Document Type: Original Article


1 Department of Otolaryngology-Head and Neck Surgery, Amir Alam Hospital, Tehran University of Medical Sciences, Tehran, Iran

2 Department of E-Learning in Medical Education, Virtual School, Tehran University of Medical Sciences, Tehran, Iran


Introduction: In the test-enhanced spaced learning, educational
contents are presented in small packages of well-developed
test questions with a defined frequency to the learners. It is not
clear that applying this educational style might have a positive
impact on the summative assessment. Therefore, in this study
we assessed the effect of the test-enhanced spaced learning on
the otolaryngology board and annual examinations of residency
Methods: In a quasi-experimental study with consecutive
sampling, all forty-four residents of otolaryngology in four levels
of training in 2016 at Tehran University of Medical Sciences
(TUMS) received daily-standardized multiple-choice questions
with a twice-repeated frequency of 10 days. Individual feedback
according to one’s response to each test was provided. The results
of national board and annual exam were compared with the same
results of all residents of other universities and previous year
TUMS’ residents for whom spaced learning were not applied and
they were considered as the control groups. The board exam had
two parts, multiple-choice questions, and computer-based clinical
examination. The annual exam format was multiple-choice
questions. The total score for each one was 150. Student’s t-test
and Mann-Whitney U test were used for comparative analyses.
Results: The mean of the board exam results showed statistically
significant improvement compared to other medical schools
(113.6±10.7 vs. 102.9±13.4 in multiple-choice questions,
p=0.048, 118.7±12.5 vs. 54.1±60.0 in the computer-based clinical
examination, p<0.001), while similar comparison results in the
previous year did not show any significant difference.
Conclusion: Spaced learning with testing effect may be useful in
the clinical education setting to improve the learning outcomes.


1. Byrne JH. Learning and Memory. 2nd ed. New York:
Macmillan Reference; 2003. 124 p.
2. Fields RD. Making memories stick. Sci Am.
3. Smolen P, Zhang Y, Byrne JH. The right time to learn:
mechanisms and optimization of spaced learning. Nat
Rev Neurosci. 2016;17(2):77-88.
4. Cepeda NJ, Pashler H, Vul E, Wixted JT, Rohrer
D. Distributed practice in verbal recall tasks: A
review and quantitative synthesis. Psychol Bull.
5. Cepeda NJ, Vul E, Rohrer D, Wixted JT, Pashler H.
Spacing effect in learning: a temporal ridgeline of
optimal retention. Psychol Sci. 2008;19(11):1095-102.
6. Lee TD, Genovese ED. Distribution of practice in motor
skill acquisition: learning and performance effects
reconsidered. Res Q Exerc Sport. 1988;59(4):277-87.
7. Kerfoot BP. Interactive spaced education versus
web based modules for teaching urology to medical
students: a randomized controlled trial. J Urol.
8. Mathes EF, Frieden IJ, Cho CS, Boscardin CK.
Randomized controlled trial of spaced education
for pediatric residency education. J Grad Med Educ.

9. Gandhi M, Beasley A, Vinas E, Sangi-Haghpeykar
H, Ramin SM, Kilpatrick CC. Electronic Learning-
Spaced Education to Facilitate Resident Knowledge
and Guide Program Didactics. Obstet Gynecol.
2016;12(Suppl 1):23s-26s.
10. Blazek MC, Dantz B, Wright MC, Fiedorowicz JG.
Spaced learning using emails to integrate psychiatry
into general medical curriculum: Keep psychiatry in
mind. Med Teach. 2016;38(10):1049-55.
11. Andersen SA, Konge L, Caye-Thomasen P, Sorensen
MS. Learning Curves of Virtual Mastoidectomy in
Distributed and Massed Practice. JAMA otolaryngol
Head Neck Surg. 2015;141(10):913-8.
12. Mammarella N, Fairfield B, Di Domenico A. Does
emotion modulate the efficacy of spaced learning in
recognition memory? Cogent Psychol. 2014;1:986922.
13. Glover JA. The testing phenomenon: not gone but
nearly forgotten. J Educ Psychol. 1989;81(3):392-9.
14. Roediger HL, Karpicke JD. The power of testing
memory: basic research and implications for educational
practice. Perspect Psychol Sci. 2006;1(3):181-210.
15. Larsen D P, B utler A C, R oediger H L. T estenhanced
learning in medical education. Med Educ.
16. Evgeniou E, Loizou P. The theoretical base of

e-learning and its role in surgical education. J Surg
Educ. 2012;69(5):665-9.
17. Maertens H, Madani A, Landry T, Vermassen F,
Van Herzeele I, Aggarwal R. Systematic review
of e-learning for surgical training. Br J Surg.
18. Yu AY, Tian SW, Vogel D, Kwok RC. Can
learning be virtually boosted? An investigation of
online social networking impacts? Comput Educ.
19. Biggs J. Assessment and classroom learning: a
role for summative assessment? Assessment Educ.
20. Smeds MR, Thrush CR, Mizell JS, Berry KS, Bentley
FR. Mobile spaced education for surgery rotation
improves National Board of Medical Examiners scores.
J Surg Res. 2016;201(1):99-104.
21. Cecilio-Fernandes D, Cnossen F, Jaarsma DADC, Tio
RA. Avoiding Surgical Skill Decay: A Systematic
Review on the Spacing of Training Sessions. J Surg
Educ. 2018;75(2):471-80.
22. Kim ASN, Wong-Kee-You AMB, Wiseheart M,
Rosenbaum RS. The spacing effect stands up to big
data. Behav Res Methods. 2019;51: 8.
23. Larsen DP. Picking the right dose: the challenges of
applying spaced testing to education. J Grad Med
Educ. 2014;6(2):349-50.