If you don’t use it, you lose it

It’s a common perception that “book knowledge” does not give on the ability to perform skills. People can answer the questions correctly on a test, but not do the right thing in a real life scenario. For the practical component to be there, you must have some degree of hands-on education and experience. Most (if not all) wilderness medicine courses have a mixture of both lecture and practical stations because of this need. But how long does that knowledge stay with the learner?

Honestly, nobody seems to know. Skills degrade when they aren’t used, but does it happen in one day, a week, a month, or a year? To see how well students retained the information they received from wilderness first aid courses, the authors of this study took participants and measured their baseline (post course) knowledge, and then randomized them to be followed up at 4, 8, or 12 months for retesting. To measure knowledge, they were given a 25 question multiple choice exam. It doesn’t mention if the followup test was identical to the original, but lets hope it isn’t. The participants were also asked to rate their own self efficacy based on an 11 point Likert scale that ranged from “cannot perform this at all” to “can perform this with high certainty”. The designers of that scale must have been fans of Spinal Tap.

At their followup testing, the study participants were again given the exam and asked to rate themselves. Then, first aid skill was measured by observing them do 8 specific skills as part of a clinical scenario. Unfortunately, this skill measurement was not performed at baseline, so absolute decline in practical application cannot be determined. However, based on their data (not shown in the article), they determined that skills declined as the time delta widened. It’s a bit confounding though, as the 8 month group did worse than the 12 month group in some skills. Their exam scores also decreased as time went on, but not to the same degree.

Thus, ability to do well on repeat written examination does not magically give one the ability to manage an actual clinical scenario (but those people probably do better than someone who did poorly on the written exam). And, as it turns out, how well you think you’re going to do doesn’t mean you’ll have the practical skills needed either. Like tying knots, the more regularly you practice them, the better you’ll get. And the knot you should use in a rescue situation is the one you can tie the best, not necessarily the ideal one taught in a class. In that regard, it’s important to note that they specifically excluded anybody who did have further training in wilderness medicine since the first course.

The problem is this: How often do you have to refresh those skills? This article doesn’t answer that question, but it certainly points out that those practical skills erode to a higher degree in between training than test scores do.  Some of this is common sense. It’s easy to do well on a multiple guess test if you’ve had some passing familiarity with the material, as the answers often refresh your memory. Doing the same in a clinical scenario is much more difficult if you haven’t practiced it since the last course. None of this is necessarily groundbreaking, as other studies have shown similar time dependent degradation. Thus, anything that you need to be facile with, needs to be done more regularly than every two years.


  • Schumann SA, Schimelpfenig T, Sibthorp J, Collins RH. An examination of wilderness first aid knowledge, self-efficacy, and skill retention. Wilderness Environ Med. 2012 Sep;23(3):281-7. [PMID 22857870]

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EBM Gone Wild

Wilderness Medicine

Emergency physician with interests in wilderness and prehospital medicine. Medical Director of the Texas State Aquarium, Padre Island National Seashore, Robstown EMS, and Code 3 ER | EBM gone Wild | @EBMGoneWild |

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