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Neurology Training: Repeated Test Taking Works Better Than Just Studying; Simulated Patient Encounters Work Best of All


doi: 10.1097/01.NT.0000383483.99653.34
News From the Aan Annual Meeting
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Findings from a new study point to a simple way for medical schools and neurology residencies to improve lasting recall of the clinically relevant knowledge they're teaching: by repeatedly testing students and residents on the same material over a period of weeks.

TORONTO'Repeated test-taking works better than repeated studying as a means to raise long-term recollection in clinical neurology education, and repeated clinical encounters with faux patients posing as a patient works best of all, according to a study presented here at the AAN annual meeting in April.

The randomized trial was the first to extend a growing body of research on the so-called “testing effect” from written tests to the use of so-called standardized patients, trained actors following scripts — in neurological education.

The substantial, statistically significant results point to a simple way for medical schools and neurology residencies to improve lasting recall of the clinically relevant knowledge they're teaching: by repeatedly testing students and residents on the same material over a period of weeks.

Leaders in neurology education praised the study as groundbreaking and well designed, but said that larger studies will be necessary to justify the redesign of academic programs.

“The issue is how this kind of groundbreaking research can be applied to larger cohorts,” said Barney J. Stern, MD, chair of the AAN Education Research Subcommittee and professor of neurology at the University of Maryland, who was not involved with the study. Expanding the use of live actors to simulate patient encounters, he said, “will require funds, which are terribly hard to come by.”



Still, Dr. Stern added, “There is a robust literature suggesting that the way we've always done it, with lectures, doesn't have much carry-over into patient care. This study is a proof of principle, showing that these new techniques can be used in the neurologic arena.”

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The study drew on laboratory research in cognitive psychology and medical education, showing that repeated written tests produce better long-term recollection months after a class is over than does repeated studying. The goal was to see if this “testing effect” would work as well or better when the repeated tests involved standardized patient encounters, using trained actors following a script pertaining to myasthenia gravis, seizures, or migraines.

“Standardized patients are already used at most medical schools for teaching communication and physician examination skills,” said the study's principal investigator, Douglas P. Larsen, MD, an instructor in neurology at Washington University School of Medicine in St. Louis. “Where they haven't been used is in promoting knowledge retention and clinical examination skills. That's where our study opens up some new ground.”

After participating in a standard classroom session about three neurologic conditions, 41 first-year medical students were randomly assigned to four weekly follow-up sessions involving either studying a review sheet, repeated written testing, or repeated simulation testing with a standardized patient encounter for one of the three different topics. Six months later, their long-term retention was tested in standardized patient encounters.

In the six-month follow-up examination, students who had studied a review sheet received a score of 42 percent, compared to 49 percent for those who had taken repeated written tests, a difference that fell short of statistical significance (p=.030). Compared to the performance after repeated written tests, however, scores following repeated simulation testing were significantly better, at 58 percent (p=0.002.)

In other words, participating in four weekly simulated patient encounters enabled the students to achieve final scores that were 16 points higher (42 percent versus 58 percent) than those produced by the old-fashioned method of studying the information on a review sheet.

“Based on our results we would recommend that educators plan repeated testing practice both with simulation and through written tests in their curricula in order to improve student performance,” Dr. Larsen and his colleagues concluded. Such an approach would mark a major change to current practice, Dr. Larsen said.

“The typical practice is to have medical students listen to a lecture, study the information — often by cramming — and then to have a final exam,” he said. “What we're trying to establish is an evidence base to generate retention beyond a six-week course.”



Lori Schuh, MD, chair of the AAN A.B. Baker Section of Neurology Educators and neurology residence program director at the Henry Ford Hospital in Detroit, said: “This really was a very well designed, important study. We do need to know how medical students and physicians learn best — not just how they learn information, but how can we improve clinical performance.”

But, she added, “The greatest challenge for medical schools that want to try this out is the cost of these multiple standardized patient encounters. They're costly and time consuming.”

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• Larsen DP, Butler AC, Roediger HL. Repeated testing improves long-term retention relative to repeated study: a randomised controlled trial. Medical Education 2009:43:1174–1181.
    ©2010 American Academy of Neurology