Using Digital Tools to Promote Spaced Repetition
by Cia Kessler, Instructional Designer, EdTech
Few fields are as complex as healthcare, not only because of the cognitive complexity of the information required to apply conceptual knowledge in a clinical setting but also because of continual developments in technology and understanding of basic science. Recent studies have shown that medical knowledge is currently doubling exponentially, at a rate of 73 days (Denson, 2011.) In fact, incoming medical students are often told that they had better “learn to drink from a firehose” because that’s what the first two years of instruction will be like for them (Augustin, 2014.)
Yet they are not alone in undertaking tasks that are at times so overwhelming that they may feel like hazing. Many students find it challenging to efficiently master critical conceptional information, especially in rapidly changing fields, because they haven’t been taught fundamental retention strategies, nor are they able to assess the quality of their learning to better support the review process. The strategy proposed below, spaced repetition, is used by many medical students to master information, particularly in the first two years, and it is also suitable in many other fields (Augustin, 2014; Production Fish, 2023.) Recent improvements in digital technology which make use of spaced repetition in their algorithms, can make these tools even more efficient and accessible for students.
The Theory of Disuse and Spaced Repetition
Before moving to memory, however, we should understand forgetting. The German scholar Ebbinghouse was among the first to study forgetting, which he did by memorizing nonsense syllables and trying to recall them at intervals (Ebbinghouse, 2013; Tamm, 2023.) What he found was interesting because it showed that recall loss occurs along a curve: additional study periods along a timeline could improve overall retention (Tamm, 2023.) Put another way, for a variety of reasons a learner can strengthen their memory by deliberately allowing some time to lapse and forgetting some of it, an idea called the “theory of disuse” (Tamm, 2023.)
Fig. 1 Annotated Ebbinghouse Curve (Spiro, 2022.)
Later theorists studied the Ebbinghouse Curve and proposed various intervals for refreshing knowledge before recall dropped off the table (Tamm, 2023.) This idea goes beyond simply encouraging planning vs. cramming. Instead, it suggests that there is an optimal window for forgetting and then re-learning; and that the re-learning process is critical to long-term retention (Tamm, 2023.) Algorithms were developed to maximize the efficiency of this model, finding the “sweet spot” to return to the studied material (Settles, 2016; Pham, 2016.) This is the basis of spaced repetition: by reviewing concepts at strategically defined intervals (which are gradually lengthened), recall is improved (Pham, 2016.)
The most common use of spaced repetition is in flashcards, something many of us may have used to memorize a language. Generally, a learner will shuffle through a deck of cards, testing themselves and putting aside the cards that are the most challenging to review later. Now there are a variety of programs available that use the basic flashcard model while incorporating an algorithm that optimizes the space repetition model to improve learning (Pham, 2016.) They can easily be incorporated as additional resources for students into Blackboard (and coming soon, Brightspace). Used diligently, they will improve student retention and lessen the impact of drinking from a firehose. Here are two of the most popular:
Flashcard Programs: Anki
Anki (the Japanese word for memorization) is an open-sourced program that is available free. It is media-rich, allowing you to incorporate audio, video, and image files and it is highly customizable. There are a huge number of pre-built decks available from the Anki community that be downloaded. You can create decks for your classes yourself as a study aid and provide a link to them on Blackboard or ask the students to create and share decks as an assignment. Students can customize intervals for repetition by ranking how hard or easy a given card is, providing self-awareness of their own strengths and weaknesses.
Download from: https://apps.ankiweb.net/
Fig. 2 Anki Master Works of Art deck
The deck in Figure 2 was downloaded from a community forum. On the front of each card is a masterwork of art, on the back of each is the name of the painter along with some pertinent details to remember. The student flips the card when they have an answer and compares it to the information on the back. Before moving on the student rates their ability to answer the question (a form of metacognitive resolution.) Their rating determines how soon, and how frequently they will see this card again. Other features of the program allow them to sync their deck with another device such as a tablet or mobile phone, view statistics on their performance, add another card or additional content, and browse tags associated with a particular card.
Flashcard Programs: Quizlet
Many of us may have used Quizlet in the classroom to promote collaboration. The Quizlet flashcard model is very similar to the Anki offering but with slightly more features. It is not open-sourced, but it is low-cost.
Fig. 3 Quizlet Interface
Flashcard decks can be created by a learner and used on the platform or downloaded. There are a variety of ways to use the cards: to learn the items, test yourself by working through the cards, or play a “match” game in which cards disappear when correctly matched. Q-Chat, a recently added “beta” feature, allows users over 18 to use a chat engine for one-on-one tutoring in any subject. Hints and pronunciation help are also available in the interface.
Quizlet also includes an award-winning library of materials called “Be the Change Social Justice Library” which includes media-rich study sets, lesson plans, and original content on race and ethnicity, gender and identity, immigration, and much more. The teacher version allows you to create study materials for students and monitor their success. There is also a new AI enhancement feature that can transform slide sets or lecture notes automatically into outlines, quizzes, and flashcards. Teachers can try the full product for a free trial. Both students and teachers can also create their own materials using a free Quizlet account with more limited capabilities.
Augustin, M. (2014, June 6). How to learn effectively in medical school: Test yourself, learn actively, and repeat in intervals. The Yale journal of biology and medicine. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4031794/
Densen, P. (2011). Challenges and opportunities facing medical education. Transactions of the American Clinical and Climatological Association. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3116346/#:~:text=It%20is%20estimated%20that%20the,0.2%20years%E2%80%94just%2073%20days
Ebbinghaus, H. (2013, October). Memory: A contribution to experimental psychology. Annals of neurosciences. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4117135/
Lemov, D. (2021, February 8). An Annotated Forgetting Curve. Teach Like a Champion. https://teachlikeachampion.org/blog/an-annotated-forgetting-curve/
Pham, X.-L., Chen, G.-D., Nguyen, T.-H., Hwang, W.-Y., Dreyer, C., Furió, D., Hong, J.-C., Sanchez, C. A., Adams, P., Albers, M., Arning, K., Baddeley, A. D., Baird, J. W., Buchanan, E. A., Butler, A. C., Cao, J., Cutter, J. D., Dictionaries, O., Edge, D., & Ellis, N. C. (2016, March 29). Card-based design combined with spaced repetition: A new interface for displaying learning elements and improving active recall. Computers & Education. https://www.sciencedirect.com/science/article/pii/S036013151630077X
Productive Fish. (2023, March 23). How to memorize faster with the spaced repetition system. How To Memorize Faster with The Spaced Repetition System. https://productive.fish/blog/spaced-repetition/
Settles, B. (2016). A Trainable Spaced Repetition Model for Language Learning – Duolingo. Association for Computational Linguistics. https://research.duolingo.com/papers/settles.acl16.pdf
Spiro, K. (2022, August 23). How to beat the forgetting curve. Easygenerator. https://www.easygenerator.com/en/blog/e-learning/use-variety-to-beat-forgetting curve/#:~:text=Repetition%20is%20key%20to%20retention,it%20as%20long%2Dterm%20memory
Tamm, S. (2023, February 13). What is the Ebbinghaus Forgetting Curve? – e-student. eStudent.org. https://e-student.org/ebbinghaus-forgetting-curve/