When I first started teaching Harvard medical students, I became despondent over how little of my teaching the students actually retained in the months following my course. I should not have been surprised. It turns out that Harvard medical students are human, and like the rest of us, they are subject to the natural physiologic processes of forgetting. In healthy humans, forgetting is normal and is not a disease or failure of effort. The question for educators is how to most effectively structure the educational process to prevent forgetting, to boost long-term retention, and to generate meaningful behavior change. It is this question that led me to search for solutions within the field of cognitive psychology and ultimately to develop a new form of online education (termed “spaced education”) based on these brain science insights.
Spaced education is founded upon two core cognitive psychology research findings: the spacing effect and the testing effect. The spacing effect refers to the research finding that educational encounters that are spaced and repeated over spaced intervals of time (spaced distribution) result in more efficient learning and improved retention, compared to mass distribution at a single point in time (also known as binge-and-purge learning). Lab researchers have made substantial progress recently in elucidating the biochemistry and neurophysiology of the spacing effect. Spaced training of lab rats has been shown to generate increased neuronal number and longevity in their hippocampi, not to mention faster maze escape times. In addition, the protein enzyme mediating the spacing effect in Drosophila fruit flies was recently identified. Currently, functional magnetic resonance imaging (fMRI) studies are being conducted to determine where the spacing effect is processed in the human brain and how it can be facilitated.
Most people think of testing as merely a method to determine how much has been learned. This is only half of the story. The testing effect refers to the psychological research finding that testing can dramatically alter the learning process itself to significantly improve long-term retention of learned material. One of my favorite studies demonstrating this was conducted by Drs. Roediger and Karpicke among 120 college students. In this randomized study, students who studied a prose passage for seven minutes and were immediately tested on the passage over a seven-minute period had significantly better retention of the material one week later, compared to students who spent 14 minutes studying the prose in the absence of testing.
To take advantage of the spacing and testing effects, we structured spaced education as a series of detailed questions and explanations delivered via mobile device or computer over spaced intervals of time. Learners receive a notification containing a clinical scenario and a multiple-choice question. Upon submitting their answers, participants are immediately presented with the correct answer and learning points germane to the question. The questions are then re-presented over spaced intervals of time in a series of cycled reviews (interval reinforcements). An adaptive engine customizes these reinforcement intervals based on each learner’s performance. The test-question format is utilized specifically to harness the long-term retention benefits of the testing effect. In more than 20 large randomized trials, we have shown that spaced education can improve long-term retention of learning, boost learner engagement, and generate meaningful behavior change. To our surprise, learners really liked these programs too. Based on these consistently impressive results, Harvard University launched the company Qstream (Qstreamhealthcare.com) to host the spaced education methodology outside of its firewalls.
Behavior change matters! Any medical educator will tell you that the goal of an educational event should be improvement in clinicians’ practice patterns and ideally in patients’ health. This is not easy to achieve or to demonstrate, but in a series of large randomized trials, we have done just that:
Cancer Screening: Ninety-five primary care clinicians in eight medical centers were randomized to either receive spaced education over 36 weeks on prostate cancer screening, or no new training (thus representing the current standard of care at these medical centers). We monitored how these clinicians screened their patients for prostate cancer. Over the 72 weeks following the spaced education, the clinicians who received it performed 40 percent fewer inappropriate screening tests compared to the control clinicians.
Hypertension Management: One hundred eleven primary care clinicians in eight medical centers were randomized to receive either spaced education over a mean 38 weeks on the management of patients with hypertension, or the identical content in an online posting. We monitored how these clinicians treated their patients with hypertension over 52 weeks. We found that the patients of the spaced education clinicians achieved their blood pressure targets significantly more quickly than the patients of the control clinicians.
Blood Glucose Management: Four hundred fifty-six patients with diabetes along the eastern U.S. were randomized to receive either spaced education for six months on diabetes self-management education (DSME) and a booklet on civics, or spaced education for six months on civics and a booklet on DSME. The content delivered to all patients was identical, with the only difference being the method of delivery. We monitored their blood glucose levels via home test kits. Six months after the spaced education had ended, we found that those patients who received spaced education on DSME had significantly greater improvements in blood glucose compared to the control patients. Among those patients with severe diabetes, the reduction in blood glucose was of a magnitude comparable to starting a new diabetes medication.
In summary, these rigorously conducted randomized trials provide Level 1 evidence that spaced education is an effective tool to change clinicians’ behaviors and patients’ health. Since the spaced education methodology is content neutral, it can be utilized to drive significant behavior change across the many fields within healthcare. Cancer screening, hypertension management, and diabetes care are only three of many clinical management challenges in which spaced education can make a meaningful impact.