Q&A with B. Price Kerfoot, MD EdM: Can Qstream Be Used to Teach New Material?

In a new blog series, Qstream co-founder and Spaced Education expert B. Price Kerfoot MD EdM answers some of the frequently asked questions we receive about how our solution improves knowledge retention and changes behaviors in just minutes a day. Have a question for our expert? Email us at

Can Qstream be used to teach new material?

(1) Kerfoot BP, Baker H. An online spaced-education game for global continuing medical education: a randomized trial.  Annals of Surgery 2012 Jul;256(1):33-8.

Involving 1470 physicians in 63 countries, this randomized trial sent 40 questions & explanations on clinical practice guidelines over a 34-week period. Adaptive game mechanics re-sent the questions in 12 or 24 days if answered incorrectly and correctly, respectively. Questions expired if not answered on time (appointment dynamic). Physicians retired questions by answering each correctly twice-in-a-row (progression dynamic). Competition was fostered by posting of relative performance among physicians on leaderboards. This was new educational content for the majority of the participants. Even though there were significant regional variations in baseline performance on the questions, physicians from all regions were able to demonstrate similar mastery of this new content by the end of the program.

We also were able to demonstrate that new content was effectively learned via spaced education in similar randomized trials involving doctors-in-training (J Am Coll Surg. 2012 Mar;214(3):367-73) and medical students (Acad Med. 2012;87:1443–1449).

(2) Kerfoot BP, Armstrong EG, O’Sullivan PN.  Interactive spaced education to teach the physical examination: a randomized controlled trial. J Gen Intern Med. 2008; 23(7):973-8.

In this randomized trial conducted in the early years of spaced education’s development, 36 questions and explanations on "how to perform the physical exam" were emailed over 6 weeks to 120 students in their second year at Harvard Medical School. This was all new material to the students – they had not learned about the physical exam before this. After the initial presentation of the material, it was re-presented to them twice more over the following 12 weeks. Under an intent-to-treat analysis, the spaced education program caused students’ baseline scores to increase from a mean 57.9% (SD 10.7) in cycle 1 to 74.4% (SD 13.9) in cycle 3 (P<.001), representing a 28.6% relative score increase and a Cohen’s effect size of 1.54.

(3) Shaw TJ, Pernar LI, Peyre SE, Helfrick JF, et al. Impact of online education on intern behaviour around joint commission national patient safety goals: a randomised trial. British Medical Journal Quality & Safety 2012;21:819–825.

Three hundred seventy-one new doctors-in-training at two of Harvard’s teaching hospitals were randomized to receive new content on patient safety behaviors either (1) via web-based teaching modules [AKA "binge-and-purge" education] or (2) via a spaced education program. Average post-test scores were higher among those doctors who learned the new material via the spaced education program. To assess the impact of the programs on clinical behavior, the investigators then had the doctors complete simulations which were then rated by blinded observers as to how well the doctors demonstrated patient-safety behaviors. Those doctors who were randomized to the spaced education program demonstrated more patient-safety behaviors than those who completed the web-based teaching modules.

In summary, these three trials show that spaced education is an effective method to teach new content to learners. In addition, the latter study by Dr. Shaw et al demonstrates that (1) spaced education can be more effective at teaching new content than web-based teaching modules and (2) can generate meaningful differences in observable behaviors.

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