The benefit of self-testing and interleaving for synthesizing concepts across multiple physiology texts

Systematic review of distributed practice and retrieval practice in health professions education

To determine the effect of distributed practice (spacing out of study over time) and retrieval practice (recalling information from memory) on academic grades in health professions education and to summarise a range of interventional variables that may affect study outcomes. A systematic search of seven databases in November 2022 which were screened according to predefined inclusion criteria. The Medical Education Research Study Quality Instrument (MERSQI) and Newcastle-Ottawa Scale-Education (NOS-E) were used to critically appraise eligible articles. A summary of interventional variables includes article content type, strategy type, assessment type and delay and statistical significance. Of 1818 records retrieved, 56 were eligible for inclusion and included a total of 63 experiments. Of these studies, 43 demonstrated significant benefits of distributed practice and/or retrieval practice over control and comparison groups. Included studies averaged 12.23 out of 18 on the MERSQI and averaged 4.55 out of 6 on the NOS-E. Study designs were heterogeneous with a variety of interventions, comparison groups and assessment types. Distributed practice and retrieval practice are effective at improving academic grades in health professions education. Future study quality can be improved by validating the assessment instruments, to demonstrate the reliability of outcome measures. Increasing the number of institutions included in future studies may improve the diversity of represented study participants and may enhance study quality. Future studies should consider measuring and reporting time on task which may clarify the effectiveness of distributed practice and retrieval practice. The stakes of the assessments, which may affect student motivation and therefore outcomes, should also be considered.

Desirable Difficulty: Theory and application of intentionally challenging learning

CONTEXT

Health professions trainees must acquire a vast amount of clinical knowledge and skills, and a deliberate instructional design approach is needed to provide trainees with effective learning strategies. One powerful yet counterintuitive strategy that facilitates long-term learning is incorporating intentional difficulties during the learning process. Difficulties that require more effort from learners may impede short-term learning but are ultimately beneficial for long-term learning and are therefore termed Desirable Difficulties.

OBJECTIVES

In this cross-cutting edge paper, we describe the Desirable Difficulty effect from three theoretical perspectives originating in different fields, discuss common evidence-based Desirable Difficulty strategies used in Health Professions Education and explore emerging research that could further optimise Desirable Difficulty-enhanced learning for health professions trainees.

METHODS

We synthesise theory and research from psychology, cognitive science and Health Professions Education literatures to further the understanding and application of Desirable Difficulties. We introduce three theoretical perspectives that provide a comprehensive overview of the theoretical underpinnings of the Desirable Difficulty effect: the New Theory of Disuse, the Challenge Point Framework and Cognitive Load Theory. We then illustrate how three common Desirable Difficulty strategies in medical education research-retrieval practice, spaced practice and interleaved practice-can be understood through these theoretical lenses. Finally, we provide relevant examples from the literature and explore emerging research in this area.

CONCLUSIONS

This paper summarises the theory and empirical research on Desirable Difficulties during the learning process, from explaining what they are and why they may be effective to how they have been applied in different contexts. We argue that providing educators and trainees with a comprehensive theoretical and applied understanding of Desirable Difficulty will promote deliberate instructional design decisions and lead to more effective learning.

Using the study cycle model to support better student learning: a faculty guide

Despite years of varied school experiences, many college students do not have adaptable study methods that allow them to collect, organize, and reorganize information to critically assess what they know and what they need help with until after a poor exam performance. Faculty are frequently called on to help students become better learners. In addition, as the tasks and complexity of the material become more challenging, students will need to adopt new study habits and adapt them to each new learning opportunity to reach their goals. This article describes an evidence-based framework that teachers can share with students that will support better studying habits leading to deeper learning.NEW & NOTEWORTHY Many college students do not have adaptable methods habits that allow them to get the most out of in-class time and structure their out-of-class study time. As a result, faculty are frequently called on to help students become better learners. This article describes an evidence-based framework focusing on learning anatomy and physiology examples that faculty can share with students to support better studying habits leading to deeper learning.

Combining desirable difficulty learning strategies to address the amount-to-learn vs. time-to-learn imbalance in residency training

PURPOSE

Residents have limited time and much to learn. Mounting evidence shows that Desirable Difficulty (DD) learning strategies can ease that imbalance, but few studies have specifically studied combinations of these strategies.

METHODS

We tested two different combinations of DD strategies: a double combination of distributed practice and retrieval practice and a triple combination additionally including interleaved practice. We compared residents' annual In-Training Exam (ITE) scores and graduates' board certification performance between both DD curricula and a historical baseline.

RESULTS

Average ITE scores rose from 149.06 in the historical baseline to 160.04 under the combined DD curricula (p < 0.001). Average ITE scores fell from 162.50 under the double combination to 155.11 under the triple combination (p = 0.03). There were no significant changes in graduates' board performance between any of the curricula.

CONCLUSIONS

These results add to the evidence that DD strategies can enhance residents' learning. The drop in ITE scores under the triple DD combination may suggest that it pushed learners past beneficial desirable difficulty into detrimental overwhelming difficulty. Further research should apply this framework in larger and more diverse settings to clarify how these DD strategies can be optimally used to enhance residents' learning.

Self-reported Learning and Study Strategies in First and Second Year Medical Students

Medical school presents a unique challenge to the average learner as the instructional strategies used in medical curricula are often different than what the student has experienced prior. The large volume of information taught in medical school is delivered with a variety of techniques. After the educational material has been delivered, it is the student's responsibility to study and learn the information for future exams and for their future patients. The current study aims to explore what learning activities and teaching strategies first (M1) and second year (M2) medical students use and prefer. Additionally, the study aims to determine if there are cohort differences in classroom and study habits. A group of 95 M1 students and 109 M2 students were recruited to participate in this online survey study. The analyses indicated statistical differences between M1 and M2 student cohorts with M1 students preferring group work and small group discussions more than M2 students. Classic didactic lecturing was preferred by 71.6% of students surveyed. M1 students reported a greater tendency for self-testing and group study versus M2 students. GPA and study technique preference were not correlated. These findings indicate that medical students are not using research-based learning and study strategies at the possible detriment of long-term knowledge retention. Modeling of research-based learning and study strategies by medical educators is one possible solution to encourage medical students to change their study practice. Future work should focus on how medical student learning preferences change as they progress through medical school.

Learning how to learn: can embedded discussion boards help first-year students discover new learning strategies?

Learning anatomy and physiology at university can be challenging, as students need to understand both the language of the discipline and complex topics, such as system integration. Yet learning strategies are rarely taught at university, making it difficult for students to adopt new strategies, if their approach to learning has not been effective or efficient. This study evaluated the use of small-group peer discussion boards as an avenue for sharing learning strategies between students in a first-year anatomy and physiology course. The majority of students (91%) identified strategies from the discussion board worth trying before they completed the midsemester exam. The most frequently reported type of strategy was transforming records. By the end of semester, 76% of students had adopted at least one new strategy; however, these students performed significantly worse on the exam compared with students who did not adopt new strategies. The students who adopted new strategies learned about them from peers (33%), the discussion board (32%), or through self-discovery (32%). The majority of students (83%) found the discussion boards to be useful as a source of new learning strategies and for insight into how others learn. Although the discussion boards provided an avenue for students to learn about new strategies from each other, further guidance from instructors may be required to help students evaluate the effectiveness of these learning strategies.

The Role of General and Selective Task Instructions on Students' Processing of Multiple Conflicting Documents

This study was designed to test the role of general and selective task instructions when processing documents, which vary as regards trustworthiness and position toward a conflicting topic. With selective task instructions, we refer to concrete guidelines as how to read the texts and how to select appropriate documents and contents, in contrast to general task instructions. Sixty-one secondary school students were presented with four different conflicting documents in an electronic learning environment and were told to write an essay based on the information from the texts. Only half of the students were told to only use information from two out of the four texts to write their essay (i.e., selective condition). As predicted, students told to focus on specific documents and not use all of them for the assigned task (i.e., selective condition) better discriminated the quality of documents and type of information for the task.

Retrieval practice and judgements of learning enhance transfer of physiology information

It is well-documented that retrieval practice enhances the recall of simple and complex information (Karpicke and Aue in Educ Psychol Rev 27(2):317-326, 2015). Evidence is also accumulating that retrieval practice can enhance other cognitive processes such as the ability to critically evaluate research articles (Dobson et al. in Med Educ 52(5):513-525, 2018) and transfer of learning (Butler in J Exp Psychol Learn Mem Cogn 36(5):1118, 2010). One aim of this investigation was to explore the effects of retrieval practice on transfer of learning with physiology information. A second aim was to compare recall and transfer of physiology information following retrieval practice versus a judgment of learning task (JOL) that is potentially less time consuming for students to use. Participants were randomly assigned to learn three physiology texts using each of the following strategies: (1) studying a text four times (S-S-S-S), (2) studying and then retrieving a text two times (S-R-S-R), and (3) studying a text four times while completing multiple JOL during the second and fourth repetitions (S-S/J-S-S/J). Recall and accuracy on transfer questions were assessed 1 week after the learning phase, and the results were analyzed using repeated measures ANOVAs. The S-R-S-R strategy (21.35 ± 1.08%) produced significantly greater recall than the S-S-S-S strategy (17.35 ± 0.86%), and both the S-R-S-R (44.60 ± 2.55%) and S-S/J-S-S/J (41.79 ± 2.63%) strategies lead to significantly greater transfer than the S-S-S-S strategy (36.07 ± 2.40%). These results provide evidence that retrieval practice enhances recall and transfer of physiology information and that a JOL task can also prove to be beneficial but to a lesser degree.

Measuring Multiple Text Integration: A Review

Multiple text integration is an important skill in modern society, required in heterogeneous situations, across many disciplines and in daily life. It is a complex skill that builds on bottom-up and top-down processes (Britt and Rouet, 2012). As a complex skill it has been measured in the literature using different techniques. To date, the different ways in which researchers have defined and operationalized the term have not been reviewed. Therefore, the aim of this paper is to review how multiple text integration has been theoretically and empirically assessed. The current paper reviews which texts were typically used, which aspects of integration were assessed, and with which scoring rubrics. Finally, we propose that despite the diverse use of tasks, important features of multiple text integration are missing from current research.

Retrieval practice enhances the ability to evaluate complex physiology information

OBJECTIVE

Many investigations have shown that retrieval practice enhances the recall of different types of information, including both medical and physiological, but the effects of the strategy on higher-order thinking, such as evaluation, are less clear. The primary aim of this study was to compare how effectively retrieval practice and repeated studying (i.e. reading) strategies facilitated the evaluation of two research articles that advocated dissimilar conclusions. A secondary aim was to determine if that comparison was affected by using those same strategies to first learn important contextual information about the articles.

METHODS

Participants were randomly assigned to learn three texts that provided background information about the research articles either by studying them four consecutive times (Text-S) or by studying and then retrieving them two consecutive times (Text-R). Half of both the Text-S and Text-R groups were then randomly assigned to learn two physiology research articles by studying them four consecutive times (Article-S) and the other half learned them by studying and then retrieving them two consecutive times (Article-R). Participants then completed two assessments: the first tested their ability to critique the research articles and the second tested their recall of the background texts.

RESULTS

On the article critique assessment, the Article-R groups' mean scores of 33.7 ± 4.7% and 35.4 ± 4.5% (Text-R then Article-R group and Text-S then Article-R group, respectively) were both significantly (p < 0.05) higher than the two Article-S mean scores of 19.5 ± 4.4% and 21.7 ± 2.9% (Text-S then Article-S group and Text-R then Article-S group, respectively). There was no difference between the two Article-R groups on the article critique assessment, indicating those scores weren't affected by the different contextual learning strategies.

CONCLUSION

Retrieval practice promoted superior critical evaluation of the research articles, and the results also indicated the strategy enhanced the recall of background information.

Using whiteboards to support college students' learning of complex physiological concepts

Research underscores the importance of retrieval-based practice and application of knowledge for meaningful learning. However, the didactic lecture format continues to persist in traditional university physiology courses. A strategy called whiteboarding, where students use handheld dry erase boards and work in small groups to actively retrieve, discuss, and apply concepts presented in the lecture, has the potential to address challenges associated with actively engaging students in science courses for greater learning. The purpose of this study was to empirically examine the potential benefits of whiteboarding for increasing students' understanding of animal physiology concepts. Student performance on physiology questions assessing concepts taught using lecture only vs. concepts taught using lecture and whiteboarding were compared within the term that whiteboarding was used, as well as across whiteboard and lecture-only terms taught by the same instructor. Results showed that when whiteboarding was incorporated in the course, student performance on items that assessed concepts corresponding to the whiteboarding activities were significantly higher compared with performance on items that assessed concepts taught through lecture only. These patterns in student performance were found within and across terms. Taken together, findings point to whiteboarding as an effective tool that can be integrated in traditional lecture courses to promote students' understanding of physiology.

Evaluating the effect of instruction and practice schedule on the acquisition of ECG interpretation skills

INTRODUCTION

Evidence of the benefit of distributed instruction and interleaved practice comes from studies using simple materials (e. g. word pairs). Furthermore, there is currently no evidence of the combined impact of these strategies in undergraduate medical education. The present study evaluated the impact of varying both instruction and practice schedules for the acquisition of ECG interpretation skills.

METHODS

We conducted a 2 × 2 factorial study with two levels of instruction (massed and distributed) and two levels of practice (interleaved and blocked). A three-module introductory course in ECG interpretation was delivered to 80 first year medical undergraduate students. Students were assigned to one of four Instruction-Practice conditions: Massed-Interleaved, Massed-Blocked, Distributed-Interleaved and Distributed-Blocked. Learning was evaluated by a multiple choice quiz at the end of each module and a final multiple choice quiz at the end of the course.

RESULTS

End of module mean scores showed that distributed instruction was consistently superior to massed instruction (52% vs 42%, p < 0.01). However, there was no effect of practice and no interaction between teaching and practice methods. The delayed final test scores revealed an advantage for blocked over mixed practice (34% vs 24%, p < 0.05) and distributed over massed instruction (34% vs 24%, p < 0.05).

DISCUSSION

These results suggest that these popular strategies may have varying effects with complex learning materials. Further research is required to understand how these strategies affect the learning of simple and very complex skills.

Distributed retrieval practice promotes superior recall of anatomy information

Effortful retrieval produces greater long-term recall of information when compared to studying (i.e., reading), as do learning sessions that are distributed (i.e., spaced apart) when compared to those that are massed together. Although the retrieval and distributed practice effects are well-established in the cognitive science literature, no studies have examined their additive effect with regard to learning anatomy information. The aim of this study was to determine how the benefits of retrieval practice vary with massed versus distributed learning. Participants used the following strategies to learn sets of skeletal muscle anatomy: (1) studying on three different days over a seven day period (SSSS_7,2,0 ), (2) studying and retrieving on three different days over a seven day period (SRSR_7,2,0 ), (3) studying on two different days over a two day period (SSSSSS_2,0 ), (4) studying and retrieving on two separate days over a two day period (SRSRSR_2,0 ), and (5) studying and retrieving on one day (SRx6₀ ). All strategies consisted of 12 learning phases and lasted exactly 24 minutes. Muscle information retention was assessed via free recall and using repeated measures ANOVAs. A week after learning, the recall scores were 24.72 ± 3.12, 33.88 ± 3.48, 15.51 ± 2.48, 20.72 ± 2.94, and 12.86 ± 2.05 for the SSSS_7,2,0 , SRSR_7,2,0 , SSSSSS_2,0 , STSTST_2,0 , and SRx6₀ strategies, respectively. In conclusion, the distributed strategies produced significantly better recall than the massed strategies, the retrieval-based strategies produced significantly better recall than the studying strategies, and the combination of distributed and retrieval practice generated the greatest recall of anatomy information. Anat Sci Educ 10: 339-347. © 2016 American Association of Anatomists.