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Can the ‘Spacing Effect’ Improve the Acquisition and Long-term Retention of Physical Skills?

One of the core components of the Qstream methodology is the ‘spacing effect’, the cognitive psychology research finding that training presented in small amounts over spaced intervals of time substantially boosts long-term retention of the material compared to massed training (AKA ‘binge-and-purge’). I have conducted several large randomized trials showing that the Qstream methodology can generate long-term improvements in clinical decisions made by primary care providers. While clinical decision-making is a skill, this skill is demonstrably different than the physical skills of riding a bike or suturing a wound.

This week in our combined Boston University and VA Boston surgical journal club, we discussed an interesting article that explored how the spacing effect impacts the acquisition and retention of surgical skills: Avoiding surgical skill decay: a systematic review on the spacing of training sessions, by Cecilio-Fernandes et al. in the Journal of Surgical Education (75:471-480, 2017;

This research team searched the published literature to identify 1302 papers that addressed some combination of skill development, skill retention, distributed practice, and/or the spacing effect. They then narrowed this list to only those studies that were randomized trials on surgical skill acquisition among medical trainees. Only 11 papers met these inclusion criteria. The take-home message from their review is that the spacing of training sessions improves long-term surgical skills retention when compared to massed practice. Two of the papers in their review merit detailed attention:

(1) Moulton CE et al. Teaching surgical skills: what kind of practice makes perfect?: a randomized, controlled trial. Annals of Surgery 2006;244(3):400-409 ( This is a beautiful study showing that spaced training (four weekly 1-hour training sessions) generates greater retention of surgical skills on a microsurgery practice model than massed training (one 4-hour training session). In addition, they demonstrated that the spaced group outperformed the massed group on a subsequent live-rat anastomosis (the suturing of two vessels together), thus showing superior transfer of skills from the practice model to a live (rodent!) patient.

(2) Gallagher et al. Prospective, randomized assessment of the acquisition, maintenance, and loss of laparoscopic skills.Annals of Surgery 2012;256(2):387-393 ( In this randomized trial among 24 novices in laparoscopic (minimally-invasive) surgery utilizing a virtual-reality surgical-training simulator, the researchers demonstrated that (a) laparoscopic skills are optimally acquired on an interval (spaced) training schedule and (b) these skills significantly decline with 2 weeks of nonuse. I am a robotic surgeon at the VA Boston Healthcare System, and on the basis of this research showing that skills decay very quickly in the absence of practice, I require that the junior residents practice their robotic surgical skills for an hour on the simulator in the week prior to a case if they wish to join me to perform the surgery.

The bottom line: spaced training such as that provided by Qstream can substantially improve both the acquisition and long-term retention of physical skills, not just knowledge.

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