The importance of seeing the patient: test-enhanced learning with standardized patients and written tests improves clinical application of knowledge.

Previous research has shown that repeated retrieval with written tests produces superior long-term retention compared to repeated study. However, the degree to which this increased retention transfers to clinical application has not been investigated. In addition, increased retention obtained through written testing has not been compared to other forms of testing, such as simulation testing with a standardized patient (SP). In our study, 41 medical students learned three clinical topics through three different learning activities: testing with SPs, testing using written tests, and studying a review sheet. Students were randomized in a counter-balanced fashion to engage in one learning activity per topic. They participated in four weekly testing/studying sessions to learn the material, engaging in the same activity for a given topic in each session. Six months after initial learning, they returned to take an SP test on each topic, followed by a written test on each topic 1 week later. On both forms of final testing, we found that learning through SP testing and written testing generally produced superior long-term retention compared to studying a review sheet. SP testing led to significantly better performance on the final SP test relative to written testing, but there was no significant difference between the two testing conditions on the final written test. Overall, our study shows that repeated retrieval practice with both SPs and written testing enhances long-term retention and transfer of knowledge to a simulated clinical application.