Spaced Repetition Enhances Self-Rated Learning Confidence: A Large Randomized Trial Among Practicing Family Physicians

Introduction: Metacognitive accuracy—the extent to which individuals’ perceptions of their knowledge align with actual performance—is critical in clinical decision making. Overconfidence can lead to diagnostic errors, while insufficient confidence may delay decisions or prompt unnecessary testing, increasing health care costs. Although longitudinal knowledge assessments with spaced repetition have been shown to improve learning and knowledge transfer, their impact on metacognition remains underexplored. This study investigates changes in confidence under different spaced repetition strategies in a large cohort of family physicians. Methods: Data were drawn from the American Board of Family Medicine’s Continuous Knowledge Self-Assessment, a longitudinal assessment administered quarterly. Participants rated their confidence on a 6-point scale after each question. In total, 16,751 physicians who completed assessments at baseline, quarter 6, and quarter 10 were included. Participants were randomized to control or intervention groups receiving repeated or clone questions at various intervals. One-sample t tests assessed confidence changes for questions initially answered incorrectly but subsequently answered correctly. Multivariate regression controls demographic factors. Results: Confidence increased significantly for repeated questions, with moderate effect sizes in single repetition groups and large effect sizes in two-time repetition groups. Clone questions also showed gains, though smaller in magnitude. After adjusting for clinician demographics, male and younger physicians generally reported higher confidence. Discussion: Spaced repetition enhances both learning and metacognitive accuracy. Two spaced repetitions yielded larger gains. These findings support incorporation of metacognitive-enhancing strategies into CME to improve clinician self-assessment and potentially reduce diagnostic error.