Test-enhanced learning in medical education
Open accessAbstract
Context In education, tests are primarily used for assessment, thus permitting teachers to assess the efficacy of their curriculum and to assign grades. However, research in cognitive psychology has shown that tests can also directly affect learning by promoting better retention of information, a phenomenon known as the testing effect. Cognitive psychology research Cognitive psychology laboratory studies show that repeated testing of information produces superior retention relative to repeated study, especially when testing is spaced out over time. Tests that require effortful retrieval of information, such as short‐answer tests, promote better retention than tests that require recognition, such as multiple‐choice tests. The mnemonic benefits of testing are further enhanced by feedback, which helps students to correct errors and confirm correct answers. Application to medical education Medical educational research has focused extensively on assessment issues. Such assessment research permits the conclusion that clinical expertise is founded on a broad fund of knowledge and effective memory networks that allow easy access to that knowledge. Test‐enhanced learning can potentially strengthen clinical knowledge that will lead to improved expertise. Conclusions Tests should be given often and spaced out in time to promote better retention of information. Questions that require effortful recall produce the greatest gains in memory. Feedback is crucial to learning from tests. Test‐enhanced learning may be an effective tool for medical educators to use in promoting retention of clinical knowledge.
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Written from the paper’s full text.
TL;DR
This narrative review argues that tests are not merely assessment devices but active memory modifiers, and that "test-enhanced learning" — frequent, spaced, effortful retrieval with feedback — could strengthen the clinical knowledge base underlying medical expertise. It synthesizes cognitive psychology laboratory evidence and maps it onto the history and priorities of medical education assessment.
Key findings
- Repeated testing produces better long-term retention than repeated study. In Karpicke and Roediger's flashcard experiment with 40 Swahili–English word pairs, students in the standard and repeated-testing groups recalled approximately 80% of pairs on a test 1 week later, versus 36% (repeated study) and 33% (drop) — indicating that repeated retrieval, not continued study, drives retention.
- More tests are better than fewer: students who took three tests on picture names recalled more 1 week later than those who took one test, who in turn recalled more than those not tested at all (Wheeler & Roediger).
- Production tests (short-answer, fill-in-the-blank, essay) yield better retention than recognition tests (MCQ, true/false). In Butler and Roediger's art-history video lecture study, an initial short-answer test produced better retention on a final test 1 month later than an initial MCQ test or studying a lecture summary.
- Feedback enhances the testing benefit by correcting errors and confirming correct answers; feedback containing the correct answer is critical, and delayed feedback sometimes produces superior retention relative to immediate feedback.
Methods
- Design: narrative/conceptual review, not an empirical study; the authors state no new data were collected ("Ethical approval: not applicable").
- Evidence base: cognitive psychology laboratory experiments on the testing effect, spacing effect, test format, and feedback, plus a review of the medical education assessment literature (MCQ vs OEQ, key features problems, script-concordance questionnaires, progress tests, in-training assessment).
- Analysis: qualitative synthesis organized into three sections — testing research in cognitive psychology, the evolution of testing in medical education, and application of test-enhanced learning to medical education — concluding with recommendations for practice.
Limitations
- Stated: most evidence for the direct effects of testing comes from laboratory experiments, and many applied studies occurred in simulated classrooms; testing benefits have not been fully studied in lectures, problem-based sessions, or clinical activities.
- Stated: most "long-term" testing studies used retention intervals of less than 1 week, with a few up to 6 weeks, whereas medical trainees need to retain information for months to years, so efficacy over long periods is unestablished.
- Stated: it is unknown whether improved test recall translates into retrieval during patient encounters or better patient care; the authors call for real patient outcome and care metrics as the strongest validation. Evident from the text: the paper offers no primary data, effect sizes, or meta-analytic synthesis of its own, so its recommendations rest on the cited studies.
Model-written summary. Check it against the paper before relying on it.
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Cites
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Claims the paper makes
0 of 47 cited sources checked · 0 supported · 0 flagged
- Premisecitation
Repeated testing promotes better retention than taking a single test.
“Repeated testing has been shown to promote better retention than taking a single test.”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [17] source
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- Interpretationreasoning
Test-enhanced learning may be an effective tool for medical educators to use in promoting retention of clinical knowledge.
“Test-enhanced learning may be an effective tool for medical educators to use in promoting retention of clinical knowledge.”
- Also stated in: § CONCLUSIONS · hedged
“It could provide a welcome addition to the tools with which educators can help medical students, residents and practising doctors retain information and progress towards greater clinical expertise.”
Quote in the paperSubstantial claim - Also stated in: § CONCLUSIONS · hedged
- Premisecitation
In Karpicke and Roediger's experiment, on a final test 1 week later, students in the standard and repeated testing groups recalled approximately 80% of word pairs, whereas the repeated study and drop groups recalled 36% and 33%, respectively.
“students in both the standard and repeated testing groups recalled approximately 80% of the word pairs, whereas students in the repeated study and drop groups recalled 36% and 33%, respectively.”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [16] source
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- Premisecitation
Repeated testing of information produces superior retention relative to repeated study.
“Cognitive psychology laboratory studies show that repeated testing of information produces superior retention relative to repeated study, especially when testing is spaced out over time.”
- Also stated in: § INTRODUCTION · plain
“Being tested is a better way to learn material than is further study, as we discuss below.”
Quote in the paperSubstantial claim - Also stated in: § INTRODUCTION · plain
- Premisecitation
The indirect benefits of frequent testing improve performance in large lecture classes.
“These indirect benefits of frequent testing have been shown to improve performance in large lecture classes.7,8”
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- Interpretationreasoning
Repeated retrieval is key to promoting superior retention.
“These results indicate that repeated retrieval is key to promoting superior retention.”
Quote in the paperSubstantial claim - Premisecitation
Tests that require effortful retrieval, such as short-answer tests, promote better retention than tests that require recognition, such as multiple-choice tests.
“Tests that require effortful retrieval of information, such as short-answer tests, promote better retention than tests that require recognition, such as multiple-choice tests.”
- Also stated in: § Suggestions for further research · plain
“Research has shown that production tests lead to better retention than recognition tests, presumably because production tests require more effortful retrieval of information from memory than recognition tests.3,22”
Quote in the paperSubstantial claim0 of 2 sources checked - Also stated in: § Suggestions for further research · plain
- Premisecitation
Feedback enhances the mnemonic benefits of testing by helping students correct errors and confirm correct answers.
“The mnemonic benefits of testing are further enhanced by feedback, which helps students to correct errors and confirm correct answers.”
- Also stated in: § Suggestions for further research · plain
“Although testing improves retention in the absence of feedback, as shown in many of the studies described above, providing feedback enhances the benefits of testing by correcting errors and confirming correct responses.27”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [27] source
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- Also stated in: § Suggestions for further research · plain
- Interpretationreasoning
Continuing to study an item once it has been recalled has a negligible effect on retention.
“Interestingly, the standard group did not demonstrate better retention than the repeated testing group, which suggests that continuing to study an item once it has been recalled has a negligible effect on retention.”
Quote in the paperSubstantial claim - Premisecitation
The superiority of repeated testing over repeated study is greater when testing is spaced out over time.
“Cognitive psychology laboratory studies show that repeated testing of information produces superior retention relative to repeated study, especially when testing is spaced out over time.”
- Also stated in: § Suggestions for further research · plain
“The benefits of repeated testing are even greater when tests are distributed over time.18,19”
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- cites [19]
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- Also stated in: § Suggestions for further research · plain
- Premisecitation
Clinical expertise is founded on a broad fund of knowledge and effective memory networks that allow easy access to that knowledge.
“Such assessment research permits the conclusion that clinical expertise is founded on a broad fund of knowledge and effective memory networks that allow easy access to that knowledge.”
- Also stated in: § APPLICATION OF TEST-ENHANCED LEARNING IN MEDICAL EDUCATION · boosted
“The medical education assessment literature has concluded that clinical expertise and problem solving rely heavily on a fund of clinical knowledge that is organised into a usable network.32,35”
Quote in the paperSubstantial claim0 of 2 sources checked - Also stated in: § APPLICATION OF TEST-ENHANCED LEARNING IN MEDICAL EDUCATION · boosted
- Premisecitation
Tests can directly affect learning by promoting better retention of information, a phenomenon known as the testing effect.
“However, research in cognitive psychology has shown that tests can also directly affect learning by promoting better retention of information, a phenomenon known as the testing effect.”
- Also stated in: § INTRODUCTION · plain
“Although tests certainly have a function as assessment devices, we make the argument here that tests can also promote learning by directly increasing the retention of information.”
Quote in the paperSubstantial claim - Also stated in: § INTRODUCTION · plain
- Interpretationreasoning
Test-enhanced learning can potentially strengthen clinical knowledge that will lead to improved expertise.
“Testenhanced learning can potentially strengthen clinical knowledge that will lead to improved expertise.”
- Also stated in: § CONCLUSIONS · hedged
“However, we are optimistic that incorporating testing exercises of all sorts within the educational process can benefit learning, help create organised networks of knowledge, and promote the retrieval of information in contexts where it is needed.”
Quote in the paperSubstantial claim - Also stated in: § CONCLUSIONS · hedged
- Interpretationreasoning
Response format is not as important as the content of the question.
“Therefore, the conclusion followed that response format is not as important as the content of the question.35”
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- Premisecitation
Delayed feedback produces superior retention relative to immediate feedback, at least in some cases.
“recent research shows that, at least in some cases, delayed feedback produces superior retention relative to immediate feedback.27,31”
Quote in the paperNot a substantial claim0 of 2 sources checked - Premisecitation
In Butler and Roediger's experiment, on a final test 1 month later, taking an initial short-answer test yielded better retention than either taking an initial MCQ test or studying the lecture summary.
“On a final test administered 1 month later, taking an initial short-answer test yielded better retention than either taking an initial MCQ test or studying the lecture summary.”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [23] source
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- Premisecitation
Assessment tests are typically given weeks to months after learning events, when the effects of tests to promote memory are minimised.
“Assessment tests are typically given weeks to months after learning events, when the effects of tests to promote memory are minimised.11”
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- Premisecitation
Similar results have been found for in-training assessment programmes during postgraduate medical education.
“Similar results have been found for in-training assessment programmes during postgraduate medical education.43”
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- Interpretationreasoning
Test-enhanced learning facilitates improved retention of factual knowledge.
“Test-enhanced learning seems particularly useful in that it facilitates improved retention of factual knowledge.”
Quote in the paperSubstantial claim - Interpretationreasoning
Multiple-choice questions can be used just as well as OEQs to assess the foundations of expertise.
“Multiplechoice questions can be used just as well as OEQs to assess the foundations of expertise.36”
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- Interpretationcitation
Using production tests in the classroom will promote better retention than recognition tests.
“This study and others indicate that using production tests in the classroom will promote better retention than recognition tests.23,24”
Quote in the paperSubstantial claim0 of 2 sources checked - Premisecitation
Providing correct answer feedback can be essential to learning from tests, especially when performance on an initial test is very low.
“Indeed, providing students with correct answer feedback can be essential to their learning from tests, especially when performance on an initial test is very low.29”
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- Premisecitation
The ability to solve problems is highly dependent on the knowledge on which the case is based, also known as case specificity.
“With further study, it became clear that the ability to solve problems was highly dependent on the knowledge on which the case was based ) also known as case specificity.32,37”
Quote in the paperSubstantial claim0 of 2 sources checked - Premisecitation
Studies of question format showed high correlation between MCQs and OEQs.
“Studies of question format showed high correlation between MCQs and OEQs.40”
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- Interpretationcitation
The theoretical reason for the production test advantage is the amount of effort needed to recall the information.
“The theoretical reason for this effect seems to be driven by the amount of effort needed to recall the information.4”
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- Premisecitation
Of the more applied studies that have used standard educational materials, many have taken place in simulated classrooms.
“Of the more applied studies that have used standard educational materials, many have taken place in simulated classrooms.23”
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- Premisecitation
At least one study showing the benefits of testing occurred in a university course.
“However, at least one study showing the benefits of testing occurred in a university course.24”
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- Interpretationreasoning
The efficacy of testing in promoting retention over long periods of time has yet to be established.
“Thus, the efficacy of testing in promoting retention over long periods of time has yet to be established.”
Quote in the paperSubstantial claim- Rests on an assumption: Medical trainees need to retain information for months to years.
- Interpretationcitation
Repeated testing that is spaced over time has great potential for improving learning in the classroom.
“Thus, repeated testing that is spaced over time has great potential for improving learning in the classroom.21”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [21] source
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- May combine two claims. 10
- Classified as probably not a substantial claim. 2
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PremisecitationThe total time hypothesis is incorrect; taking a test leads to better retention than re-studying material for an equivalent amount of time.
“Ultimately, the total time hypothesis was found to be incorrect by experiments showing that taking a test leads to better retention than re-studying the material for an equivalent amount of time.2,14,15”
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PremisecitationFrequent testing increases the amount of study time and improves study strategies, producing indirect effects of testing.
“The indirect effects of testing refer to the increase in the amount of study time and improvement in study strategies that result from frequent testing.”
- Also stated in: § TESTING IN MEDICAL EDUCATION · plain
“Studies of educational impact provide a thorough summary of the indirect effects of testing and assessment, which include increased motivation to study, more efficient learning strategies, and improved accuracy in the measurement of curriculum efficacy.32”
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- Also stated in: § TESTING IN MEDICAL EDUCATION · plain
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PremisecitationSpaced study sessions aid memory performance, and distributed or spaced practice is superior to massed practice for long-term retention.
“Much research shows that spaced study sessions aid memory performance.5,6”
- Also stated in: § Suggestions for further research · boosted
“Indeed, the superiority of distributed or spaced practice over massed practice in promoting long-term retention, commonly referred to as the spacing effect, is highly replicable and quite robust.5,20”
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PremisecitationLearning occurs during tests, and retrieval acts as a memory modifier.
“Later research also showed that learning does occur during tests and led to the re-conceptualisation of retrieval as a memory modifier.12,13”
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PremisecitationProduction tests lead to better retention than recognition tests, presumably because production tests require more effortful retrieval of information from memory.
“Research has shown that production tests lead to better retention than recognition tests, presumably because production tests require more effortful retrieval of information from memory than recognition tests.3,22”
Quote in the paperSubstantial claim0 of 2 sources checked- cites [3]
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PremisecitationIn Wheeler and Roediger's study, the group that took three tests recalled more names on a final test than the group that took one test, which in turn recalled more than the group not tested at all.
“One week later, the group that took three tests recalled more of the names on a final test than the group that took one test, which in turn recalled more names than the group that was not tested at all.”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [17]
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Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).
InterpretationreasoningThe finding that simulation prevents forgetting of cardiac life support knowledge could be interpreted as a testing effect because the simulations serve as hands-on tests.
“This finding could be interpreted as a testing effect because the simulations serve as handson tests.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationEvidence shows that teaching cardiac life support through simulation prevents the forgetting of this knowledge over time.
“One potential clinical example concerns evidence that teaching cardiac life support through simulation prevents the forgetting of this knowledge over time.45”
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PremisecitationProgress tests allow students to measure their growth in knowledge and plan study strategies, and allow faculty to gauge curriculum effectiveness and integration over time.
“The repeated testing of the curriculum allows students to measure their growth in knowledge and plan their study strategies in an ongoing manner.32,42 The test results also allow faculty members to gauge the effectiveness of the curriculum and its integration over time.”
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PremisecitationSimply providing right/wrong feedback does little to help students correct errors; including the correct answer in the feedback message is critical.
“However, much research has shown that simply providing information about the outcome of the response (i.e.right ⁄ wrong) does little to help students correct their errors, and that including the correct answer in the feedback message is critical.28”
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Interpretationnone givenThe types of test that seem most effective are those that involve active production of knowledge, are spaced in time, and have feedback given at some delay after the test.
“The types of test that seem to be most effective are those that involve active production of knowledge (rather than its more passive recognition), are spaced in time, and have feedback given at some delay after the test.”
Quote in the paperNot a substantial claimMay combine two claims.
PremisecitationMost studies of long-term testing effects have used retention intervals of less than 1 week, although a few have used longer intervals of up to 6 weeks.
“Most studies of Ôlong-termÕ testing effects have used retention intervals (i.e. the time before the final examination) of less than 1 week, although a few have used longer intervals of up to 6 weeks.16,23,24”
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The paper relies on this without support.
Testing in medical education has largely served as an instrument of assessment.
“Testing in medical education has largely served as an instrument of assessment.”
The paper relies on this without support.
Assessment drives learning.
“The importance of this context is encapsulated in the oft-repeated aphorism that assessment drives learning.”
The paper relies on this without support.
The majority of evidence for the direct effects of testing has come from laboratory experiments.
“For example, the majority of evidence for the direct effects of testing has come from laboratory experiments.”
The paper relies on this without support.
Improved retention through testing has not yet been fully studied in many teaching situations, such as lectures, problem-based sessions or clinical activities.
“Still, improved retention through testing has not yet been fully studied in many teaching situations, such as lectures, problem-based sessions or clinical activities.”
The paper relies on this without support.
Medical trainees need to retain information for months to years.
“However, medical trainees need to retain information for months to years.”
The paper relies on this without support.
The fact that tests can be used to improve learning is not widely realised within education, especially higher education.
“The fact that tests can be used to improve learning is not widely realised within education, especially higher education.”
The paper relies on this without support.
More than recall of information is needed to be an effective doctor.
“Although this is applicable in medical education, we recognise that more than recall of information is needed to be an effective doctor.”
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
Randomized controlled trials demonstrate that repeated testing promotes better retention of information than repeated studying (the testing effect).
“For example, randomized controlled trials demonstrate that repeated testing promotes better retention of information than repeated studying, a phenomenon known as the testing effect.3,4”
From Effect of repeated/spaced formative assessments on medical school final exam performance (2017) · cites this paper as [3]
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- Authors
- Larsen, D. P., Butler, A. C., & Roediger III, H. L.
- Affiliations
- Washington University in St. Louis (US)
- Corresponding author
- Larsen, Douglas P
- Venue
- Medical Education
- Publisher
- Wiley
- Published
- 2008-09-15
- Volume
- 42
- Issue
- 10
- Pages
- 959-966
- ISSN
- 0308-0110 (ISSN-L)
- 1365-2923
- OpenAlex
- W2152957004
- Semantic Scholar
- 5348cd3116e8b3ecb6a37d9cb0f0719582f24cd4
- Cited by
- 610
- References
- 48
- Citations by year
- 2026: 27 · 2025: 24 · 2024: 23 · 2023: 37 · 2022: 49 · 2021: 42 · 2020: 41 · 2019: 51 · 2018: 54 · 2017: 36 · 2016: 42 · 2015: 39 · 2014: 24 · 2013: 38 · 2012: 29
- FWCI
- 17.81
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Medical Education (publishedVersion)
- PubMed (publishedVersion)
- Funders
- James S. McDonnell Foundation
- Washington University in St. Louis
- Institute of Education Sciences (R305H060080)
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Innovations in Medical Education
- Life Sciences › Neuroscience › Cognitive Neuroscience › Memory Processes and Influences
- Health Sciences › Medicine › Family Practice › Clinical Reasoning and Diagnostic Skills
- Keywords
- retrieval practice, testing effect, spaced repetition, memory retention, feedback, clinical knowledge, assessment
- MeSH terms
- Education, Medical, Educational Measurement, Memory, Students, Medical, Time Factors
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-10.
Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-10.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
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