Enhancing application and long-term retention of clinical knowledge using an extracurricular non-credit course

BACKGROUND AND PURPOSE

Curricular overload in doctor of pharmacy (PharmD) programs is necessitating innovative approaches to support student learning. The purpose of this study was to describe the design, delivery, and assessment of a non-credit extracurricular course that reinforced foundational concepts through the application of learning in case-based activities.

EDUCATIONAL ACTIVITY AND SETTING

A 14-week extracurricular course, designed using principles of spaced repetition and interleaving in the context of case-based exercises, was offered to third-year PharmD students. Content focused on Top 300 and over-the-counter medications, brown bag sessions/drug utilization review, and medication therapy management. Short-term course effectiveness was assessed through post-course focus groups. Longitudinal effectiveness was assessed nine months post-course using an online survey. Qualitative data were analyzed using a content analysis process with overarching themes identified. Clinical interventions identified in the post-course survey were analyzed descriptively.

FINDINGS

Twenty-four students completed the course and all assessments. Focus group themes were: (1) making connections to prior learning; (2) moving beyond memorizing facts; and (3) benefit from a low-stakes course. Students identified 162 course-linked clinical interventions during advanced pharmacy practice experiences (APPEs) in 16 different settings.

SUMMARY

Student learning can be enhanced through integration of evidence-based teaching strategies both within and across the curriculum. This can be accomplished not only through introduction of an extracurricular course but through modification of existing courses. Providing additional opportunities for reinforcing core clinical knowledge and applying clinical decision-making in a low-stakes environment was well-received by students and helped them make clinical interventions during APPEs.

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.

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.

Harnessing the power of spaced repetition learning and active recall for trainee education in otolaryngology

Medical education is rapidly evolving. The historical reliance on textbook reading is being increasingly replaced by trainees in favor of using non-traditional platforms such as podcasts, videos, and app-based learning. Neuroscience research on human learning has demonstrated superior long-term retention when the synergistic principles of spaced repetition and active recall are employed. Spaced repetition entails the repeated exposure to learned material over successive iterations, whereas active recall involves the intentional reconstructive process of retrieving previously learned material, often through prompting (e.g., answering open-ended questions without multiple choice answers), rather than passively reviewing previously learned information (e.g., re-reading a textbook chapter). These concepts have revolutionized medical student education, with use of open-source spaced repetition platforms, such as Anki, and question banks becoming ubiquitous. Paralleling educational platforms within otolaryngology are emerging. Headmirror's OtoRecall app provides a free, peer-reviewed, open-access option for otolaryngology trainees to harness the power of these learning principles.

Engagement and learning in an electronic spaced repetition curriculum companion for a paediatrics academic half-day curriculum

Postgraduate residencies utilize academic half-days to supplement clinical learning. Spaced repetition reinforces taught content to improve retention. We leveraged spaced repetition in a curriculum companion for a paediatric residency program's half-day. One half-day lecture was chosen weekly for reinforcement (day 0). Participants received 3 key points on day 1 and a multiple-choice question (MCQ) on day 8. On day 29, they received two MCQs to test reinforced and unreinforced content from the same day 0. Thirty-one (79%) residents participated over 17 weeks, but only 14 (36%) completed more than half of the weekly quizzes. Of all quizzes, 37.4% were completed, with an average weekly engagement of 5.5 minutes. Helpfulness to learning was rated as 7.89/10 on a Likert-like scale. Reported barriers were missing related half-days and emails, or limited time. There was no significant difference in performance between reinforced (63.4%, [53.6-73.3]) and unreinforced (65.6%, [53.7-73.2]) questions. Spaced repetition is a proven strategy in learning science, but was not shown to improve performance. Operational barriers likely limited participation and underpowered our analysis, therefore future implementation must consider practical and individual barriers to facilitate success. Our results also illustrate that satisfaction alone is an inadequate marker of success.

Novel Spaced Repetition Flashcard System for the In-training Examination for Obstetrics and Gynecology

INTRODUCTION

Electronic flashcards allow repeated information exposure over time along with active recall. It is increasingly used for self-study by medical students but remains poorly implemented for graduate medical education. The primary goal of this study was to determine whether a flashcard system enhances preparation for the in-training examination in obstetrics and gynecology (ob-gyn) conducted by the Council on Resident Education in Obstetrics and Gynecology (CREOG).

METHODS

Ob-gyn residents at Duke University were included in this study. A total of 883 electronic flashcards were created and distributed. CREOG scores and flashcard usage statistics, generated internally by interacting with the electronic flashcard system, were collected after the 2019 exam. The primary outcome was study aid usage and satisfaction. The secondary outcome was the impact of flashcard usage on CREOG exam scores.

RESULTS

Of the 32 residents, 31 (97%) participated in this study. Eighteen (58%) residents used the study's flashcards with a median of 276 flashcards studied over a median of 3.7 h. All of the flashcard users found the study aid helpful, and all would recommend them to another ob-gyn resident. Using the flashcards to study for the 2019 CREOG exam appeared to correlate with improvement in scores from 2018 to 2019, but did not achieve statistical significance after adjusting for post-graduate year (beta coefficient = 10.5; 95% confidence interval =  - 0.60,21.7; p = 0.06).

DISCUSSION

This flashcard resource was well received by ob-gyn residents for in-training examination preparation, though it was not significantly correlated with improvement in CREOG scores after adjusting for post-graduate year.

Spaced radiology: encouraging durable memory using spaced testing in pediatric radiology

Applied memory research in the field of cognitive and educational psychology has generated a large body of data to support the use of spacing and testing to promote long-term or durable memory. Despite the consensus of this scientific community, most learners, including radiology residents, do not utilize these tools for learning new information. We present a discussion of these parallel and synergistic learning techniques and their incorporation into a software platform, called Spaced Radiology, which we created for teaching radiology residents. Specifically, this software uses these evidence-based strategies to teach pediatric radiology through a flashcard deck system.

Student-directed retrieval practice is a predictor of medical licensing examination performance

INTRODUCTION

A large body of evidence indicates that retrieval practice (test-enhanced learning) and spaced repetition increase long-term information retention. Implementation of these strategies in medical curricula is unfortunately limited. However, students may choose to apply them autonomously when preparing for high-stakes, cumulative assessments, such as the United States Medical Licensing Examination Step 1. We examined the prevalence of specific self-directed methods of testing, with or without spaced repetition, among preclinical students and assessed the relationship between these methods and licensing examination performance.

METHODS

Seventy-two medical students at one institution completed a survey concerning their use of user-generated (Anki) or commercially-available (Firecracker) flashcards intended for spaced repetition and of boards-style multiple-choice questions (MCQs). Other information collected included Step 1 score, past academic performance (Medical College Admission Test [MCAT] score, preclinical grades), and psychological factors that may have affected exam preparation or performance (feelings of depression, burnout, and test anxiety).

RESULTS

All students reported using practice MCQs (mean 3870, SD 1472). Anki and Firecracker users comprised 31 and 49 % of respondents, respectively. In a multivariate regression model, significant independent predictors of Step 1 score included MCQs completed (unstandardized beta coefficient [B] = 2.2 × 10^- 3, p < 0.001), unique Anki flashcards seen (B = 5.9 × 10^- 4, p = 0.024), second-year honours (B = 1.198, p = 0.002), and MCAT score (B = 1.078, p = 0.003). Test anxiety was a significant negative predictor (B= - 1.986, p < 0.001). Unique Firecracker flashcards seen did not predict Step 1 score. Each additional 445 boards-style practice questions or 1700 unique Anki flashcards was associated with an additional point on Step 1 when controlling for other academic and psychological factors.

CONCLUSIONS

Medical students engage extensively in self-initiated retrieval practice, often with spaced repetition. These practices are associated with superior performance on a medical licensing examination and should be considered for formal support by educators.