBL) and test (lecture followed by SRL demonstration) groups after randomization. Rigorous expert review ensured the quality of PowerPoint presentation and mobile flashcard contents. Knowledge assessments were conducted at baseline, first, and third months using a validated and reliable questionnaire. A perception survey on learning techniques was administered after the first month. Analysis methods included descriptive analysis, Pearson's chi-square test, independent t-test, and repeated measures ANOVA with Bonferroni's post hoc test.

RESULTS

The pre- and post-intervention knowledge showed no significant differences, but the SRL group exhibited significantly higher retention at both first month (p ≤ 0.001) and third months (p ≤ 0.001) than the LBL group. Repeated measures ANOVA revealed significant pairwise differences in mean knowledge scores in SRL group. Students had significantly favorable perception toward SRL than LBL group.

CONCLUSION

SRL delivered through mobile flashcards significantly enhances knowledge retention compared to LBL among dental students. Positive student perceptions support SRL's integration into dental curricula, with implications for improving knowledge retention among them.

Twelve tips for supporting medical learners through high-stakes assessment challenges

Learners across the medical education continuum will encounter numerous high-stakes exams and assessments. Effectively preparing for and performing well on these types of assessments can be challenging for learners for a wide variety of reasons. It is imperative that medical educators provide appropriate support for learners who experience challenges with high-stakes exams, particularly given the complexity of factors like life circumstances of individual learners and the significance of these assessments for career advancement/progression. Grouped into areas including educator mindset, information-gathering, and developing and executing a study plan, the following 12 tips will help medical educators be better prepared to meaningfully support learners in need of assessment remediation and guidance.

Digital flashcards and medical physiology performance: a dose-dependent effect

Use of digital flashcards promotes active recall, spaced repetition, and self-assessment academic principles. This work explores the association and dose-dependent effect of this study method and locomotor (LP) and cardiovascular physiology (CP) grades. A single-faculty cohort study of medical LP and CP students was conducted, and 155 and 676 flashcards, respectively, were created through Moodle. An exploratory analysis examined three exam results (2019), and a confirmatory study used a fourth exam (2021) in another CP cohort. Of 685 students enrolled, 558 participated in the exploratory analysis: 319 (69%) for LP and 311 (84%) for CP, of which 203 LP and 267 CP students were flashcard users. Median grades were higher among flashcard users, and the number of cards reviewed was positively correlated with grades (r = 0.275 to 0.388 for LP and r = 0.239 to 0.432 for CP, P < 0.001). Multiple linear regression models confirmed a positive dose-dependent association between results and the number of flashcards studied: for every 100 LP cards reviewed, exam grades increased 0.44-0.75 on a 0-20 scale range (P < 0.001), and for every 1,000 CP flashcards, results raised 0.81-1.08 values (P < 0.05). These findings were confirmed in the 2021 CP cohort of 269 participants, of whom 67% were flashcard users. Digital flashcard revision has a consistent positive dose-dependent association on LP and CP grades.NEW & NOTEWORTHY Implementing flashcard-based strategies is a feasible way to promote active recall, spaced repetition, and self-assessment, and students are highly adherent to these initiatives. There is a positive dose-dependent association between the number of flashcards reviewed and physiology grades. These results are consistent across different physiology subjects, under different cohorts, over short and medium terms.

Are Medical School Curricula Adapting With Their Students? A Survey on How Medical Students Study and How it Relates to USMLE Step 1 Scores

OBJECTIVES

Over the years, medical schools have evolved their curricula in response to the medical field, faculty, and students. The current study aims to examine how medical students study, what resources they most commonly use, and how it relates to United States Medical Licensing Examination (USMLE) Step 1 scores.

METHODS

A cross-sectional survey study of United States medical students was distributed via social media, GroupMe school chats, and school listservs from September 8, 2020, to December 12, 2020. The survey gathered data including, demographic and school information, resources students, time spent using each resource, and USMLE Step 1 scores.

RESULTS

The survey was completed by 560 students from 102 different United States medical schools. Study guides as online resources (83.2%) were mostly used, lecture (82.5%), Anki (spaced repetition flashcards, 68.3%), and school-organized sessions (workshops, labs, and small groups) (60.7%). Of the students surveyed, 90% attended schools with a recorded lecture option. Only 54% of these students watched their lectures live. When watched online, the average watching speed was 1.75 ± 0.4× with a mode of 2× speed. In examining different medical school styles, schools with a 1.5-year preclinical curriculum had higher USMLE Step 1 scores (244.5 ± 15.6 vs 236.9 ± 16.2, P-score = .024) compared to schools that did not (1- or 2-year preclinical curriculum).

CONCLUSION

Medical students seem to be using third-party resources in addition to their medical school curriculums. Because students are already broadly using these, medical schools could allow their curriculums to reference, require, or complement third-party online resources. Additionally, because of their increased cost, medical schools could consider ways to alleviate the cost on medical students as a means of equitable support. Lastly, Step 1 scores significantly correlated with schools with a 1.5-year preclinical curriculum, although the exact reasoning for this remains uncertain.

Medical Students' Perceptions and Use of Formal and Informal Curriculum Resources

Introduction  Resource overload describes the feeling medical students experience in choosing formal (faculty-prescribed) and informal study resources (not faculty-prescribed). This study aims to characterize students' use and perceptions of formal and informal study resources to inform their use in medical education. Methods  This is a mixed-methods study utilizing a convenience sample of first-year medical students enrolled at the University of Central Florida College of Medicine during the academic year 2020-2021. A 40-question, five-point Likert scale, survey based on Keller's Attention, Relevance, Confidence, and Satisfaction (ARCS) Model of Motivational Design was distributed to medical students during the end of their first year of medical school. Multivariate analysis of variance determined differences between formal and informal resources for each construct. Interviews were also conducted by first-year medical students and analyzed using thematic analysis. Learning logs were completed during the beginning of the medical students' second year to assess daily study habits. Results  Fifty-one students completed the survey with a response rate of 42.5%. Informal resources scored higher across all constructs: attention (formal: 3.4±1.2, informal: 4.0±1.1; p<.0125), relevance (formal: 3.8±1.1, informal: 4.3±1.0; p<.0125), confidence (formal: 3.2±1.2, informal: 4.1±1.1; p<.0125), satisfaction (formal: 2.8±1.2, informal: 3.6±1.2; p<.0125) (Likert scale 1-5, Mean±SD). Students found formal resources lacked depth and organization while informal resources allowed for concise understanding with retention cues. Learning log data reported similar use of formal and informal resources during week 1 (88.2% formal vs. 87.8% informal) and week 2 (84.6% formal vs. 82.6% informal). Conclusions  Students preferred informal resources based on ARCS constructs. However, the actual usage of formal and informal resources was similar. Formal resources align more with curricular assessments, but informal resources aid student retention and understanding. Therefore, students find both formal and informal resources necessary for success. Faculty should consider integrating informal curriculum resources to optimize student learning.

Using instructor-developed study resources to increase evidence-based learning strategies among medical students: A mixed-methods study

PURPOSE

Applying effective learning strategies to address knowledge gaps is a critical skill for lifelong learning, yet prior studies demonstrate that medical students use ineffective study habits.

METHODS

To address this issue, the authors created and integrated study resources aligned with evidence-based learning strategies into a medical school course. Pre-/post-course surveys measured changes in students' knowledge and use of evidence-based learning strategies. Eleven in-depth interviews subsequently explored the impact of the learning resources on students' study habits.

RESULTS

Of 139 students, 43 and 66 completed the pre- and post-course surveys, respectively. Students' knowledge of evidence-based learning strategies was unchanged; however, median time spent using flashcards (15% to 50%, p < .001) and questions (10% to 20%, p = .0067) increased while time spent creating lecture notes (20% to 0%, p = .003) and re-reading notes (10% to 0%, p = .009) decreased. In interviews, students described four ways their habits changed: increased use of active learning techniques, decreased time spent creating learning resources, reviewing content multiple times throughout the course, and increased use of study techniques synthesizing course content.

CONCLUSION

Incorporating evidence-based study resources into the course increased students' use of effective learning techniques, suggesting this may be more effective than simply teaching about evidence-based learning.

A Curriculum Ignored? The Usage of Unofficial Commercial and Peer Learning Resources in Undergraduate Medical Education at a Canadian Medical School

Medical students often seek educational resources outside of the formal curriculum to support their education. Commercial and student-developed educational resources are readily available, and may supplement or even replace aspects of the formal curriculum. Since this has the potential to impact what students learn and ultimately impact patient care, gaining a better understanding of the prevalence and patterns of use of these resources is of great interest. The purpose of this study, therefore, is to explore the use of non-traditional resources in undergraduate medical education. We surveyed University of Ottawa medical students to determine the usage, rationale, and perceived benefits and drawbacks of these educational resources. The response rate was 57/342 (17%). Of 57 respondents (first year = 21, second year = 34, MD/PhD = 2), 98.2% report using non-traditional resources, with Upper Year Notes, Student Developed Anki decks (a spaced repetition flashcard tool), and Student Developed Question Banks being most common. Although 75% of students reported using official lecture slides and practice tests, they reported spending more of their time (63%) using third-party resources compared to official curriculum offerings. Reported advantages of non-traditional resources listed were faster, more efficient, and easier to understand/search. Disadvantages were difficulty aligning unofficial resources with local exams, determining the level of detail required, and cost. These results suggest a need to examine curriculum design and delivery and further investigate the role of non-traditional resources developed by medical students and the role of medical students as peer educators.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40670-023-01899-5.

Implementation of Spaced Repetition by First-Year Medical Students: a Retrospective Comparison Based on Summative Exam Performance

Many medical students use spaced repetition as a study strategy to improve knowledge retention, and there has been growing interest from medical students in using flashcard software, such as Anki, to implement spaced repetition. Previous studies have provided insights into the relationship between medical students' use of spaced repetition and exam performance, but most of these studies have relied on self-reports. Novel insights about how medical students use spaced repetition can be gleaned from research that takes advantage of the ability of digital interfaces to log detailed data about how students use software. This study is unique in its use of data extracted from students' digital Anki data files, and those data are used to compare study patterns over the first year of medical school. Implementation of spaced repetition was compared between two groups of students who were retrospectively grouped based on average performance on three exams throughout the first year of medical school. Results indicate that students in the higher scoring group studied more total flashcards and implemented spaced repetition via Anki earlier in the year compared to the lower scoring group. These findings raise the possibility that implementing spaced repetition as a study strategy early in medical school may be related to improved knowledge retention and exam performance. Additional research should be performed at more sites to further examine the relationship between spaced repetition implementation and exam performance.

Live Patient Encounters: A Perspective From Second-Year Medical Students

Background Interactive patient cases have been shown to be a valuable resource in medical education. Previous studies have demonstrated that using patients as teachers can help students improve clinical reasoning and have educational benefits; however, there is limited research on student feedback on patients as teachers. The objective of this study is to evaluate second-year medical students' (MS2s) perceptions of patient encounters during the teaching of the Skin and Musculoskeletal System Course (BMS 6635). Methods A retrospective descriptive study on prospectively maintained survey data was performed. Following course completion, MS2s were surveyed on their experience from four to five live patient encounters at the University of Central Florida College of Medicine from 2016-2022. The interactive cases involved patients with dermatologic, autoimmune, and musculoskeletal diseases. All MS2s enrolled in BMS 6635 were included. Statistical analysis was performed on survey responses to students' perceptions of live patient encounters. Results Seven hundred surveys were completed following the interactive patient encounters. Ninety percent of participants answered that they enjoyed the cases, 92% agreed the cases were an appropriate learning experience for their education, and 76% agreed the cases helped with material retention. From 2016 to 2022, there was a slight decrease in enjoyment in the cases over time (97%, 88%, 93%, 94%, 86%, 81%, p<.001, respectively), and student agreement that patient cases were an appropriate learning experience in their education (98%, 92%, 94%, 95%, 93%, 84%, p=.001, respectively), but overall remained greater than 80% satisfaction. Conclusions Patient cases are perceived to be a valuable educational resource by second-year medical students and therefore should be integrated in medical curricula. Students enjoyed patient cases, believed they had an educational benefit, and perceived they aided in material retention.

Incision Precision: Engaging Students during Dissection Labs

Active learning tools, such as gamification, have facilitated teamwork and improved decision-making skills in Anatomy and Physiology classes. However, most Anatomy and Physiology labs currently contain dissection activities where students are not likely to engage in inquiry, critical thinking, or problem-solving. Usually, the instructor gives a brief lecture on the topic, and students are left to dissect without understanding how the lecture relates to what is in front of them, which is frustrating. Coupled with the frustration, some students have adverse opinions on dissecting specimens, including hesitation to dissect the specimen and religious or ethical concerns with dissection. Utilizing similar game mechanics to Taboo (Hasbro) and Milton Bradley's Operation, Incision Precision is a card game that was made to engage students in the dissection lab by allowing them to connect lecture-based information to a physical structure within an organ system. Each card contains an anatomical or physiological description of the organs commonly dissected in the undergraduate Anatomy and Physiology laboratory. For effective gameplay and full participation, the class should be divided into groups containing 3 to 4 students. The group will draw two cards where members can either correctly name the organ or identify the named organ on the dissected specimen. Playing Incision Precision resulted in participation from all group members during the dissection activity, including those with negative feelings about touching the dissected specimen. Due to positive student feedback, Incision Precision has been adapted and played with system-specific organ dissections.

A Cohort Study Assessing the Impact of Anki as a Spaced Repetition Tool on Academic Performance in Medical School

Introduction

Anki is an application that capitalizes upon the techniques of spaced repetition and is increasingly utilized by medical students for examination preparation. This study examines the impact of Anki usage in a medical school curriculum on academic performance. Secondary objectives analyzed individual Anki utilization and a qualitative assessment of Anki use.

Methods

A cohort-control study was conducted at Boonshoft School of Medicine. One hundred thirty first-year medical students were enrolled in an Anki utilization training program from July 2021 to September 2021. Training included educational Anki courses and subsequent survey data collection over Anki usage. Data variables included all course final examinations, the Comprehensive Basic Science Exam (CBSE), individual Anki user statistics, nationally standardized exams scores, and Qualtrics surveys on student perceived ease of use.

Results

Seventy-eight students reported using Anki for at least one of the exams, and 52 students did not use Anki for any exam. Anki users scored significantly higher across all four exams: Course I (6.4%; p < 0.001); Course II (6.2%; p = 0.002); Course III (7.0%; p = 0.002); and CBSE (12.9%; p = 0.003). Students who reported higher dependency on Anki for studying performed significantly better on the Course I, II, and CBSE exams.

Conclusion

Anki usage may be associated with an increase in standardized examination scores. This supports Anki as an evidence-based spaced repetition and active retrieval learning modality for medical school standardized examinations. There was little correlation between its specific statistical markers and examination performance. This is pertinent to physicians and medical students alike as the learning and preservation of biomedical knowledge is required for examinations and effective clinical care.

Flashcards: The Preferred Online Game-Based Study Tool Self-Selected by Students to Review Medical Histology Image Content

Medical students use several supplementary digital resources to support learning. Majority of these supplementary resources enhance learning by recall and repetition. A few examples of these resources are concept maps, flashcards (FCs), and self-testing tools. Traditionally, paper-based FCs are used in higher education. The concept of paper-based FCs is extended to the digital world in the form of electronic/web-based FCs. The use of electronic/digital flashcards has been reported to review course material in the medical school curriculum. Some of the medical school coursework requires students to acquire visual skills, for example, histology and pathology. Students, who do not have prior knowledge of the basic content on histology and pathology struggle to identify microscopic tissues and organs. Therefore, students look for other supplementary resources to support visual learning. Digital resources like Anki, Quizlet, and Osmosis provide study tools that support visual skills. A review of the literature revealed only a few publications pertaining to the use of digital testing tools for histology education in medical school curriculum. In the medical histology course at the Albert Einstein College of Medicine (Einstein), Bronx, NY, first-year medical students used a game-based platform (Quizlet) to review image-based histology course content in the form of four Quizlet study sets. Students chose from six Quizlet study tools (Flashcards, Learn, Speller, Test, Match, and Race/Gravity) to review the image-based course material and test their knowledge on accurate identification of histological images. The data on student usage of study tools was tracked and analyzed for 4 years (Graduating Classes of 2018 to 2021) to calculate: the total usage of the game-based study tools (Flashcards, Learn, Speller, Test, Match, and Race/Gravity) over the period of 4 years, total percent usage over 4 years of each game-based study tools (Flashcards, Learn, Speller, Test, Match, and Race/Gravity) in each of the four Quizlet study sets and to identify the preferred game-based study tool. The data showed a consistent year-on-year increase in usage of game-based study tools by 50% (M = 445 in 2018 compared to M = 849 in 2021). For the four Quizlet study sets the percent usage of each study tool Flashcards, Learn, Test, Match, Gravity, and Speller was tracked and combined across the four academic years. It was found that Flashcards were used significantly more frequently than any other tool and this was followed by Learn, Test, Match, Gravity, and Speller (p < 0.0001 using chi-square). The study concludes that flashcards are the preferred study tool used by students to acquire visual skills for identifying histological images and could be incorporated when designing online study tools.

Academic and Wellness Outcomes Associated with use of Anki Spaced Repetition Software in Medical School

OBJECTIVES

Medical students are increasingly using a spaced repetition software called Anki to study. There are limited studies evaluating the relationship between Anki and learner outcomes. In this study, we describe the history of Anki use in medical school and assess the potential relationships between use of Anki and medical student academic, extracurricular, and wellness outcomes.

METHODS

We used cross-sectional data from a 50-item online survey and retrospective academic performance data from our institution's outcomes database. Participants were medical students. The survey assessed the frequency and timing of Anki use, student perceived stress, sleep quality, burnout risk, and involvement in extracurricular activities. Academic success was measured by USMLE Step 1 and Step 2 scores.

RESULTS

165 students responded survey. 92 (56%) identified as daily Anki users. Daily Anki use was correlated with increased Step 1 score (P = .039), but not Step 2 scores. There was an association between Anki use and increased sleep quality (P = .01), but no difference for other measurements of wellness or extracurricular involvement.

CONCLUSION

The study demonstrates potential benefits of daily use of Anki but also confirms that a variety of study methods can be used to achieve similar medical school outcomes.

Simulação realística como estratégia de ensino na graduação médica

Objetivo: avaliar a eficácia da simulação realística (SR) na graduação em medicina com base no conhecimento adquirido e na melhoria do desempenho clínico e analisar a percepção dos estudantes quanto à aplicabilidade do método como ferramenta de ensino. Métodos: foi realizada uma revisão sistemática de artigos científicos nas bases de dados PubMed, Lilacs e SciELO, em inglês e português, publicados no período de 2015 a 2020, utilizando a seguinte estratégia de busca: (simulation training OR simulation patient) AND (students medical AND education, medical, undergraduate). Resultados: dos 261 artigos identificados, apenas sete atenderam aos critérios de inclusão e exclusão estabelecidos, 57,2% deles com baixo ou moderado nível de evidência. Todos demonstraram que a SR promove modificações positivas no processo de construção acadêmica dos estudantes, contribuindo para o desenvolvimento de habilidades e competências essenciais para a formação médica. Além disso, houve majoritária percepção positiva dos estudantes quanto à utilização da SR como método de ensino durante a formação médica. Conclusão: houve evidências de eficácia da SR na aprendizagem e favorável percepção dos estudantes de medicina quanto à sua utilização. Todavia, os desafios relativos à sua implantação e execução, bem como o restrito número de artigos de alto rigor metodológico, limitam a inferência inequívoca de sua eficácia na educação médica.

Attitudes of an international student cohort to the Quizlet study system employed in an advanced clinical health care review course

Computer-based learning applications and mobile technology have transformed many aspects of the educational experience over the last decade, producing software aimed at improving learning efficiency and streamlining the presentation of course materials. One such class of software, purpose-created to take advantage of spaced learning and spaced testing principles, are electronic flashcard applications. We provide a perspective on the novel use of the Quizlet flashcard application in a tertiary educational setting. To reduce cognitive load for international graduate dental students taking a pharmacology review course, we implemented Quizlet, which integrates both spaced learning and self-testing, to improve the student learning experience. This study assessed students' perceptions of the Quizlet flashcard system in a student cohort comprised of two consecutive years' classes (n = 51 students in total). Results indicated broad acceptance of Quizlet based on ease of use of the software and ease of study of the material. Our data provide insight into the use of this common software in a professional healthcare tertiary education setting and further demonstrate the successful application of electronic flashcards for a mixed international student cohort. Further research should include an assessment of the impact of flashcard on long-term knowledge retention in this setting.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s10639-022-11371-3.