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Interactive Spaced-Education to Teach the Physical Examination: A Randomized Controlled Trial

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Several studies have documented that physical examination knowledge and skills are limited among medical trainees.


The objective of the study is to investigate the efficacy and acceptability of a novel online educational methodology termed ‘interactive spaced-education’ (ISE) as a method to teach the physical examination.


The design of the study is randomized controlled trial.


All 170 second-year students in the physical examination course at Harvard Medical School were eligible to enroll.


Spaced-education items (questions and explanations) were developed on core physical examination topics and were content-validated by two experts. Based on pilot-test data, 36 items were selected for inclusion. Students were randomized to start the 18-week program in November 2006 or 12 weeks later. Students were sent 6 spaced-education e-mails each week for 6 weeks (cycle 1) which were then repeated in two subsequent 6-week cycles (cycles 2 and 3). Students submitted answers to the questions online and received immediate feedback. An online end-of-program survey was administered.


One-hundred twenty students enrolled in the trial. Cycles 1, 2, and 3 were completed by 88%, 76%, and 71% of students, respectively. Under an intent-to-treat analysis, cycle 3 scores for cohort A students [mean 74.0 (SD 13.5)] were significantly higher than cycle 1 scores for cohort B students [controls; mean 59.0 (SD 10.5); P < .001], corresponding to a Cohen’s effect size of 1.43. Eighty-five percent of participants (102 of 120) recommended the ISE program for students the following year.


ISE can generate significant improvements in knowledge of the physical examination and is very well-accepted by students.

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We thank Ronald Rouse, Jason Alvarez, and David Bozzi of the Harvard Medical School Center for Educational Technology for the development of the ISE online delivery platform utilized in this trial; Sarah Grudberg and Zaldy Tan for content-validation of the spaced-education items; Arlene Moniz and Karin Vander Schaaf at Harvard Medical International for administrative support; Lippincott Williams & Wilkins for use of images from Bates’ Guide to Physical Examination and History Taking (9th Edition) by L.S. Bickley & P.G. Szilagyi; and William Taylor and the Patient–Doctor 2 course faculty for their support of this project.

The views expressed in this article are those of the authors and do not necessarily reflect the position and policy of the United States Federal Government or the Department of Veterans Affairs. No official endorsement should be inferred.

Conflict of Interest

None disclosed.


This study was supported by Harvard Medical International and the Harvard University Provost's Fund for Innovation in Instructional Technology.

Financial Disclosures

None of the authors have relevant financial interests to disclose.

Author Contributions

Dr Kerfoot had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Conception and design: Kerfoot, O’Sullivan

Acquisition of data: Kerfoot

Analysis and interpretation of data: Kerfoot

Drafting of the manuscript: Kerfoot

Critical revision of the manuscript for important intellectual content: Armstrong, O’Sullivan

Statistical analysis: Kerfoot

Obtaining funding: Armstrong

Administrative, technical, or material support: Armstrong

Supervision: Armstrong

Ethical Approval to Perform the Study

The study protocol was approved by the institutional review board at Harvard Medical School.

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Correspondence to B. Price Kerfoot MD EdM.

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Kerfoot, B.P., Armstrong, E.G. & O’Sullivan, P.N. Interactive Spaced-Education to Teach the Physical Examination: A Randomized Controlled Trial. J GEN INTERN MED 23, 973–978 (2008).

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