AL Potosky

BP Kerfoot

Dario Cecilio-Fernandes

DT Shek

Jakob de Vries

JD Vermunt

LWT Schuwirth

NJ Cepeda

RA Tio

René A. Tio

S Patel

SW Raudenbush

Wytze S. Aalders

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The Impact of Massed and Spaced-Out Curriculum in OncologyKnowledge AcquisitionDario Cecilio-Fernandes1 & Wytze S. Aalders2 & Jakob de Vries3 & René A. Tio4Published online: 13 February 2017# The Author(s) 2017. This article is published with open access at Springerlink.comAbstract Starting in 2009, cancer has been the leading causeof death in the Netherlands. Oncology is therefore an impor-tant part of the medical curriculum in undergraduate educa-tion. It is crucial that medical students know about cancer,since doctors will encounter many cases of oncology.We havecompared the influence that teaching oncology has whenspread over a 3-year curriculum versus concentrated in onesemester. The participants comprised 525 medical studentsfrom one medical school with comprehensive integrated cur-ricula. Of those, 436 followed the massed curriculum, withoncology concentrated in one semester. The remaining 89students followed a spaced-out curriculum, in which oncologywas spread out over 3 years. To measure students’ knowledge,we used their progress test results from 2009 to 2012. Allquestions about oncology were categorized and selected.Because of our unbalanced sample and missing data and toreduce the chances for a type II error, we compared the growthof oncology questions using mixed effect models. A cubicgrowth model with an unstructured covariance matrix fittedour data best. At the start, students in the spaced-out curricu-lum scored higher on oncology questions. The initial growthwas faster for the spaced-out curriculum students, whereas theacceleration over time was slower compared to the massedcurriculum students. At the end of the growth curve, theknowledge of the massed curriculum students increased faster.In the last test, the massed curriculum students outperformedthose in the spaced-out curriculum. The way students acquiredand applied their knowledge was similar in both curricula. Itseems, however, that students benefitted more from massedthan spaced-out education, which may be due to the compre-hensive integrated teaching involved.IntroductionEnsuring that medical students acquire and retain knowledgeof oncology during their medical education is essential forexcellent oncological care later on. Most doctors will facemany oncological patients during their practice, regardless oftheir specialization. Potosky and colleagues (2014) [1] con-ducted a survey of US physicians showing that many physi-cians, without a specialization in oncology, lack criticalknowledge and education on this topic. Moreover, these phy-sicians lacked confidence in their knowledge of cancer.Similar results were found in undergraduate medical students[2]. To address this problem, several curricula for residencyeducation were developed to provide structure, content, andguidance in teaching oncology [3]. Furthermore, integratedholistic approaches are increasingly being implemented in un-dergraduate oncology education [4]. Despite the number ofcurricula that have emerged, the efficacy of oncology educa-tion remains unclear [3]. In the Netherlands, cancer has beenthe leading cause of death since 2009. Since then, oncologyhas played an important role in the medical curriculum in* Dario Cecilio-Fernandesd.cecilio.fernandes@umcg.nl1 Center for Education Development and Research in HealthProfessions (CEDAR), University of Groningen and UniversityMedical Center Groningen, Antonius Deusinglaan1, FC40, 9713AV Groningen, The Netherlands2 University of Groningen, University Medical Center Groningen,Groningen, The Netherlands3 Department of Surgery, University of Groningen and UniversityMedical Center Groningen, Groningen, The Netherlands4 Center for Education Development, Research in Health Professions(CEDAR) and Department of Cardiology, University of Groningenand University Medical Center Groningen,Groningen, The NetherlandsJ Canc Educ (2018) 33:922–925DOI 10.1007/s13187-017-1190-yundergraduate education. It is crucial that medical studentsacquire and retain knowledge of oncology during their pre-clinical phase, so they can apply that knowledge when face toface with a patient.One way of improving students’ knowledge retention is byspacing and repeating the learning material throughout medi-cal school. Spacing the study sessions improves long-termretention as compared to massed practice [5, 6]. In this study,we compared the influence of teaching oncology spread over a3-year Bachelor’s phase with what is known as massed pre-sentation (with most of the study material concentrated in onesemester). Both curricula covered the same content, and bothwere used in the same medical school. We hypothesized thatthe spaced-out curriculum would prove more beneficial forstudents’ learning and retention, since students would re-study the learned topic throughout the Bachelor’s phase.MethodsSettingSince 2009, the University Medical Center Groningen(UMCG) has offered an international Bachelor’s degree pro-gram in medicine in parallel with a national Bachelor’s pro-gram. Both programs have the same learning goals, content,material, and teaching methods (PBL), but the order of disci-plines is as different as the language used. At this stage, that is,the Bachelor’s phase, students do not have individual contactwith real patients. During the patient lectures, patients arecarefully selected. Most of these patients speak basicEnglish, although in some cases the lecturer translates theanswers given by the patient.In the national track, the program is taught inDutch, where-as in the international track, the program is taught in English.Both groups have the same admission requirements. Allinternational students take a proficiency in English test(IELTS) to ensure that they are proficient in English, unlessthey are native English speakers. Moreover, students need toshow proof of their level of science education. If they fail to doso, they are allowed to attend 1 year of pre-university educa-tion. The proficiency of both tracks is comparable in terms oftheir knowledge, and they are both regulated by the same rulesand cutoff scores.Oncology EducationBoth curricula follow a comprehensive integrated curric-ulum, which is structured and part of the curriculum de-sign. The content, learning objectives, material, number ofhours, and the teachers are the same for the national andinternational tracks. In addition to language, the only dif-ference is that, in the national track, oncology iscondensed into one semester at the beginning of the thirdyear, whereas in the international track, it is spread outover the three Bachelor’s years.Throughout the Bachelor’s phase, medical students inboth curricula, in addition to being exposed to patientcases during patient lectures, encounter patient problemsin the form of assigments on paper. These patient casesmight contain topics related to oncology. Students fromboth curricula encounter similar patient cases. Since in thespaced-out curriculum, students have various ontologicaltopics spread out over the entire Bachelor’s phase, theymay have acquired more knowledge about oncology ascompared to those students in the massed curriculum.Progress TestTo measure students’ knowledge of oncology, we usedtheir progress test results from 2009 to 2012. The Dutchprogress test is based on the Dutch National Blueprint forthe Medical Curriculum, and it aims to assess knowledgeat the end of the curriculum level. The Dutch progress testis administered four times a year, and each test contains200 multiple-choice questions on all subjects, includingoncology. Furthermore, the questions can be divided intovignette questions, in which a patient case is presented,and knowledge questions without any patient cases. Thequestions differ for each test; the level of difficulty, how-ever, is the same for all progress tests.The progress test has a formative and a summativeformat. Students cannot fail because of one test or onesubject. After completing the progress test, students re-ceive feedback per discipline, which compares their meanwith the overall mean of their reference group, and whichis thus an indication of their performance. In addition,they receive a fail, pass, or good grade. Over a 1-yearperiod, students are required to pass three of the fourprogress tests; otherwise, they will have to repeat theprogress test as a whole and not necessarily just the blockthat they failed (for more information about the Dutchprogress test, see Tio et al. 2016 [7]).The national track takes the test in Dutch, whereas theinternational track takes the test in English. The English testis translated by an official certified translator (native speaker)with years of experience in translating medical documents(including tests). This translation is revised by a nativeEnglish-speaking physician. After that, the translation processis reviewed by members of the Board of Examiners of ouruniversity.During the Bachelor’s phase, students from both curriculahave to take 12 progress tests in total. These tests contain thesame questions and are taken at the same time for bothcurricula.J Canc Educ (2018) 33:922–925 923Data AnalysisThe 2400 questions from the 12 progress tests were catego-rized, and so we were able to select all questions related tooncology (n = 185).To analyze the growth of students’ knowledge of oncology,we used a mixed effect model with maximum likelihood (ML)estimation [8]. We chose this analysis because it handles theunbalanced sample and missing data [9]. Furthermore, thismethod allowed us to determine the shape of the growthcurves (linear, quadratic, or cubic) and examined the effectsof covariates (type of curriculum) on the growth curves. Timewas categorized inmonths. Students in the massed group werecoded as −1 and those in the spaced-out group as 1.Several models were tested. We used a backward elimina-tion starting with the saturated model to first assess the covari-ance structure (unstructured, compound symmetry, and first-order autoregressive) of the model. We then eliminated non-significant parameters. The models were compared using −2log likelihood, Akaike’s Information Criterion (AIC), andSchwarz’s Bayesian Criterion (BIC) criteria; the smaller thestatistical values, the better the model fits the data. By usingthis methodology, our outcomes were protected against a typeI error, which means detecting an effect that is not present.However, protecting against a type I error increases thechances of finding a type II error, which means not detectingan effect even if it is present. From a practical point of view,the probability of finding a significant outcome is lower with atype II error—only a strong effect would result in a significantdifference. Analyses were performed using the mixed modelprocedure in SPSS 23.0 statistical software.ResultsData from 525 medical students were retrieved. Of those, 436followed the massed curriculum, and the remaining 89 stu-dents followed the spaced-out curriculum. Of the latter, 37%were Dutch, 20% European, 38% from the Middle East, and5% from other countries. In the massed curriculum, the ma-jority of the students were Dutch, although some of themwereborn in another country or had a different cultural background.A cubic growth model with an unstructured covariancematrix fitted our data best. Students in both curricula showedan increase in knowledge of oncology. The type of curriculumwas a significant predictor of the initial status, and linear,quadratic, and cubic slopes (Table 1).Initially, students in the spaced-out curriculum scoredhigher on oncology questions. The initial growth was fasterfor the spaced-out curriculum, whereas the acceleration overtime was slower compared to the massed curriculum. At theend of the growth curve, the acceleration of the massedcurriculum increased faster. In the four last tests, the massedcurriculum outperformed the spaced-out curriculum (Fig. 1).DiscussionIn this study, we hypothesized that students in a spaced-outcurriculum would retain more knowledge of oncology thanstudents in a massed curriculum. However, at end level, wefound that students in the massed curriculum scored higherthan students in the spaced-out curriculum.Our finding is not in line with the spacing effect literature,which states that students in a spaced-out situation will scorehigher on a retention test than students in a massed situation[5, 6]. One explanation for our finding might be due to thecomprehensive integrated teaching in our university. Whenstudents take the oncology block, they have already acquiredbasic knowledge of cancer, such as cell biology, and havesolved a small number of cases. Students in the massed situ-ation build up their basic knowledge of cancer before facingcases that require applying their knowledge, whereas studentsin the spaced-out curriculum had to apply their cancerTable 1 Results of cubic growth model with unstructured covariancematrixParameter Estimation of the growth modelIntercept 9.699705*Linear −1.343423*Quadratic 0.142924*Cubic −0.002512*Group 2.560432*Linear × group 0.219179*Quadratic × group −0.013840**p > 0.00505101520253035401 2 3 4 5 6 7 8 9 10 11 12Progress TestsBlockSpacedFig. 1 Growth trajectories of the massed group and spaced participants.Mean of the percentage of the correctly answered questions in oncologyregarding the 12 progress tests that students took during their Bachelorphase924 J Canc Educ (2018) 33:922–925knowledge before they had acquired the necessary basicknowledge. We have previously shown that medical studentsneed to acquire basic factual knowledge first before they areable to apply their knowledge [10]. Alternatively, the massedcurriculum is more structured than the spaced-out curriculum.In this case, structure refers to integrating the newly acquiredknowledge with the existing knowledge [11], since the contentis not spread out over a long period of time. The space be-tween the oncology teaching moments for the spaced-out cur-riculum might be too far apart, which would hamper students’performance on a retention test later on. Laboratory studies forsimple knowledge have shown that the optimal gap betweenre-study sessions should be around 10–15% of the desiredretention interval [5]. One implication might be that the effectof spacing oncology education may only become evident aftera longer period of time.Our study has a few limitations. First, the unbalanced samplebetween both curricula might have influenced the outcomes,despite the fact that we used an analysis method that deals withunbalanced samples. Second, there might be an influence fromthe language. The massed curriculum was taught in Dutch,whereas the spaced-out curriculum was taught in English.Both curricula answered identical questions in the progresstests, but the questions for the spaced-out curriculum were inEnglish. The translation of the questions was a thoroughgoingprocess, which was supervised by an official translator, a nativeEnglish-speaking medical doctor, the national progress testcommittee, and the Board of Examiners. Our retrospectivestudy does not allow us to control for many of the variablesthat might have influenced our findings. However, the naturalistsetting offers a closer look at real-life situations than laboratoryresearch would, which is rarely possible in medical education.Another limitation may be the use of the Dutch progress testresults, which measure knowledge at end level. However, theuse of the progress test eliminates the bias of students’ willing-ness to participate, because it is mandatory. Furthermore, theprogress test is a valid and reliable tool to measure students’knowledge [12], whereas block tests are often not reliable orvalidated. Finally, we cannot determine whether massed educa-tion would retain more knowledge of oncology than spaced-outeducation after the Bachelor’s phase (i.e., 12 tests), because datafrom the clinical phase is not available.Our study reveals that, after students have acquired basicfactual knowledge of cancer, they might benefit more fromstudying oncology in a massed as opposed to a spaced-outcurriculum. Further research should investigate whetherspaced-out education would improve students’ performancein the clinical phase. Additionally, further studies should ex-plore the space between re-studying sessions, which play amajor role in improving long-term retention. Finally, furtherresearch needs to be conducted on different types of curricula,since a more traditional one might not repeat the same contentas often as a problem-based learning curriculum.ConclusionsCurricula have a substantial impact on knowledge acquisition.The way students acquired their knowledge was similar in bothcurricula. It seems, however, that students did benefit morefrommassed education than from spaced-out education, whichmay be due to the comprehensive integrated teaching used.–11. Vermunt JD, Verloop N (1999) Congruence and friction betweenlearning and teaching. Learn Instr 9:257–280. doi:10.1016/S0959-4752(98)00028-010.1016/S0959-4752(98)00028-012. Schuwirth LWT, van der Vleuten CPM (2012) The use of progresstesting. Perspectives on Medical Education 1(1):24–30J Canc Educ (2018) 33:922–925 925Compliance with Ethical StandardsFunding This research was partially funded by CAPES – BrazilianFederal Agency for Support and Evaluation of Graduate Education—grant 9568-13-1 awarded to Dario Cecilio-Fernandes.Open Access This article is distributed under the terms of the CreativeCommons At t r ibut ion 4 .0 In te rna t ional License (h t tp : / /creativecommons.org/licenses/by/4.0/), which permits unrestricted use,distribution, and reproduction in any medium, provided you give appro-priate credit to the original author(s) and the source, provide a link to theCreative Commons license, and indicate if changes were made.References1. Potosky AL, Han PK, Rowland J et al (2011) Differences betweenprimary care physicians’ and oncologists’ knowledge, attitudes andpractices regarding the care of cancer survivors. J Gen Intern Med26(12):1403–14102. Oskvarek, J., S. Braunstein, J. Farnan, et al. (2015) Medical studentknowledge of oncology and related disciplines: a targeted needsassessment. J Cancer Educ 1–43. Patel S, Jagsi R, Cook N, Hughes-Davies L, Parkinson C (2011)The International Core Literature Consensus (ICLC): an alternativecurriculum for oncologists. J Cancer Educ 26(3):420–4264. Ha FJ, Parakh S (2016) Novel approaches to undergraduate oncol-ogy education. J Cancer Educ 1–55. Cepeda NJ, Pashler H, Vul E, Wixted JT, Rohrer D (2006)Distributed practice in verbal recall tasks: a review and quantitativesynthesis. Psychology Bulletin 132(3):354–3806. Kerfoot BP, DeWolf WC, Masser BA, Church PA, Federman DD(2007) Spaced education improves the retention of clinical knowl-edge by medical students: a randomised controlled trial. Med Educ41(1):23–317. Tio RA, Schutte B, Meiboom AA, Greidanus J, Dubois EA,Bremers AJA (2016) The progress test of medicine: the Dutchexperience. Perspectives on Medical Education 5(1):51–558. Raudenbush SW, Bryk AS (2002) Hierarchical linear models: ap-plications and data analysis methods, 2nd edn. Sage, ThousandOaks, CA9. Shek DT, Ma C (2011) Longitudinal data analyses using linearmixed models in SPSS: concepts, procedures and illustrations. SciWorld J 11:42–7610. Cecilio-Fernandes D, Kerdijk W, Jaarsma ADC, Tio RA (2016)Development of cognitive processing and judgments of knowledgein medical students: analysis of progress test results. MedicalTeacher:1 5

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The Impact of Massed and Spaced-Out Curriculum in Oncology Knowledge Acquisition

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The Impact of Massed and Spaced-Out Curriculum in Oncology Knowledge Acquisition

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