Test-enhanced learning

A chief resident faced a diffi cult educational task. Th e residents in the programme did not feel that they adequately understood, recognized, or knew how to treat rare metabolic diseases. Th e chief resident collaborated with a faculty member who had special expertise in this area to create two 1-hour didactic conferences that reviewed the diseases. Th e faculty member provided an extensive overview and many case examples. Aft er the conferences, the residents felt that they had learned the material, and they were grateful that their educational need had been met. No further formal exposure to the material occurred. Th is example illustrates a fundamental misconception about learning that is ubiquitous in medical education—the assumption that performance during learning (or immediately aft erwards) will be maintained. Both objective assessments (e.g. tests) and subjective judgements (e.g. feelings of mastery) during learning are oft en poor predictors of long-term retention because they refl ect the accessibility of knowledge at a given moment rather than how well that knowledge has been stored in memory ( Bjork and Bjork 1992 ). Th is misconception undermines the critical educational objective of helping clinicians to acquire and retain the large body of medical knowledge that they will need to apply in the future. With this misconception in mind, educators must consider how likely it is that the residents in the real-life scenario above remembered the material that was taught in the conferences. Based on what we know from cognitive science, the answer is probably little or nothing at all, which is troubling because much of medical education occurs through similar methods and settings. For example, residents at most teaching hospitals in the United States spend at least 8 hours a week in formal didactic conferences. In fact, in the United States, the Accreditation Council on Graduate Medical Education (ACGME) mandates these conferences ( ACGME 2011 , p. 7). Yet studies have shown no diff erence in knowledge between clinicians who attended such conferences and peers who did not ( Cacamese et al. 2004 ; FitzGerald and Wenger 2003 ; Picciano et al. 2003 ; Winter et al. 2007 ). Th e same problem exists at all levels of medical education. Students spend countless hours in classrooms prior to their clinical years and then spend several hours a week in didactic sessions during their clinical rotations. Practising physicians are required by regulatory agencies to spend a certain number of hours each year at continuing medical education conferences. Th e challenge for medical education is to develop and implement learning methods that produce long-term retention of knowledge that can be fl exibly recalled and applied in the future. Th is chapter reviews one such method, called test-enhanced learning ( Roediger and Karpicke 2006a , Larsen et al. 2008 , Roediger and Butler 2011 ) Test-enhanced learning is based on the fi nding that retrieving information from memory produces superior long-term retention, commonly referred to as the testing eff ect . Although practising retrieval of information is oft en implemented as a test, it can take many forms and is not limited to traditional paper or electronic tests. A large body of research in cognitive science and related fi elds has shown the testing eff ect to be a robust and replicable fi nding. In fact, the evidence is so strong that the Institute of Education Sciences from the Department of Education in the US has recommended using retrieval practice to promote retention at all levels of education ( Pashler et al. 2007 ). The goals of this chapter are to introduce the idea of testenhanced learning, review the main fi ndings in the literature, and provide some guidance as to how test-enhanced learning might be implemented in medical education.