The DOI matches its Crossref record; 46 of the 48 references it cites were found in a registry or an index; 1 of the 47 sources its claims cite were checked for support.
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.
Overview
AI snapshot
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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Claims the paper makes
32 Not checked yet · 8 Own interpretation · 1 Supported so far
In the paper
“Repeated testing has been shown to promote better retention than taking a single test.”
§ Test-enhanced learning in medical education > Suggestions for further research
What the sources say
- Not checked yetcites [17] source
boosteddirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“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.”
§ Test-enhanced learning in medical education > Abstract
hedgedconditional- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
- Also stated in: § CONCLUSIONS · hedged
In the paper
“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.”
§ Test-enhanced learning in medical education > Suggestions for further research
What the sources say
- Not checked yetcites [16] source
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
None of the sources cited for this claim have been checked yet.
In the paper
“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.”
§ Test-enhanced learning in medical education > Abstract
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
- Also stated in: § INTRODUCTION · plain
None of the sources cited for this claim have been checked yet.
In the paper
“These indirect benefits of frequent testing have been shown to improve performance in large lecture classes.7,8”
§ Test-enhanced learning in medical education > INTRODUCTION
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“These results indicate that repeated retrieval is key to promoting superior retention.”
§ Test-enhanced learning in medical education > Suggestions for further research
hedgeddirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
None of the sources cited for this claim have been checked yet.
In the paper
“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”
§ Test-enhanced learning in medical education > Abstract
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
- Also stated in: § Suggestions for further research · plain
In the paper
“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”
§ Test-enhanced learning in medical education > Abstract
What the sources say
- Not checked yetcites [27] source
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
- Also stated in: § Suggestions for further research · plain
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“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.”
§ Test-enhanced learning in medical education > Suggestions for further research
hedged- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
None of the sources cited for this claim have been checked yet.
In the paper
“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”
§ Test-enhanced learning in medical education > Abstract
What the sources say
- Not checked yetcites [18] source
- Not checked yetcites [19]
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
- Also stated in: § Suggestions for further research · plain
- It may state two separate claims as one. 10
- Probably not a substantial claim. 2
The sources with a verdict support this claim; the rest weren’t checked yet, have no full text we could read, or their verdicts aren’t rated yet.
In the paper
“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”
§ Test-enhanced learning in medical education > INTRODUCTION
What the sources say
- Supportedcites [5] source
The Summary (p. 15) says spaced learning consistently benefits memory compared with massed learning. The General Discussion (p. 11) reports better recall with spaced study even when the retention interval exceeded one month, supporting the long-term retention point. (LLM, conf=0.94)
- Not checked yetcites [6]
- Not checked yetcites [20]
boosteddirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
- Also stated in: § Suggestions for further research · boosted
None of the sources cited for this claim have been checked yet.
In the paper
“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”
§ Test-enhanced learning in medical education > Suggestions for further research
What the sources say
- Not checked yetcites [2] source
- Not checked yetcites [14]
- Not checked yetcites [15]
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
In the paper
“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”
§ Test-enhanced learning in medical education > INTRODUCTION
What the sources say
- Not checked yetcites [32]
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
- Also stated in: § TESTING IN MEDICAL EDUCATION · plain
None of the sources cited for this claim have been checked yet.
In the paper
“Later research also showed that learning does occur during tests and led to the re-conceptualisation of retrieval as a memory modifier.12,13”
§ Test-enhanced learning in medical education > TEST-ENHANCED LEARNING IN COGNITIVE PSYCHOLOGY
What the sources say
- Not checked yetcites [12]
- Not checked yetcites [13]
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
None of the sources cited for this claim have been checked yet.
In the paper
“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”
§ Test-enhanced learning in medical education > Suggestions for further research
What the sources say
- Not checked yetcites [3]
- Not checked yetcites [22]
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
In the paper
“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.”
§ Test-enhanced learning in medical education > Suggestions for further research
What the sources say
- Not checked yetcites [17]
plaincorrelational- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“This finding could be interpreted as a testing effect because the simulations serve as handson tests.”
§ Test-enhanced learning in medical education > APPLICATION OF TEST-ENHANCED LEARNING IN MEDICAL EDUCATION
hedgedconditional- Asserted: passes — The authors put it forward as true.
- Checkable: fails — It may be too vague to check against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. It may be too vague to check against evidence. The paper’s conclusions may not depend on it.
In the paper
“One potential clinical example concerns evidence that teaching cardiac life support through simulation prevents the forgetting of this knowledge over time.45”
§ Test-enhanced learning in medical education > APPLICATION OF TEST-ENHANCED LEARNING IN MEDICAL EDUCATION
What the sources say
- Not checked yetcites [45]
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it.
None of the sources cited for this claim have been checked yet.
In the paper
“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.”
§ Test-enhanced learning in medical education > TESTING IN MEDICAL EDUCATION
What the sources say
- Not checked yetcites [32]
- Not checked yetcites [42]
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
In the paper
“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”
§ Test-enhanced learning in medical education > Suggestions for further research
What the sources say
- Not checked yetcites [28]
boosteddirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“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.”
§ Test-enhanced learning in medical education > CONCLUSIONS
hedgedconditional- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: unclear — It is unclear why the paper says it holds.
It may state two separate claims as one.
None of the sources cited for this claim have been checked yet.
In the paper
“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”
§ Test-enhanced learning in medical education > APPLICATION OF TEST-ENHANCED LEARNING IN MEDICAL EDUCATION
What the sources say
- Not checked yetcites [16] source
- Not checked yetcites [23]
- Not checked yetcites [24]
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
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?
In the citing paper
“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]
Citations
Cites
Test-Enhanced Learning: Taking Memory Tests Improves Long-Term Retention
Roediger, H. L., & Karpicke, J. D. (2006) · Psychological Science · doi:10.1111/j.1467-9280.2006.01693.x · Cited by 2,867
Memory: A Contribution to Experimental Psychology
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Information Processing and Cognition: The Loyola Symposium
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Wechsler Adult Intelligence Scale--Third Edition
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The power of testing memory: Basic research and implications for educational practice
Roediger, H. L., & Karpicke, J. D. (2006) · Perspectives on Psychological Science · doi:10.1111/j.1745-6916.2006.00012.x · Cited by 2,037
Distributed practice in verbal recall tasks: A review and quantitative synthesis.
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The Critical Importance of Retrieval for Learning
Karpicke, J. D., & Roediger, H. L. (2008) · Science · doi:10.1126/science.1152408 · Cited by 1,791
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The instructional effect of feedback in test-like events.
Bangert-Drowns, R. L., Kulik, C.-L. C., Kulik, J. A., & Morgan, M. (1991) · Review of Educational Research · doi:10.3102/00346543061002213 · Cited by 1,313
Research works printed but not linked: 1
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Cited by
Sorted by citations
A contemporary approach to validity arguments: a practical guide to K ane's framework
Cook, D. A., Brydges, R., Ginsburg, S., & Hatala, R. A. (2015) · Medical Education · doi:10.1111/medu.12678 · Cited by 644
Assessment, feedback and the alchemy of learning
Watling, C., & Ginsburg, S. (2018) · Medical Education · doi:10.1111/medu.13645 · Cited by 461
Eva, K. W., Armson, H., Holmboe, E., Lockyer, J., Loney, E., Mann, K., & Sargeant, J. (2012) · Advances in Health Sciences Education · doi:10.1007/s10459-011-9290-7 · Cited by 402
Larsen, D. P., Butler, A. C., & Roediger III, H. L. (2009) · Medical Education · doi:10.1111/j.1365-2923.2009.03518.x · Cited by 383
Self-citationThe assessment of professional competence: building blocks for theory development
van der Vleuten, C. P. M., Schuwirth, L., Scheele, F., Driessen, E. W., & Hodges, B. D. (2010) · Best Practice & Research Clinical Obstetrics & Gynaecology · doi:10.1016/j.bpobgyn.2010.04.001 · Cited by 356
Metadata
- 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
- Social Sciences › Education › 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
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