Combining desirable difficulty learning strategies to address the amount-to-learn vs. time-to-learn imbalance in residency training

Abstract

Purpose

Residents have limited time and much to learn. Mounting evidence shows that Desirable Difficulty (DD) learning strategies can ease that imbalance, but few studies have specifically studied combinations of these strategies.

Methods

We tested two different combinations of DD strategies: a double combination of distributed practice and retrieval practice and a triple combination additionally including interleaved practice. We compared residents’ annual In-Training Exam (ITE) scores and graduates’ board certification performance between both DD curricula and a historical baseline.

Results

Average ITE scores rose from 149.06 in the historical baseline to 160.04 under the combined DD curricula (p < 0.001). Average ITE scores fell from 162.50 under the double combination to 155.11 under the triple combination (p = 0.03). There were no significant changes in graduates’ board performance between any of the curricula.

Conclusions

These results add to the evidence that DD strategies can enhance residents’ learning. The drop in ITE scores under the triple DD combination may suggest that it pushed learners past beneficial desirable difficulty into detrimental overwhelming difficulty. Further research should apply this framework in larger and more diverse settings to clarify how these DD strategies can be optimally used to enhance residents’ learning.

Keywords:

• Retrieval practice
• distributed practice
• interleaved practice
• desirable difficulty
• graduate medical education

Acknowledgments

The authors acknowledge the involvement of Dr. Christin Traba, without whose support this study would not have been possible.

Disclosure statement

Dr. Nelson and Dr. Eliasz have no relevant financial relationships or other conflicts of interest to disclose.

Glossary

Desirable difficulty: Is the idea that intentionally making learning activities more difficult can be desirable because it can improve long-term learning and memory. The key is to keep the difficulties desirable; some types or degrees of difficulty can be counterproductive and undesirable because they overwhelm learners and lead to worse learning outcomes. Desirable difficulties are those that stop short of overwhelming learners and counterintuitively enhance learning outcomes.

Bjork, E. L., & Bjork, R. A. (2011). Making things hard on yourself, but in a good way: Creating desirable difficulties to enhance learning. Psychology and the Real World: Essays Illustrating Fundamental Contributions to Society, 2(59-68).

Retrieval practice: Is the learning strategy of studying using quizzing or review questions so that learners must actively retrieve desired information from their long-term memories rather than more passively reviewing the information by reading it or hearing it.

Brown, P. C., Roediger, H. L., & McDaniel, M. A. (2014). Make It Stick. Harvard University Press.

Additional information

Notes on contributors

Adin Nelson

Adin Nelson, MD, MHPE, FAAP - Assistant Professor of Clinical Pediatrics and Associate Pediatrics Clerkship Director, Weill Cornell Medicine, New York, NY.

Kinga L. Eliasz

Kinga L. Eliasz, PhD, MSc - Postdoctoral Research Scientist, New York University Grossman School of Medicine, New York, NY.