Editorial Views  |   November 2016
Commentary on the Potential of the MOCA Minute Program®
Author Notes
  • From the Department of Psychology, University of California, Los Angeles, California.
  • Corresponding article on page 1046.
    Corresponding article on page 1046.×
  • Accepted for publication April 27, 2016.
    Accepted for publication April 27, 2016.×
  • Address correspondence to Dr. Bjork:
Article Information
Editorial Views / Education / CPD
Editorial Views   |   November 2016
Commentary on the Potential of the MOCA Minute Program®
Anesthesiology 11 2016, Vol.125, 844-845. doi:10.1097/ALN.0000000000001302
Anesthesiology 11 2016, Vol.125, 844-845. doi:10.1097/ALN.0000000000001302

“[The MOCA Minute program utilizes] an adaptive feature of human memory—namely, that using our memories shapes our memories…”

Image: © ThinkStock.
Image: © ThinkStock.
Image: © ThinkStock.
FROM my perspective—as a cognitive scientist with interests in the potential of basic research findings to optimize education, and as someone who could well need the services of an anesthesiologist, hopefully an anesthesiologist who knows what to do in my particular case—I find the Maintenance of Certification in Anesthesiology (MOCA) Minute® initiative impressive on multiple dimensions. First, the initiative itself is impressive, because it represents an admirable effort by the American Board of Anesthesiology to consider ways in which current recertification practices, which are clearly nonoptimal, might be upgraded. Second, the test of a pilot version of the MOCA Minute program that is reported by Sun et al. 1 in this issue is impressive from a design and analysis standpoint. As the authors emphasize, a major limitation is that the diplomates who did and did not participate in the MOCA Minute program before the MOCA Cognitive Examination could not—for both practical and ethical reasons—be randomly assigned to participate or not participate, but they cite good evidence that the two groups were comparable. Finally, the (positive) results are impressive, especially given that the intervention took 1 min once a week (plus any additional time a given diplomate may have taken in processing the feedback provided after each question) and given that the benefits of participating in the MOCA Minute program extended to test questions on topics that were not the focus of MOCA Minute questions, as well as to questions on topics that were the focus of the program.
From the standpoint of relevant cognitive science research, the benefits of such weekly questioning are consistent with findings demonstrating the pedagogical benefits of testing—even though the word test has become a bad word in many educational contexts, presumably because the word is associated with assessment and with pejorative expressions such as “teaching to the test.” The bad image of testing is regrettable, however, because testing, especially low- or no-stakes testing, has several important benefits when compared to being presented, shown, or restudying information or procedures (for a review of relevant research, see the study by Roediger and Karpicke2 ). One benefit is that the act of retrieving some information (or procedure) is a powerful learning event in the sense of making that information more recallable in the future, more powerful than is being presented that information again. A second benefit is a metacognitive benefit—namely, that testing identifies far better for learners what has or has not been learned and understood than does restudying, or being presented, the same information. A final benefit, and one that is the topic of considerable current research, is that testing potentiates the effectiveness of subsequent studying, even when learners are able to answer few or any of the questions correctly.
Each of those benefits is important in general and especially important in the context of the MOCA Minute mission; to the extent that the MOCA Minute questions can help a given diplomate identify areas of strengths and weaknesses, for example, such testing becomes a major asset with respect to time management and efficiency of studying. Also, when MOCA Minute questions are answered correctly, the act of retrieving the answer will make the retrieved information or procedure more recallable in the future, an especially important consideration when, as in the current project, the questions address procedures in which previous diplomates have been error prone during certification-related testing.
One very basic fact about human memory is that information and procedures, no matter how well learned, become nonrecallable after a long enough period of disuse.3,4  They are not lost from memory in any absolute sense and can be relearned (or, perhaps more accurately, reactivated) in a fraction of the time necessary to acquire such knowledge or skills in the first place, but without such relearning, they can be inaccessible when needed. This “basic fact” is closely related to an adaptive feature of human memory—namely, that using our memories shapes our memories: Information and procedures we recall become more recallable in the future, whereas information and procedures in competition with those recalled become less recallable. Basically, such retrieval-induced forgetting5  is adaptive because when we are trying to retrieve a name, number, or procedure, for example, we do not want every related (and often no longer current) name, number, or procedure in our memories to come to mind. James6  made this point in a cogent way 126 yr ago: “In the practical use of our intellect, forgetting is as important as remembering. If we remembered everything, we would most occasions be as ill off as if we remembered nothing.”
That consideration notwithstanding, any practicing anesthesiologist would clearly like rarely used relevant medical knowledge and procedures, as well as commonly used procedures, to be accessible when needed—as would, of course, any patient needing such knowledge or procedures. The MOCA Minute program has the potential to address that goal, especially if the program is gradually refined to include a sophisticated algorithm that would determine what questions should be delivered to a given diplomate—based on that individual’s previous answers and on data as to domains where confusion and errors tend to be most frequent. In the pilot version of the program that was tested, questions answered in error were readministered at a later time, which was a good feature, but it is likely the program can be made more effective by having what questions are asked and whether, when, and how questions are readministered be guided by a model of a given diplomate’s state of knowledge.
The survey administered to the diplomates who completed the MOCA Minute pilot test also produced interesting findings (see table 3 in the article by Sun et al.1). As summarized by the authors, “Overall, the respondents expressed positive attitudes about the MOCA Minute program, with 75 to 97% agreeing or strongly agreeing to the seven favorable statements.” Equally impressive, perhaps, is that the remaining responses were almost entirely in the “neutral” category, with the number of respondents disagreeing or strongly disagreeing with the positive ranging from less than 1% to a little more than 3%. One factor, no doubt, in the positive reaction of the respondents is that the MOCA Minute testing was not an assessment test, but, instead, was designed to help prepare those who participated for a later—and important—assessment test. In that respect, the respondents’ reactions may be similar to the reaction of students in college courses when their teachers introduce frequent no- or low-stakes testing in their courses: When such frequent testing is announced, students’ reactions tend not to be positive, but then shift to being quite positive by the time the students reach the end of the course.
As a final comment—or speculation—I think the kind of regular once-a-week no-stakes testing that characterized the MOCA Minute program might even have some intrinsically rewarding aspects, aside from any benefits it may have had with respect to subsequent testing. Testing may have a bad name, but we seem to enjoy the process of retrieving information in some domain of interest to us. People like games such as Trivial Pursuit, for example, and fans of a given sport clearly enjoy going back and forth endlessly with each other recalling historical minutiae in that sport. In some domain of interest to me, related to an avocation or hobby perhaps, I could even imaging signing up for some MOCA Minute type questions to be delivered to my computer or cell phone once a week.
Competing Interests
The author is not supported by, nor maintains any financial interest in, any commercial activity that may be associated with the topic of this article.
Sun, H, Zhou, Y, Culley, DJ, Lien, CA, Harman, AE, Warner, DO Association between participation in an intensive longitudinal assessment program and performance on a cognitive examination in the Maintenance of Certification in Anesthesiology Program®, Anesthesiology. (2016). 125 1046–55
Roediger, HLIII, Karpicke, JD The power of testing memory: Basic research and implications for educational practice.. Perspect Psychol Sci. (2006). 1 181–210 [Article] [PubMed]
Bjork, RA, Bjork, EL Healy, AF, Krosslyn, SM, Shiffrin, RM A new theory of disuse and an old theory of stimulus fluctuation, From Learning Processes to Cognitive Processes: Essays in Honor of William K. Estes. (1992). Hillsdale, NJ, Erlbaum 35–67
Bjork, RA Benjamin, AS On the symbiosis of learning, remembering, and forgetting, From Successful Remembering and Successful Forgetting: A Festschrift in Honor of Robert A. Bjork. (2011). London, Psychology Press 1–22
Anderson, MC, Bjork, RA, Bjork, EL Remembering can cause forgetting: Retrieval dynamics in long-term memory.. J Exp Psychol Learn Mem Cogn. (1994). 20 1063–87 [Article] [PubMed]
James, W The Principles of Psychology. (1890). New York, Dover
Image: © ThinkStock.
Image: © ThinkStock.
Image: © ThinkStock.