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Learn – Repeat – Learn

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Fig. 1. Spaced education randomised trial. Kerfoot (2008)

‘The psychological conclusion demands a distribution of repetitions such that some of them should be produced at a later time, separated from the first repetition by a pause’. (Vygotsky, 1926:Location 2686)

So wrote the educational psychologist Lev Vygostsky over 80 years ago. Putting this into practice using email (and now Smart Phone apps and eventually Facebook), the team at Spaced-Ed have created a learning system that works.

SPACED EDUCATION – DR B PRICE KERFOOT

Interactive Spaced-Education to Teach the Physical Examination: A randomized Controlled Trial

BACKGROUND/PROBLEM

Several studies have documented that physical examination knowledge and skills are limited among medical trainees.

OBJECTIVES:

The objective of the study is to investigate the efficacy and acceptability of a novel online educational methodology termed ‘interactive spaced education’ (ISE) as a method to teach the physical examination.

DESIGN:

Randomized control trial.

PARTICIPANTS:

170 second year medical students.

MEASUREMENTS:

  • Spaced-education items (questions and explanations)
  • Validated by two experts
  • Piloted and 36 items selected for inclusion
  • 6 spaced-education e-mails each week for a 6 week cycle.
  • Students submitted answers to the questions online and received immediate feedback
  • An online end-of program survey was administered.

RESULTS: Successful 85% participants recommended the ISE programme for students the following year.

CONCLUSIONS: ISE can generate significant improvements in knowledge of the physical examination and is very well-accepted by students.

While many studies have documented the dearth of physical examination knowledge and skills among trainees, ISE has the potential to remediate these deficiencies across the spectrum of medical education’. (p977)

Why necessary?

Students do the training, but may still have poor recall a year later. Spacing works.

The spacing effect is the psychological finding that educational encounters that are spaced and repeated over time (spaced distribution) result in more efficient learning and improved learning retention, compared to massed distribution of the educational encounters (bolus education). (P973)

As Vygotsky expressed it 80 years previously:

‘It should also be emphasized that every person has his own customary rate of response, and that any change in this rate, either speeding it up or slowing it down, weakens the force of recall’. (Vygotsky, 1926:Location 2686)

And so here students can tailor the timing of questions they are fed – spacing them out or bunching them as they see fit and circumstances change. Go try it, there are courses you can do on topics that a far less demanding that second year physical examinations. Try world history in maps, for example, or getting the most out of your iPhone.

A distinct neurophysiologic basis for the spacing effect has been identified

‘Spaced education’ refers to online educational programs that are structured to take advantage of the pedagogical benefits of the ‘spacing effect’.

Interactive spaced-education (ISE) combines the pedagogical merits of both the ‘spacing effect’ and the ‘testing effect. (974)

Each spaced-education item consists of an evaluative component (a multiple choice question based on a clinical scenario) and an educational component (the answer and explanation)

Psychometric analysis of the questions was performed using the Integrity test analysis software (http://integrity.castlerockresearch.)

Based on item difficulty, point-biserial correlation, and Kuder–Richardson 20 score, 36 of the questions were selected for inclusion in the ISE program.

  • Students receive spaced-education e-mails at designated time intervals which contain a clinical scenario and question (evaluative component).
  • Upon clicking on a hyperlink in this e-mail, a web-page opens which displays pertinent images and allows the student to submit an answer to the question.
  • Upon downloading this answer to a central server, students are then immediately presented with a webpage displaying the correct answer to the question and an explanation of the curricular learning point (the educational component).
  • By having the provider submit a response before receiving the correct answer and an explanation, this process requires greater interactivity, which educational theory argues may improve learning outcomes.
  • The submitted answers of students were recorded using the MyCourses™ web-based education platform

The survey was constructed and administered online using the SurveyMonkey web-based platform.

Future developments and assimilation of spaced-education alongside traditional medial school teaching methods

For example, as ISE utilizes traditional web-pages for the submission of answers and for the presentation of learning points, it should be possible to use all of the functionalities of web-pages within the ISE program to meet the training needs of care providers. For example, physician trainees learning how to auscultate the heart can be presented with ISE items which contain an audio recording of an unknown heart sound, and then, trainees can be asked to identify the murmur.

LESSONS LEARNT

Micro-learning is favoured over more substantial time being given to this. I can imagine many applications.

This finding is in stark contrast to the strong resistance we encountered when conducting a recent trial of web-based teaching modules among 693 medical residents and students. In this trial focusing on systems based practice competency education, trainees were expected to spend 20 minutes per week over 9 weeks completing web-based teaching modules (interactive web-pages and online narrated slide presentations). (p977)

This high acceptability also likely reflects the ease of use of the spaced-education delivery system, the immediate relevance of the content, and the importance that students attribute to learning the physical examination. (p977)

Some items to cover if you are thinking of being a professional and thorough as the team at Harvard and Spaced-Ed:

  • · Conflict of Interest:
  • · Funding/Support:
  • · Financial Disclosures:
  • · Author Contributions:
  • · Conception and design:
  • · Acquisition of data:
  • · Analysis and interpretation of data:
  • · Drafting of the manuscript:
  • · Critical revision of the manuscript for important intellectual content:
  • · Statistical analysis:
  • · Obtaining funding:
  • · Ethical Approval to Perform the Study:
  • · Corresponding Author:

And a finaly word from Lev Vygotsky.

‘Rhythm plays a decisive role in the learning process, unifying some of the material, conferring on it a sequential symmetry, and, finally, organizing the various elements into a unified whole’. (Vygotsky, 1926)

REFERENCE

Kerfoot . B. P (2006) SPACED EDUCATION. Interactive Spaced-Education to Teach the Physical Examination: A randomized Controlled Trial.

Kerfoot. B. P (2008) Interactive Spaced-Education to Teach the Physical Examination: A Randomized Controlled Trial. Armstrong,E.G., O’Sullivan,P.M., JOURNAL OF GENERAL INTERNAL MEDICINE Volume 23, Number 7 Harvard Medical International.

Vygotsky, L (1926) Educational Psychology

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