Using the Lessons of Learning Science to Improve Medical Education in Otolaryngology

Introduction

In learning theory, the concept of a “desirable level of difficulty” for learning is supported by research findings that deeper levels of processing lead to better memory encoding and therefore enhanced learning. These levels of processing model were described by Fergus Craik and Robert Lockhart in 1972, which describes memory recall of stimuli as a function of the depth of mental processing. ¹ Craik and Lockhart categorized stimuli as structural (e.g., is the word in capital letters?), phonemic (e.g., does the word rhyme with deep?), semantic (e.g., what does the word mean?), or personal (e.g., how does the word relate to you?). Their study found that deeper levels of analysis produce longer lasting memory. Medical professionals in training have the particularly burdensome job of needing to memorize vast amounts of information in a relatively short period of time, and thus, identifying strategies to maximize learning is of particular interest. The following text will review several methods to improve studying, learning, and memory recall based in psychology and social sciences research.

Methods

A literature review was conducted of published articles and original research regarding learning theory and the psychology of learning. The outline for the information herein was adapted from a lecture by Dr. Daniel Oppenheimer, PhD.

Results

One way to enhance memory encoding is known as the generation effect.^2,3 This is when participants are forced to actively produce material during learning activities, which is later shown to improve memory performance. When compared to simply reading words, generating target words was shown to activate broad neural networks involving the prefrontal and posterior cortex and led to significantly improved memory retrieval. ⁴ These findings explain the benefits of the mnemonic technique for active learning: to organize material and improve recall. Mnemonics help to create cues to help remember things using imagery, spatial cues, rhymes, rhythms, or pre-set lists. An example of a mnemonic device is known as the method of loci. This technique relies on spatial relationships between locations on a familiar route or rooms in a familiar building (e.g., “loci”) to arrange and recollect memory content, colloquially known as a “memory palace.”^5,6 The technique is practiced by linking the key ideas of a subject to mental images and associating them with specific locations. This method has been in the press for allowing seemingly impossible feats such as one individual’s memorization and recitation of over 65,536 digits of pi. ⁷ In the context of medical education, companies such as Sketchy Medical® and Picmonic® have developed study tools for students using visual images and story scenes to enhance recall. The rising popularity of these learning aids suggests they have been an efficient method for many students.

It has been shown that long-term learning is promoted when learning events are spaced out over time, rather than presented in immediate succession. This is known in psychology as the spacing effect.^8–10 Research aimed at studying this effect has classically divided participants into two groups with the same curriculum but different learning schedules: massed (i.e., immediate succession of material and learning events) or distributed (i.e., material and learning events separated by a defined amount of time). Study subjects are then asked to recall words or material that they had been presented earlier. Results consistently demonstrate distributed or spaced learning schedules are associated with greater long-term memory retention and higher performance. ¹⁰ The decline of memory retention over time is described by the “forgetting curve” hypothesis, which describes the percentage of memory retention as a function of days (Figure 1).OPEN IN VIEWER

When material is reviewed (studied) at regular intervals after a period of forgetting, this reinforcement allows for more long-term memory retention. This theory supports the principle that allowing time between study sessions will increase effectiveness rather than increasing the time of one concentrated period of study (Table 1). The optimal time for spacing review sessions is over several weeks, allowing for delayed recall and memory reinforcement. If this is not possible, single-session spaced learning patterns are also helpful (e.g., interspace 20 minutes of study, with 10 minutes of rest, and repeat). The application Anki® is one tool students can use to practice spaced repetition through the use of user-made flashcards. A new application called OtoRecall® is specific to otolaryngology residents-in-training, with pre-made flashcards in question-and-answer format including the option to focus on a specific subspecialty area.

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Table 1.

A hypothetical study schedule that allows time for scheduled sessions at regular intervals after a period of forgetting, which has been shown to promote long-term memory retention.

Time Until Test	1st Session	2nd Session	3rd Session
1 Week	Today	Tomorrow	Day before the test
2 Weeks	Today	In 1 week	Day before the test
1 Month	Today	In 7–10 days	Day before the test
6 Months	Today	In 3–5 weeks	Day before the test

Another method to increase memory retention during a single study session is described by the interleaving effect. ¹¹ This theory describes studying multiple topics in one session by alternating between them (e.g., 20 minutes otitis, 10 minutes laryngitis, and back to 20 minutes otitis). Psychology research has demonstrated that this type of studying improves discriminative contrast between different categories, while studying each concept in separate blocks emphasizes the similarities within each category. ¹² Less inter-related topics can also help to increase the level of processing during studying by engaging an individual’s attention by switching topics. Interleaved study also helps to provide temporal spacing between repetitions of each category, which has been shown to enhance long-term memory. ¹³ Within the field of otolaryngology, this method may be particularly useful given the diversity of anatomy and associated pathologies encountered within different regions of the head and neck.

Retrieval practice or testing at intervals during a learning period has also been found to increase long-term memory.^14–16 Psychology research has shown that testing does not merely measure outcomes but can be used as a tool to change outcomes. The purpose of formative tests is to aid in one’s learning, while by contrast, a summative test is used to evaluate what one has already learned. Learning theory would advocate for students’ own self-testing via forced recall or educators promoting recall via formative testing. Recalling information via testing helps the subject to recall information, increase the level of processing, and encode information more deeply. Research shows that taking a test can have a greater positive effect on future retention of that material than spending an equivalent amount of time restudying the material. ¹⁶ In both medical school and residency, it is the authors’ experience and belief that learners rely heavily on question banks for self-study. This provides an objective measurement of knowledge, but more importantly, allows for the opportunity to target specific areas of academic weakness. Several different question banks exist for use by learners within the subspecialty of otolaryngology, some of which include OTO Quest® offered through the American Academy of Otolaryngology-Head and Neck Surgery and BoardVitals® offered through the Accreditation Council for Continuing Medical Education (ACGME).

The concept of cognitive disfluency describes an individual’s processing of new information along a continuum, from very fluent (with great ease) to very disfluent (with great difficulty).^17–19 There are several types of fluency including perceptual, linguistic, retrieval, embodied, and spatial. People tend to prefer learning fluency associated with ease of processing; however, disfluency in learning theory has been shown to produce superior learning due to the difficulty of processing information that increases attentiveness.^20,21 This so-called disfluency effect therefore represents a “desirable difficulty” as referenced earlier in this article, by manipulating the subjective level of effort in processing without altering the objective material. One study showed that presenting material in a format that is slightly harder to read (e.g., changing the font or format and using bold or italics) can significantly improve students’ retention of material by leading to a deeper processing of more distinctive and atypical stimuli (fonts). ²⁰

The modern classroom must adapt to advancements in technology. The laptop computer has greatly revolutionized education. However, this has also changed the way students think, and these changes can both reinforce the learning goals of the classroom or undermine them. Specifically, regarding note-taking, typing allows the student to write quickly and transcribe verbatim notes more mindlessly. Handwriting, in contrast, forces the student to use shorthand, differentiate key points, and paraphrase in one’s own words. One study showed that during recall of conceptual information, verbatim notes taken on a laptop were shown to result in lower scores on subsequent recall testing when compared with students’ scores who took handwritten notes. ²² In a secondary experiment in which students were able to take notes on the two mediums and then subsequently had the opportunity to study their notes before their performance was tested, handwritten notes and studying were shown to be superior to typewritten notes and studying in overall scores, factual recall, and conceptual recall. ²² Facilitating a deeper depth of processing and learning disfluency will aid in the goal of students to retain learning material.

Conclusions

The application of theories founded in the psychology of learning including the generation effect, retrieval practice, and cognitive disfluency may help to improve the information retention and productiveness of adult learners.