A call for spaced repetition in medical education

1 |. THE ‘PARALLEL CURRICULUM’

Physicians who graduated from medical school decades ago would be surprised if they walked into a medical school lecture hall today. Despite state-of-the-art facilities and improved educational technology, few students attend lectures in person. Although these trends predate COVID-19, the pandemic has catalysed the transition of medical education into the virtual world. Many students have replaced traditional lectures with commercialised online materials and are abandoning the classroom in droves.

Why the shift? One major reason is that students are anxious to perform well on standardised licensure exams, especially in the United States, where these exams have played an outsized role in student competitiveness for post-graduate training. Many popular commercialised resources (e.g. Boards and Beyond^™, Sketchy^™, Pathoma^™) include short videos that teach preclinical concepts using visual design principles for help with knowledge acquisition. These resources are often accompanied by premade flashcard decks which students use to consolidate and retain concepts from the videos. Because commercialised learning resources use evidence-based learning principles and emphasise material tested on licensure exams, students are increasingly relying on these resources in lieu of traditional lectures.¹ Pursuing external, commercialised learning resources for class and board preparation has become a ‘parallel curriculum’ leading to less classroom engagement. This practice characterised much of the authors’ experience as medical students, and a cursory search of online student communities reveals that a parallel curriculum runs rampant at nearly all medical schools.

2 |. A CO-CREATION MODEL

Some schools have transitioned to curricula that use classroom time for knowledge application rather than knowledge dissemination.² This is a step in the right direction; however, we argue that schools should also consider how they can integrate modern study tools into their curricula as a method to enhance classroom learning, rather than to replace it. Many of these modern tools employ spaced repetition, an evidence-based cognitive strategy of repeated exposure to concepts over time that promotes long-term knowledge retention.^3,4 Memorising large volumes of information is easier than ever with spaced repetition platforms students are using today, and until lectures are compatible with these platforms, students will see lower utility in attending class.

We propose a model of co-creation wherein students and faculty work together using spaced repetition platforms to create educational material that is relevant for lectures, standardised examinations and clinical rotations. The effectiveness of spaced repetition is well established.^5,6 Furthermore, usage of spaced repetition platforms is an independent predictor of US Medical Licensing Examination (USMLE) Step 1 performance,⁷ with more frequent use associated with higher scores and improved content retention.⁸

Currently, spaced repetition platforms are a major component of the parallel curriculum in medical schools, with students spending hours reviewing content via flashcards instead of attending class. While spaced repetition is highly effective for consolidating information, it is not appropriate for learning novel concepts, which typically requires more in-depth discussion. We argue for pairing these two teaching styles by giving students flashcard decks to review key learning objectives before or after class and then using class time to provide more depth and apply the information to clinical cases. Active learning is superior to passive lectures,⁹ and using spaced repetition platforms paired with active knowledge application in class capitalises on this concept. Put another way, Anna Sfard’s widely recognised two-metaphor model argues that learning is greatest when rooted in both acquisition and participation.¹⁰ Spaced repetition platforms are optimised for acquisition of large volumes of information but decidedly lack participation. Classroom-based discussion is where learners become participants in a learning community.

In practice, student-faculty co-creation of spaced repetition material could consist of senior students working with faculty to create 20–25 flashcards on the most important concepts of any given lecture. These flashcards could function as a supplement to lectures by familiarising students with new vocabulary and content prior to class (e.g. the definition and function of cytokines) and as a tool to reinforce key concepts weeks or months later (Figure 1). Flashcards could be distributed at the start of every week or academic unit to allow students time to review material over time. Ideally, these flashcard decks would also highlight board-relevant content to dissuade learners from forgoing class material in favour of board preparation alone.

FIGURE 1.

Sample Anki flashcard created by students with faculty contribution. The black text represents the prompt. The blue text and image appear when the card is ‘flipped’ to reveal the answer.

Anki (apps.ankiweb.net) is an open-source, electronic flashcard program popular among students,¹¹ which uses spaced repetition to consolidate knowledge via virtual flashcard decks. At our institution, we found success in co-creating flashcard decks with Anki for our classes. Many medical students already use Anki frequently; therefore, they can provide insight into the optimal structure and content for cards and help faculty with the technical aspects of the platform. In addition, including students in the creation process allows for greater buy-in from students and better alignment with their knowledge level.

Indeed, we have already begun to incorporate this strategy into one course at our institution. This course has become highly popular, and many students are proposing that this style of learning be incorporated throughout the entire curriculum. This example supports the feasibility and acceptability of such a strategy, and the flashcards have only required minor modifications in ensuing years.

3 |. FINANCIAL CONSIDERATIONS

Financial concerns regarding the implementation of these curricular changes can be allayed by the fact that the most common spaced repetition platform, Anki, is completely free. In fact, such an approach could provide the added benefit of saving students money on external learning resources. There are well-known disparities in financial resources among medical students.¹² By producing free learning tools that are well received by students and highly applicable to board preparation, some of these financial disparities could be mitigated.

4 |. CONCLUSION

We believe that the union of spaced repetition and co-creation represents the next step in medical education. Students want to excel in the classroom and on standardised exams, and faculty desire curious and engaged learners. If students felt that attending lectures and studying classroom-based resources would help them perform better on examinations, the current parallel curriculum would begin to disappear. Likewise, increased student attendance and participation in lectures would utilise talented faculty to their fullest potential. Co-creation of spaced repetition material represents one important step forward in solving these issues, and we encourage our colleagues to implement it at their institutions.

DATA AVAILABILITY STATEMENT

Data sharing is not applicable to this article as no new data were created or analyzed in this study.