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repeatedly tested had a higher portion of correct answers on final delayed testing
(55%) when compared to both the no additional exposure (44%) and repeated study-
ing groups (46%), who performed similarly on the delayed recall examination [ 16 ].
Test-enhanced learning has lead surgical residency programs to introduce weekly
quizzes and mock exams. The Surgical Council on Resident Education (SCORE),
an almost universally used general surgery residency curriculum developed by mul-
tiple surgical societies under the auspices of the American Board of Surgery, has
incorporated weekly quizzes in its comprehensive curricular outline. The American
Board of Surgery In-Service Training Examination (ABSITE) is a yearly exam that
predicts resident performance on the ABS Qualifying Examination. In one study,
introduction of the test-enhanced learning model by incorporating regular quizzing
alongside other academic development strategies has been shown in the authors’
own residency program to increase ABSITE mean percentile scores by as much
as 34% [ 17 ].
Spacing
Not only does repeated testing and retrieval of information enhance long-term
memory, but the spacing between testing events has an effect as well. Many curri-
cula for incoming surgical interns and continuing medical education sessions offer
short demanding courses that typically last anywhere from 1 day to 1 week. This is
known as massed practice [ 18 – 21 ]. Afterward there is often no delayed follow-up
on knowledge or skill performance, and deterioration of retention and/or perfor-
mance over time is observed. Therefore spacing (also known as distributed prac-
tice) has become an important concept in terms of retrieval of information from
long-term memory [ 18 ].
One such study that shows the importance of spacing involved a surgical skills
laboratory and junior residents’ ability to perform a microvascular anastomosis on
anesthetized rats. Moulton et al. divided the residents into a massed group, which
received all four instructional sessions in a single day, and a spaced group, which
received the four sessions once per week over a period of 4 weeks. At the end of the
month, the two groups were tested on performance of a microvascular anastomosis.
The results showed that the spaced group completed the surgery in less time, with
fewer hand movements, and had 100% success at performing the anastomosis when
compared to the massed group. Additionally, the massed group had 16% of resi-
dents damage the anastomosis beyond repair [ 18 ].
Spacing has been shown to be superior to massed practice in promoting longer-
term retention and allows for easier transfer of surgical skills to real-life situations.
It is thought that spacing activates differing regions of the brain during the learning
session and between sessions. This activation allows for the consolidation and more
enduring retention of the learned material. Spacing also stimulates the learner to
mentally rehearse and prepare for key aspects of each session or segment of material
[ 18 , 22 – 24 ].
J. Feimster et al.