Online spaced education generates transfer and improves long-term retention of diagnostic skills: a randomized controlled trial

J Am Coll Surg. 2010 Sep;211(3):331-337.e1. doi: 10.1016/j.jamcollsurg.2010.04.023. Epub 2010 Jul 13.


Background: Retention of learning from surgical training is often limited, especially if the knowledge and skills are used infrequently. Using histopathology diagnostic skills as an experimental system, we compared knowledge transfer and retention between bolus Web-based teaching (WBT) modules and online spaced education, a novel email-based method of online education founded on the spacing effect.

Study design: All US urology residents were eligible to participate. Enrollees were randomized to 1 of 2 cohorts. Cohort 1 residents received 3 cycles/repetitions of spaced education on prostate-testis histopathology (weeks 1 to 16) and 3 WBT modules on bladder-kidney (weeks 14 to 16). Cohort 2 residents received 3 cycles of spaced education on bladder-kidney (weeks 1 to 16) and 3 WBT modules on prostate-testis (weeks 14 to 16). Each daily spaced education email presented a clinical scenario with histopathology image and asked for a diagnosis. Participants received immediate feedback after submitting their answers. Each cycle/repetition was 4 weeks long and consisted of 20 questions with unique images. WBT used the identical content and delivery system, with questions aggregated into three 20-question modules. Long-term retention of all 4 topics was assessed during weeks 18 to 45.

Results: Seven-hundred and twenty-four urology residents enrolled. Spaced education and WBT were completed by 77% and 66% of residents, respectively. Spaced education and WBT generated mean long-term score increases of 15.2% (SD 15.3%) and 3.4% (SD 16.3%), respectively (p < 0.01). Spaced education increased long-term learning efficiency 4-fold.

Conclusions: Online spaced education generates transfer of histopathology diagnostic skills and substantially improves their long-term retention. Additional research is needed to determine how spaced education can optimize learning, transfer, and retention of surgical skills.

Publication types

  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adult
  • Clinical Competence*
  • Computer-Assisted Instruction*
  • Diagnosis*
  • Electronic Mail*
  • Female
  • Humans
  • Internet*
  • Internship and Residency* / methods
  • Internship and Residency* / organization & administration
  • Internship and Residency* / trends
  • Male
  • Pathology / education
  • Retention, Psychology*
  • Time Factors
  • United States
  • Urology / education*