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I Centro Universitário Christus, Fortaleza, Ceará, Brasil.
II Universidade Federal do Ceará, Fortaleza, Ceará, Brasil.
Retrieval-Based Learning in Neuroanatomy
Classes
Ensino Baseado na Evocação do Conhecimento
em Aulas de Neuroanatomia
Lia Lira Olivier SandersI
Randal Pompeu PonteI
Antônio Brazil Viana JúniorII
Arnaldo Aires Peixoto JuniorI
Marcos KubruslyI
Antônio Miguel Furtado LeitãoI
KEY-WORDS
–Anatomy.
–Neuroanatomy.
–Active learning.
–Learning.
–Medical education.
ABSTRACT
Medical schools are continuously challenged to develop teaching modalities that improve
understanding and retention of anatomical knowledge. Traditionally, learning has been regarded
as the encoding of new knowledge, whereas retrieval has been considered a means for assessing
learning. A solid body of research demonstrates that retrieval practice is a way to promote learning
that is robust, durable, and transferable to new contexts. It involves having learners set aside the
material they are learning and practice actively reconstructing it on their own. A general challenge
is to develop ways to implement retrieval-based learning in educational settings. We developed a
pedagogical approach that implements retrieval-based learning in practical neuroanatomy classes,
which differs from usual neuroanatomy teaching in that it actively engages students through active
learning. It requires students to retrieve anatomical knowledge in oral and written form, as well as
to identify structures in cadaveric material. Practical anatomy classes have traditionally relied on
students’ passive exposure to cadaveric material, with the lecturer pointing to and naming anatomical
structures. Since August 2014, we have been applying retrieval practice in neuroanatomy classes. A
total of 720 students were included in the study. Student performance one week after the practical
lesson was higher in the traditional method group than in the retrieval-based learning group (p <
0.0001, effect size = 0.60). Four weeks after the intervention, however, the performance of students
who learned using a retrieval-based approach was higher than that of students passively exposed
to the learning material (p < 0.0001, effect size = 0.75). Taken together, our results suggest that
retrieval-based learning has a greater effect on long-term retention. Retrieval-based learning is easy
to apply and cost-effective. It can be implemented in nearly any educational setting. We hope that our
report may inspire educators to adopt retrieval practice approaches and seek ways to apply methods
from learning research in actual classrooms.
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PALAVRAS-CHAVE
–Anatomia.
–Neuroanatomia.
–Metodologias ativas.
–Aprendizagem.
–Educação médica.
RESUMO
As faculdades de Medicina são continuamente desafiadas a desenvolver modalidades de ensino que
melhorem a compreensão e a retenção do conhecimento anatômico. Tradicionalmente, a aprendiza-
gem tem sido considerada como a codificação de novos conhecimentos, enquanto a evocação tem sido
considerada apenas um meio para avaliar a aprendizagem. Pesquisas demonstram que a prática da
evocação do conhecimento é uma maneira de promover um aprendizado robusto, durável e transferível
para novos contextos. Isso implica que os alunos deixem de lado o material que estão aprendendo e
pratiquem ativamente reconstruí-lo por conta própria. Um desafio geral é desenvolver maneiras de
implementar a aprendizagem baseada em evocação em ambientes educacionais. Desenvolvemos uma
abordagem pedagógica que implementa a aprendizagem baseada em evocação em aulas práticas de
neuroanatomia, que difere do ensino usual de neuroanatomia, na medida em que envolve ativamen-
te os alunos na aprendizagem. Requer que os estudantes recuperem conhecimentos anatômicos em
forma oral e escrita, bem como identifiquem estruturas em material cadavérico. As aulas práticas de
anatomia tradicionalmente se baseiam na exposição passiva dos estudantes ao material de cadáveres,
com o professor apontando e nomeando estruturas anatômicas. Desde agosto de 2014, aplicamos a
prática da evocação em aulas de neuroanatomia. Um total de 720 alunos foi incluído no estudo. O
desempenho dos alunos uma semana após a aula prática foi melhor no grupo submetido ao método de
ensino tradicional do que no grupo de aprendizagem baseada em evocação (p < 0,0001, tamanho do
efeito = 0,60). Quatro semanas após a intervenção, no entanto, o desempenho dos alunos que apren-
deram usando uma abordagem baseada na evocação foi melhor do que o dos estudantes passivamente
expostos ao material de aprendizagem (p < 0,0001, tamanho do efeito = 0,75). Em conjunto, nossos
resultados sugerem que o aprendizado baseado em evocação tem um efeito maior na retenção a longo
prazo. A aprendizagem baseada em evocação é fácil de aplicar e econômica. Pode ser implementada
em praticamente qualquer ambiente educacional. Esperamos que nosso relato possa inspirar os edu-
cadores a adotarem abordagens de práticas de aprendizagem por evocação e a buscarem maneiras de
aplicar métodos de ensino e aprendizagem derivados da pesquisa sobre educação em salas de aula reais.
Recebido em: 25/11/18
Aceito em: 17/12/18
INTRODUCTION
Anatomy is the branch of biology that deals with the study of
the structure of organisms and their parts. The complex orga-
nization of brain systems poses extra difficulty for educators,
who testify students’ struggle to master the anatomy of the
nervous system1. There has been a long-standing call for ac-
tive pedagogical experiences in medical education2,3. Medical
schools are particularly challenged to develop teaching mo-
dalities that improve understanding and retention of anatom-
ical knowledge4,5,6.
Initially, learning has been regarded as the encoding of
new knowledge, whereas retrieval has been considered a
means for assessing learning. Over 100 years of research has
shown that practice testing enhances learning and retention7.
A solid body of research demonstrates that retrieval promotes
effective long-term learning. This phenomenon has been
called testing effect8-11, or retrieval-based learning12, and has
been demonstrated across a wide range of test formats, kinds
of material, learner ages, outcome measures, and retention in-
tervals13.
Testing usually corresponds to high-stakes summative as-
sessments, which leads to most students’ unfortunate view of
exams as an undesirable necessity of education, overshadow-
ing the incremental effect of testing on learning13. Every time
we retrieve knowledge, we enhance our ability to reconstruct
it in the future14. When retrieval is successful, knowledge rep-
resentation is updated to include features of the current con-
text. Future retrieval is enhanced because updated context
representations can be used to restrict the search set and hone
in on a desired target15.
Retrieval practice testing involves practicing recall of tar-
get information via the use of flashcards, problems or ques-
tions. It is a way to promote learning that is robust, durable,
and transferable to new contexts16,17. It involves having learn-
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ers actively retrieve knowledge learned in the past and bring-
ing it to mind on their own15. A general challenge is to develop
ways to implement retrieval-based learning in educational
settings.
We developed a pedagogical approach that implements
retrieval-based learning in practical neuroanatomy classes.
It requires students to retrieve anatomical knowledge in oral
and written form, as well as to identify structures in cadaveric
material. Our aim was to translate a well-established strate-
gy from learning research to a medical education setting. We
compared students’ retention of neuroanatomy knowledge
before and after introducing retrieval-based learning in neu-
roanatomy classes. We hypothesized that the retrieval-based
approach would enhance neuroanatomy learning. Here we
describe our retrieval practice in neuroanatomy classes and
report the improvement in medical students’ retention of neu-
roanatomy knowledge after we implemented the new teach-
ing method.
METHODS
This is a cross-sectional study, carried out from November
2016 to April 2017, at a private, higher education institution.
Our undergraduate medical curriculum is structured in a hy-
brid method with active methodology PBL (Problem-Based
Learning) and conferences throughout the first eight semes-
ters, followed by four semesters of clerkship. This research fol-
lowed the ethical aspects established in Resolution 466/2012
of the National Health Council (CNS), which defines the rules
of human research. It was approved by the local Research Eth-
ics Committee (approval number: 56341916.6.0000.5049).
Participants
To verify whether retrieval practice enhances learning of neu-
roanatomy content, we compared the performance of 424
students exposed to the traditional method (theoretical class +
passive work with cadaveric material), from 2011 to the first
semester of 2014, with the performance of 296 students who
had the opportunity to learn using the retrieval-based learning
approach (theoretical class + retrieval practice), from the sec-
ond semester of 2014 to 2016.
Procedure
At our institution, neuroanatomy classes are given during the
second semester of Medical School. Students have a theoreti-
cal neuroanatomy class, followed by practice in the anatomy
lab, two weeks later. We compared two teaching methods in
the anatomy lab. The traditional method (see below) consists
of a lecturer presenting anatomical structures in embalmed
human cadaveric specimens to the students. Retrieval-based
learning (our experimental method) differs from the tradition-
al method in that it promotes retrieval practice. In the retriev-
al-based learning approach, students are requested to identify
anatomical structures on their own, using projected and print-
ed structures as well as cadaveric material. Each method is
detailed below.
Traditional method
Until the first semester of 2014, the lecturer used cadaveric
material in the anatomy lab to show students the anatomical
structures, repeating if necessary. For comparison with the
new method, we call this approach traditional method.
Retrieval-based learning
Since August 2014, we have been applying retrieval practice
in neuroanatomy classes. At the beginning of the practical
lesson, students are given printed copies of the neuroanato-
my illustrations they were shown in the theoretical class. The
docent projects these illustrations and presents the anatom-
ical structures to the students. The lecturer then applies the
retrieval-based approach, which consists of the following se-
quential steps:
1. The lecturer points to the projected structures, request-
ing students to collectively identify them. Students an-
swer aloud. Eventual errors are corrected.
2. Students write down the names of anatomical struc-
tures on the printed copies of the neuroanatomy illus-
trations they received at the beginning of the class and
compare their answers in pairs.
3. Each student identifies the anatomical structures in the
cadaveric material.
Outcome measures
As learning outcome in each group, we used the scores ob-
tained from two neuroanatomy tests, at one and four weeks
after the practical anatomy class. Each test (test 1 and test 2)
consists of 12 short answer questions (SAQ) randomly select-
ed from the list of anatomy structures taught. These tests are
part of the curriculum; both groups were subjected to them.
In both tests the task was the same: students were asked to
identify anatomic structures (i.e., write down their names).
The first test comprises structures of the telencephalon and
diencephalon; the second test, structures of the telencephalon,
diencephalon, brainstem, cerebellum, and medulla. Test 1 and
test 2 had the same number of questions and were the same
through years, which allowed us to compare the performance
of the two groups in each test. A direct comparison between
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the performance of each group in both tests was not possible
because test 1 and test 2 were different. Although both tests
consisted of 12 questions, the second test comprised structures
of more brain structures than the first test.
Statistical analyses
Students’ test performance was not normally distributed (test
1: skewness: -1.294, kurtosis: 1,610; test 2: skewness: -0.707,
kurtosis: 1.610). Therefore, we used non-parametric statistics
(Mann-Whitney two-sample rank-sum test) to test for per-
formance differences between the passive learning and the
retrieval-based learning group. All analyses were conducted
using the software SPSS 20.0 (Statistical Package for Social Sci-
ences, http://www-01.ibm.com/software/analytics/spss/).
The first and the second test were the same through years, but
the second test comprised structures of more brain structures
than the first test. Therefore, test 1 and test 2 could not be di-
rectly compared.
RESULTS
A total of 720 students were included in the study; 300 were
male and 420 were female. All students took part in test 1 and
test 2 (our method for assessing student learning outcomes).
A total of 424 students were subjected to the traditional meth-
od; 296, to the retrieval-based learning approach. The groups
did not differ in gender composition (traditional method: 173
male, 251 female students; retrieval-based learning: 127 male,
169 female students, chi-square = 0.317, p = 0.573). Students
from the traditional method group were slightly older (medi-
an = 20 years, 25-75% = 19-22) than students from the retriev-
al-based learning group (median: 20 years, 25-75% = 19-21,
Mann-Whitney U test, p = 0.005). Students’ performance in
the previous semester, taken as a general measure of academic
performance, was higher in the retrieval-based learning group
(median = 78.50%, 25-75% = 75.40-81.25% vs. 76.00, 25-75% =
72.50-79.25%, Mann-Whitney U test, p < 0.0001). The effect
size (r) calculated for the Mann-Whitney U-test (r = z/(√N))
was 0.22, which, according to Cohen’s guidelines for r, is con-
sidered a small effect size18.
Students’ performance (%) in test 1 and 2 is plotted in
Figure 1. Performance in test 1 (one week after the practical
lesson) was higher in the traditional method group than in
the retrieval-based learning group (Mann-Whitney U test, p
< 0.0001, effect size = 0.60). Test 2 (four weeks after the lesson)
showed the opposite pattern: the performance of students
who learned using a retrieval-based approach was higher than
that of students passively exposed to the learning material
(Mann-Whitney U test, p < 0.0001, effect size = 0.75), suggest-
ing a positive impact of the retrieval-based approach on long-
term retention. Although academic performance of students
from the retrieval-based group was slightly superior than that
of students from the traditional method, previous academic
performance (effect size of 0.22) does not account for the dif-
ferential performance in test 2 (effect size of 0.75).
Fig ur e 1
Learning outcomes. Group performance (%) A) one
week (test 1) and B) four weeks after the lesson (test 2).
A
B
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DISCUSSION
Practical anatomy classes have traditionally relied on stu-
dents’ passive exposure to cadaveric material, with the lec-
turer pointing to and naming anatomical structures. Retriev-
al-based learning in neuroanatomy classes differs from usual
neuroanatomy teaching in that it actively engages students
through active learning. Students are requested to retrieve
anatomical knowledge in oral and written form, as well as
to identify structures in cadaveric material. The most crucial
factor determining whether a memory is long lasting seems to
be how much one thinks about it19. An active teaching activity
makes students think about the taught content, such as when
they try to retrieve anatomical knowledge, be it in written or
in oral form.
Retrieval practice has been shown to enhance long-term
retention of statistical knowledge in psychology20 and of anat-
omy information21. Our results suggest that retrieval-based
learning has a greater effect on long-term retention. Retriev-
al-based learning enhanced students’ performance in a test
4-weeks after the learning intervention. The traditional meth-
od, however, yielded higher grades on a test administered a
week later. It has been previously shown that repeated study-
ing produces short-term benefits, whereas repeated testing
produces greater benefits in delayed test22,23. Studies on the
testing effect revealed no difference in retention for tested
versus studied items under conditions of immediate testing,
but an advantage for tested items under conditions of delayed
testing24. Dobson and colleagues found a significantly better
recall using retrieval-based strategies already one week after
the learning phase21. In our study, however, this effect was ev-
ident only four weeks after the retrieval-based method was
applied. Although the memory and learning literature regard
four weeks as long-term retention, we acknowledge that neu-
roanatomy knowledge is expected to last much longer. Four
weeks is a relatively short period, which limits our conclu-
sions. It is still not clear why learning conditions that make
initial learning more difficult may result in very good long-
term retention. Some authors explain the long-term learning
effect of retrieval-based learning as desirable difficulties that
require more effort from the learner and result in better mem-
ory retention25.
In our study, the tests used to measure students’ learning
outcome (test 1 and test 2) were different to each other, which
made a direct comparison between the two tests impossible.
As the classes went on, students learned more anatomical
structures. Test 2 comprised the same amount of questions as
test 1 but taken from a wider pool of possible neuroanatomy
structures. Therefore, we could only compare the performance
of the two learning methods (traditional and retrieval-based)
in each test. This can also be regarded as a limitation of our
study, making an analysis that could consider both time of
testing and learning method (such as Anova) impracticable.
We can only speculate that a non-gaussian distribution of the
test scores would make a parametric statistical analysis still
impossible even if test 1 and test 2 were the same.
As a real classroom scenario, we could not control for
baseline differences between groups, such as academic per-
formance and previous neuroanatomy knowledge. In fact, the
academic performance of students from retrieval-based group
was slightly superior to that of students from the traditional
method. The magnitude of the effect size of previous academic
performance (d = 0.22) was much lower than the effect size of
learning method (d = 0.75), suggesting that general academic
performance does not fully explain the better performance of
the group subjected to the retrieval-based approach. More-
over, the lower performance of the retrieval-based group in
test 1 suggests that the long-lasting effect of retrieval practice
cannot be explained by differences in student profile.
Although our study adds to the existing evidence in favor
of retrieval-based learning, it does not offer a mechanism that
explains how retrieval may improve learning. Future research
should focus on elucidating the mechanisms by which retriev-
al processes improve learning. Why does retrieving knowl-
edge produce better long-term retention relative to spending
the same time restudying? One possible explanation is that
it makes sense to practice retrieving because learners will be
required to retrieve knowledge during a final assessment. Al-
though the importance of practice may seem obvious in some
skill domains, such as music and sports, retrieval practice is
not a widely used strategy in educational settings26.
Practicing retrieval involves some effort on the part of the
learner; so-called “desirable difficulties” strengthen knowl-
edge, increasing the likelihood that it can be accessed in the
future27. That might explain why retrieval practice can make
initial learning slower and more difficult but result in very
good long-term knowledge retention. There is also an elabo-
rative retrieval account, according to which subjects activate
several semantically related words during the process of re-
trieval, that are then encoded along with the target knowledge
to form a more recallable representation28. Karpicke et al.15 pro-
posed an alternative explanation: the episodic context account
of retrieval-based learning, according to which people encode
information about items and the temporal/episodic context
in which those items occurred29. During retrieval, people at-
tempt to reinstate the episodic context associated with an item
as part of a memory search process30. When an item is success-
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fully retrieved, the original context representation is updated
to include features of the present test context. When people
attempt to retrieve items on a later test, the updated context
representations facilitate information recovery, improving
memory performance.
Retrieval has long been regarded as a means for assessing
learning, but there is compelling evidence from cognitive sci-
ences that retrieval also produces direct effects on learning17.
Although flexibility is required to translate such strategies to
specific learning settings, results replicated in real-life settings,
with actual educational materials, provide strong support to
studies conducted in learning labs.
Our results confirm previous evidence showing that re-
trieval practice enhances learning and long-term memory.
Moreover, it shows that it is possible to adapt laboratory-de-
veloped methods to classrooms. Strategies that lead students
to retrieve learning are more effective than passive exposure
to classroom material. Retrieval-based learning in anatomy
classes is easy to apply and cost-effective. It can be implement-
ed in nearly any educational setting. Retrieval-based learning
requires lecturers to change their teaching methods, planning
and preparing retrieval practices. We can imagine that such a
paradigm change, which implies more time to prepare the lec-
ture and puts the learner at the center of the learning process,
may face resistance from some traditional lecturers. Consider-
ing that the final goal of medical education goes way beyond
four weeks, it would be very interesting to see how long the
benefits of retrieval practice last. Future studies may investi-
gate longer knowledge retention periods. Nevertheless, we
hope that our report may inspire educators to translate meth-
ods from learning research into actual classroom practice.
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CONTRIBUTIONS
A.M.F.L. conceived the original idea and carried out the exper-
iments. L.L.O.S., R.P.P. and A.B.V.J. analysed the data. L.L.O.S.
wrote the manuscript with support from A.A.P.J., M.K. and
A.M.F.L. A.M.F.L. and L.L.O.S. supervised the project.
CONFLICT OF INTERESTS
The author(s) declare(s) that there is no conflict of interest re-
garding the publication of this article.
POSTAL ADDRESS
Lia Lira Olivier Sanders
Centro Universitário Christus (Unichristus) – Escola de
Medicina
Rua João Adolfo Gurgel, 133 – Fortaleza
CEP 60192-345 – CE – Brazil
E-mail: lia_sanders@hotmail.com
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