Learning Is Not Just Retention – Complex Questions vs Learning Questions: How We Remember and Why Question Types Matter

Med-ChallengerBedside Diagnostic Challenge, Emergency Medicine, Family Medicine, Internal Medicine, Medical News, Nurse Practitioner, Nursing RN/PN, Pediatric Emergency Medicine, Pediatric Medicine, Personal Education, Physician Assistant

Learning and retention

Learning Is Not Just Retention - Complex Questions vs Learning Questions

How We Remember and Why Question Types Matter

Learning, the acquisition and retention of the information that helps us navigate the world, is simple as a concept. The actual psychological process of it, however, is intricate and complex. Before talking about how we retain and learn materials, it is important to recognize that retention is just one part of learning, and that other components such as meaning, perception of relevancy, and instructional organization play a larger role in learning.  There are many (many!) books written on the three main learning theories, domains of knowledge, and how to match instructional strategy, design, and assessment mechanisms.

A set of Q&A questions relates to two areas in learning.  The first is relevancy and framework. The second is retention - and that’s usually the focus of products like Med-Challenger’s.  How do we create a framework of knowledge, and how do we educate so that information is carried on not only for examination, but later on into practice?

With that in mind, let’s talk about how we remember.  At least, the short version of it. 

Retention is just one component of learning. Other parts, such as meaning, instructional organization, and perception of relevancy play a larger role in the process of learning.

How We Remember: Retention by Association, Relevance and Repetition

Understanding how you remember material (and how you forget!) can help you better prepare for future assessments, as well as demonstrate how different question types, mnemonics, and studying tools can help you in different ways  

Retention of information is driven by association, by relevance, and by the repetition that convinces your brain the material is relevant.  Yes, there are other factors, but association, relevance, and repetition are the big three.


Association means that you learn material easier if it is associated with things you already know.  One form of this is association because they are logically related - if you can draw an outer-middle-inner ear diagram today, then learning the individual names of the inner ear canals already has a relevancy framework, because it’s attached to information you already have and is thus easier to learn.

Association can also be driven by relationships with things you know even if they are not logically related.  If you’ve studied anatomy, you are probably already have dozens of mnemonics in your head like “Virgil Cannot Make My Pet Zebra Laugh” for vomer, conchae, nasal, maxilla, mandible, palatine, zygomatic, lacrimal for facial bones.  Or PEST OF 6 for the cranial bones.

This is an interesting area of study, as it can be used in conjunction with peg systems and visualization to create associations in your memory between otherwise undifferentiated lists or numbers.

The point here, though, is that your memory doesn’t act like a computer.  It doesn’t pigeonhole things into a slot for later recall. It’s an association and pattern machine, and it is unique to you.  Working with memory means recognizing that the more associations a concept or list has with other facts, the more likely you are to remember.


Relevancy deals more with, “Why do we forget?”  We forget things that are not relevant. There are interesting arguments about whether we forget, or whether the associations in the memory structure that let us recall information simply dissipate, or whether they get unlinked and jumbled.  But for our purposes, the idea is that our mind helpfully recalls information that is deemed relevant, and hides or fails to recall information that is not deemed relevant.

Besides repetition, the forced recollection of information and development of associations helps convince your mind that material is relevant and needs to be available for recall. 

To make material that you are learning more relevant, you want focused, conscious attention and analysis of information. That’s why we rewrite study notes, for instance.  

The action of rewriting and reorganizing the material, whether you do that by hand or on the computer, forces you to pay attention to the material.  Writing up summaries or reordering the content by how you think of it, not just how it appears in your study materials, creates associations.  Finally, the repeated action of this increases the information’s relevancy in your mind - if you study something every day for just five minutes, seven days in a row, you will remember it better than if you had sat down and repeated it to yourself for half an hour.


The last of the three, repetition, forces long-term storage simply because you are asking the brain to recall the information repeatedly, over time.  Therefore, the brain decides that it must be relevant, and worthy of a spot in your long-term memory.

Spaced repetition, though, is key.  The process of learning takes time-spaced repetition of study material, and needs to take place over days and weeks.  That’s why you’ll see a lot of advice about big, high-pressure exams that warn against cramming. The biological processes required to create associations and long-term recall can’t be made by reviewing the material three times in an hour.

A review of key material is fine before the exam - glancing through the test overview or flipping through notes helps establish a framework for the assessment you are about to undertake.  However, thinking you’ll learn complex new material in a day is not.

learning and retention, complex questions, association, relevancy, and repetition

Question > Answer > Remediation As Study Mechanism

Question > Answer > Remediation structures are a popular form of study, because they hit on all three of those memory mechanisms: association, relevancy, and repetition.  Questions can be used to focus conscious thought on a set of facts, and that in turn drives relevancy.

Where we sometimes go wrong with using "question banks" to study is that the same form can also be used as an assessment.  An assessment question is generally designed to be simple, to elicit one fact or concept from your recall, and test whether you know material.  They are designed purposefully to avoid deep thought and test framework and recall - they’re not supposed to make you really work for the answer.

In addition to question purpose, there are different question structures.  They are related, and similar in structure, but vary in difficulty. There are the dreaded “select all that apply” or SATA questions, single answer multiple choice questions (popularly known as “boards style”,) and lastly some examinations, such as nursing, have fill-in-the-blank, ranking, and true/false question constructions.

You need to know the purpose of the questions being constructed.

Assessment questions are usually, but not always, designed to simply judge recall and framework.  There are distractor answers that, in a well-designed question, gauge knowledge levels, as in “not at all familiar with material”, “somewhat familiar”, and “familiar”.  

Learning questions in medicine are often case-based.  They present some preconditions and a few measures or facts about the case, and some treatment plan, testing, or diagnosis answers presented.  For your exam-taking purposes, know that often many of the facts or conditions presented in the question stem are irrelevant - they themselves function as the distractors.  The design of the question is to force conscious thought and evaluation.  

Forced thinking is the driver of retention - getting out of the ‘recall information’ cycle and putting together a more complete evaluation in your mind drives relevancy, which helps establish the learning framework.

Complex Questions vs. Simple Questions: Question Types Matter

The way that we process simple and complex questions helps drive our retention of information.

If I give you a question like “How does impetigo present?” you are going to scan the answers looking for the textbook keywords “crust” and “erythematous.”

If I restructure the question into a case-based layout, give you some key facts of the case, and offer as answers “impetigo”, “scabies”, “ringworm”, “herpes,” then you use a different processing mechanism. 

Rather than scanning for keywords in the answers you have to recall the differences between impetigo and each of the other answers.

Keyword scanning is a form of recall test, while a case-based question stem with distractor presentations and distractor answers, on the other hand, tests or reinforces recall of entire systems.  That’s also where the ‘remediation’ part of question/answer/remediation study comes in - if you get the question wrong, it’s explained why, and you’re shown what to look for next time you process the question.

Complex questions can be a little frustrating to answer, and difficult to write, but they’re vital to retention when using Q&A as a study mechanism. These questions are also a more practical implementation of the medical practice that you are learning; knowing textbook answers but not being able to implement that knowledge will not benefit you down the line. 

Some of the certification examinations in diagnostic medicine use complex questions as well.  Most physician examinations are of the single-answer multiple-choice format. But nursing examinations (and the nurse practitioner exams are infamous for this) use complex question formats like SATA on the exams.  This type of complex question structure is a little different when used as an assessment mechanism, the goal here being separate the ‘somewhat familiar’ from the ‘very familiar’.

How to handle those in an assessment is a subject we’ll talk about in another article on our Medical Education Blog.

Learning and Retention Summarized

Summary of Learning and Retention

  • Memory depends on relevancy, association, and repetition.
  • Simple questions test recall.
  • Complex questions are designed to force thinking and retention.

Ideally for study you want question banks that both emulate the computer-based exam you’ll be taking and test recall, but you also want blueprint material covered with more complex questions and learning material.

Good luck on the exam. 🙂

Related Posts

More from Med-Challenger

The Leader in Online Board Review, CME Courses, and Medical Education

Did you like this?
Get more free medical Q&A and informative CME articles.

Subscribe to the Medical Education Blog

SubscribeGet notified of more Q&A challenges.

More from Med-Challenger's Medical Education Blog

Board Review & CME Offers

Med-Challenger provides online medical education, top-rated board review courses, annual MOC and CME credit solutions for physicians, nurses, PAs and students.  Take advantage of our current offers.

2022 Cyber Sale

Save 15% on ANY ORDER with code:


including PRO bundles.

Learn More
Contact us for upgrade & bulk pricing.

Enter code at checkout. SHOP NOW.

Enter Store
See All Offers


Career Value Bundles

in your specialty.

One-time purchase.
Useful every year.

Ideal use your CME budget.

emergency medicine PRO bundle
family medicine PRO bundle
internal medicine PRO bundle
pediatric medicine PRO bundle
nurse practitioner PRO bundle
physician assistant PRO bundle

Buy or upgrade ONCE.
Save up to 55% and save time, money, and stress - every year.

View All Options