These Three Practical Tips Can Help You Use the Neuroscience of Learning to Successfully Prepare for the ABSITE Exam

The American Board of Surgery In-Training Examination (ABSITE) was originally created to be an assessment tool of a resident’s knowledge, as well as to formatively identify individual and programmatic deficiencies.^1,2 Over time, the ABSITE has been increasingly used as a data point to assess residents for remediation as well as for fellowship applications due to the observed correlation between ABSITE scores and the subsequent American Board of Surgery qualifying examination.² However, residents have limited time to prepare for the ABSITE, and previously published recommendations to maximize ABSITE scores have intermittent success.³ In addition to these recommendations, we feel that a better understanding of how to apply the neuroscience of learning principles may provide insight into how to learn most effectively and help residents when preparing for the ABSITE. These principles include three key concepts: the testing effect, retrieval practice, and interleaving.⁴ In this article, we review these key concepts and suggest available resources that residents can use to leverage their effects.

The testing effect is the concept that retrieving information from memory during a simulated exam or practice test can increase the long-term retention of that material or information.⁴ In practice, this concept implies that being tested on information, rather than merely reading it, is critical for knowledge mastery.⁵ To fully leverage the testing effect, learners must engage in the retrieval of information through answering recall-type or recognition-type multiple-choice questions and completing short-answer questions on the same knowledge topics.6 In addition, learners need to receive timely feedback on whether or not their answer is correct, along with rationale, in order to maximize this effect.⁶

There are many testing resources available for residents to prepare for ABSITE, including books, review courses, and various e-learning platforms, such as question banks.^7,8 To apply the testing effect to books, a resident can create questions on specific topics covered in the text and return to these questions after reading that chapter. PeerWise is a free collaborative question writing application where groups of learners can create multiple-choice question banks and then revise and choose the best questions for testing practice. There are also paid subscription question banks that give residents direct access to multiple-choice questions and practice exams. Table 1 illustrates a sampling of paid subscription question banks for ABSITE preparation and Table 2 a sampling of educational programs that can aid in ABSITE preparation.

Retrieval practice, which is closely related to the testing effect, implies that frequent retrieval of information from memory, preferably in a spaced manner, enhances learning and long-term retention.⁶ The frequent retrieval of information from memory appears to be superior when compared to repeated studying or re-reading of material.^4,9 Similar to the testing effect, feedback is important to allow for correct knowledge to be transferred between different contexts (e.g., the ABSITE examination versus real-life clinical context) and retained.⁴ There is no specific literature on the optimal spacing to maximize retention, and it likely varies with the learner’s overall comfort and experience with a given topic. Well-established topics can be spaced at greater and greater intervals compared to new knowledge or knowledge that is difficult for the learner to retain.

Residents can apply retrieval practice to their ABSITE preparation in a variety of ways. First, residents can develop flashcards (e.g., Anki flashcards) on topics that occur in the clinical context, didactic teaching sessions, or the OR and revisit them regularly (e.g., once per week). Additionally, residents can collaborate by sharing their flashcards on various ABSITE topics. Please see Table 3 for a sampling of flashcard creation applications. Of note, some online question banks also apply retrieval practice by allowing flagged questions to be repeated at a specified time interval.

Interleaving, which is the shifting and revisiting of topics, can lead to improved learning and retention in comparison to blocked learning, which is attempting to master a topic in isolation before moving on to the next topic.¹⁰ The frequent interleaving of various topics may seem both arduous and counterintuitive, but it results in greater retention likely by stimulating more effortful recall and by avoiding mistaking familiarity and fluency for retention and comprehension. In addition to facilitating long-term recall,¹¹ interleaving also enables superior discrimination of different topics, as shown throughout the educational landscape within and beyond medical and surgical education.¹² For example, an interleaved approach to learning EKGs has been shown to be superior in medical students. Students who practiced using different categories of EKGs throughout their practice, as opposed to blocked learning, performed significantly better in the final assessment of knowledge.¹³

Similar to the testing effect and retrieval practice, interleaving can be applied to dedicated individual studying and/or facilitated by faculty within a program’s curriculum. For example, on the individual level, residents should aim to cover a different topic each time they read, review flashcards, or use question banks and systematically revisit each topic. Practically, residents should try to review at least one old topic each time they study before they move on to a new topic. Another example of interleaving would be if a resident wants to create a block of 100 ABSITE practice questions to test their knowledge. Instead of doing many questions on just a few topics, they should create a practice exam that follows the ABSITE test blueprint. Furthermore, programs should institute weekly didactic teaching in conjunction with asynchronous methods, including video-based education and online journal clubs, that can be scheduled in a fashion that collectively varies and revisits relevant ABSITE topics.

In summary, by actively engaging in self-directed learning and utilizing key neuroscience of learning principles, residents will be more effective in their ABSITE preparation. Importantly, the key neuroscience of learning principles described above are universal and can be applied in a variety of situations, regardless of the learning environment or setting, and can help our residents prepare to be true lifelong learners.

• The testing effect describes the concept that retrieving information from memory during a simulated exam or practice test can increase the long-term retention of that material or information.
• Retrieval practice, which is closely related to the testing effect, implies that frequent retrieval of information from memory, preferably in a spaced manner, enhances learning and long-term retention.
• Interleaving, which is the shifting and revisiting of topics, can lead to improved learning and retention in comparison to blocking, which is attempting to master a topic in isolation before moving on to the next topic
• By actively engaging in self-directed learning and utilizing key neuroscience of learning principles, our residents will be more effective in their ABSITE preparation and can help them prepare to be true life-long learners.

1. Ray JJ, Sznol JA, Teisch LF, et al. Association Between American Board of Surgery In-Training Examination Scores and Resident Performance. JAMA Surgery. 2016; 151(1):26-31.
2. Miller AT, Swain GW, Widmar M, Divino CM. How Important are American Board of Surgery In-Training Examination scores when applying for fellowships? Journal of Surgical Education. 2010 May-Jun;67(3):149-51.
3. Schmitz CC, D’Cunha J, Antonoff MB. Developing Self-Regulated Learning Habits Can Help Residents Be Better Learners. Resources In Surgical Education. Published Online November 5, 2010. Available online at: https://www.facs.org/education/division-of-education/publications/rise/articles/rap-archive/developing-self-regulated-learning-habits-can-help-residents-be-better-learners. (Accessed on November 25, 2019).
4. Roediger HL and Butler AC. The critical role of retrieval practice in long-term retention. Trends in Cognitive Sciences 2011 Jan; 15(1): 20-27.
5. Larsen, DP et al. Test-enhanced learning in medical education. Medical Education 2008 Oct; 42(10): 959-966.
6. Soderstrom NC and Bjork RA. Learning versus performance: an integrative review. Perspectives on Psychological Science 2015 Mar; 10(2): 176-199.
7. Imran JB, Madni TD, Taveras LR et al. Assessment of general surgery resident study habits and use of the TrueLearn question bank for American Board of Surgery In-Training exam preparation. American Journal of Surgery 2019; 218(3):653-657.
8. Kantar RS, Wise E, Morales D et al. The American Board Style Practice In-Training Examination as a Predictor of Performance on the American Board of Surgery In-Training Examination. Journal of Surgical Education 2018;75(4):895-900.
9. Francisco A. Ask the cognitive scientist: retrieval practice. Digital Promise. October 15, 2014.
10. Sana F et al. Study sequence matters for the inductive learning of cognitive concepts. Journal of Educational Psychology 2017 Jan; 109(1):84-98.
11. Brown PC, Roediger HL III, McDaniel MA. Mix up your practice. In: Make it stick: the science of successful learning. Harvard University Press, 2014.
12. Rohrer D. Interleaving helps students distinguish among similar concepts. Educ Psychol Rev 2012;24:355-67.
13. Hatala RM, Brooks LR, Norman GR. Practice makes perfect: the critical role of mixed practice in the acquisition of ECG interpretation skills. Adv Health Sci Educ Theory Pract 2003;8:17-26.

Carl Gustaf S. Axelsson, MD, MPhil, MMSc., is a Post-Doctoral Medical Education Researcher at Massachusetts General Hospital, Harvard Medical School in Boston, MA.

Michael G. Healy, EdD, is a Research Fellow at Massachusetts General Hospital, Harvard Medical School in Boston, MA.

Roy Phitayakorn, MD, MHP, is a General and Endocrine Surgeon and Director of Medical Student Education & Surgery Education Research at Massachusetts General Hospital in Boston, MA and an Associate Professor of Surgery at Harvard Medical School in Boston, MA.