By Megan Sumeracki

Cover image by Mohamed Hassan from Pixabay

About 8 years ago (seriously, I can’t believe we’ve been doing this for so long…), we published a pair of blog posts on understanding both near and far transfer (Part 1; Part 2). Transfer is one of my favorite topics, in part because it is arguably the whole point of most formal education. The purpose of learning something in school is to be able to at the very least produce it outside of school, and ideally use it or apply it outside of school in some other context. This is true in many, many grades, subject areas, and programs. However, this feels particularly true in premedical and medical education.

Within medical education, learners need to build their knowledge base and carry it with them across courses, semesters, and phases of their training (premed to medical school, medical school to residency, residency to fellowship for some, and all to medical practice, for example). This requires far transfer. The authors of the paper I focus on today, Kulasegaram and colleagues (1), state it so well that I’ll quote them here:

“In undergraduate medical training, the issue of transfer is particularly serious as many different domains of knowledge such as basic sciences are taught with the expectation of future utility for problem solving…the transfer of basic science knowledge to the clinical task is essential if learners are to derive benefit from basic science teaching.” (Kulasegaram et al., 2015, p. 954)

 In today’s blog, I am writing about an experiment by Kulamakan Kulasegaram and colleagues (1) investigating which combinations of certain learning strategies led to greater levels of transfer. This paper discusses their work in the context of transfer of premedical information. But but I think the conclusions could also be generalized to other types of learners and other phases of medical education when dealing with novices. (Especially given that they are in line with other research we have written about in other domains, discussed a bit below.)

Also of note for medical educators with access to peer-reviewed journals, I am a co-author on a paper that covers this experiment as well. The paper is on the use of interleaving in continuing professional development, CPD, in health professions, (2).

The Experiment Method

In the experiment, first-year undergraduate psychology students learned three physiological principles. The researchers manipulated two variables: whether the students engaged in interleaving or blocked practice, and whether the students practiced within one or two different contexts with the concepts they were learning.

Manipulation 1: Interleaving vs. blocking

In the interleaving condition, students read explanations for all three of the physiological principles. Then they practiced with six practice cases in a random order. Because the practice cases were interleaved (or mixed up), the students had to identify which physiological  principle applied and how it explained the practice case.

In the blocked condition, students read an explanation first and then completed the two practice cases associated with that principle before moving onto the next principle. Thus, three principles and six total cases were presented, but they were blocked or organized by principle.

Manipulation 2: Context

When students learned with one context, the two practice cases associated with each physiological principle involved the same organ system. For example, when learning about fluid dynamics, respiratory disorders were used for both cases.

When students learned with two contexts, the two practice cases associated with two of the three physiological principles involved two different organ systems. For example, when learning about fluid dynamics, one practice case involved the respiratory system and the other the cardiovascular system. (The third physiological principle, Starling’s law, only applied to cardiovascular systems, and this is dealt with in the data.)

Students in the experiment read the explanations and completed their practice cases with feedback in the way outlined by their particular experimental condition (i.e., interleaved with one context, interleaved with two contexts, blocked with one context, blocked with two contexts).

Measuring Learning and Transfer

The students were then tested to see how much they could remember by answering multiple-choice and short-answer questions that assessed their knowledge about the concepts they learned.

Students were then given 15 transfer cases. These cases were clinical vignettes similar to those from the practice session. Students had to identify the physiological principle that applied, and provide an explanation for how the concept accounted for the clinical signs and symptoms presented in the vignette. Some of the transfer cases involved systems that were previously learned (e.g., fluid dynamics and respiratory disorders), or that were not previously learned (e.g., fluid dynamics and urinary tract cases).

Results

The researchers present a lot of data, but I summarize what I think are the main findings here.

First, the students answered about 70-80% of the knowledge questions, and performance did not depend on the experimental manipulations. So, at least for these questions, interleaving vs. blocking and context of examples didn’t really matter.

The results on the transfer cases are much more interesting. The students who learned with interleaving and two contexts had the highest scores on the near and far transfer cases. For the far transfer cases, having practice with two contexts was particularly important. There was no significant difference on the far transfer cases between the blocked and interleaved learning conditions as long as two contexts (i.e., two different organ systems) were used.

Conclusion

Overall, the results suggest that giving students practice with multiple contexts seems to be particularly important for far transfer, and when that happens, interleaving the examples is better than blocking.

 The authors write about the importance of transfer for medical education, and specifically discuss transfer of premed knowledge to later clinical training (presumably undergraduate medical education, more casually referred to as medical school). But plenty of students take physiology for other reasons other than preparation for formal medical school. For example, in my department at Rhode Island College the behavioral health studies program students take physiological psychology and should be able to transfer the knowledge to their internship courses and work in mental health. And, these findings are in line with other research we have presented in other domains.

These findings make sense in light of the other research we have covered on our blog related to interleaving vs. blocking, and related to concrete examples and transfer of knowledge to other domains more generally. We know, for example, that using multiple concrete examples with different surface features is particularly helpful in helping students transfer the concept to other new examples (check out this blog: two examples are better than one). We also know that novices tend to focus on surface details more than experts (check out this blog: what do students remember from our examples?).

Essentially, multiple examples with different surface features is what the researchers did here for the two contexts conditions. When they gave students practice cases in two contexts, the underlying principle (e.g., fluid dynamics) was the same, but the surface features (e.g., respiratory system cases, cardiovascular system cases) were different. Thus, students in this condition were likely better able to clearly see the underlying principle and how it functioned in different contexts. This led to better performance applying the concept on their own in a third, new context (e.g., urinary tract cases).

Interested in more learning science in medical education? I have been collaborating with a colleagues in neuroscience (Chris Madan) and continuing medical education (Thomas van Hoof). Together we have now published a series of 5 articles in Journal of Continuing Education in the Health Professions (JCEHP) about the application of science of learning principles to continuing medical and health professions education. If you have access to this peer-reviewed journal, you may be interested in checking the series out! We have articles on (1) distributed practice (spacing), (2) retrieval practice, (3) interleaving, (4) infusing the former 3 strategies into educational meetings, and (5) the importance of sleep. Each article contains sections for CPD planners and participants.

References:

(1) Kulasegaram, K., Min, C., Howey, E., Neville, A., Woods, N., Dore, K., & Norman, G. (2015). The mediating effect of context variation in mixed practice for transfer of basic science. Advances in Health Science Education, 20, 953-968. https://doi.org/10.1007/s10459-014-9574-9

(2) Van Hoof, T. J., Sumeracki, M. A., & Madan, C. R. (2022). Science of learning strategy series: Article 3, interleaving. Journal of Continuing Education in Health Professions, 42(4), 265-268. https://doi.org/10.1097/CEH.0000000000000418