Desirable Difficulty: Theory and application of intentionally challenging learning

Health professions trainees must acquire a vast amount of clinical knowledge and skills, and a deliberate instructional design approach is needed to provide trainees with effective learning strategies. One powerful yet counterintuitive strategy that facilitates long-term learning is incorporating intentional difficulties during the learning process. Difficulties that require more effort from learners may impede short-term learning but are ultimately beneficial for long-term learning and are therefore termed Desirable Difficulties.

In this cross-cutting edge paper, we describe the Desirable Difficulty effect from three theoretical perspectives originating in different fields, discuss common evidence-based Desirable Difficulty strategies used in Health Professions Education and explore emerging research that could further optimise Desirable Difficulty-enhanced learning for health professions trainees.

We synthesise theory and research from psychology, cognitive science and Health Professions Education literatures to further the understanding and application of Desirable Difficulties. We introduce three theoretical perspectives that provide a comprehensive overview of the theoretical underpinnings of the Desirable Difficulty effect: the New Theory of Disuse, the Challenge Point Framework and Cognitive Load Theory. We then illustrate how three common Desirable Difficulty strategies in medical education research-retrieval practice, spaced practice and interleaved practice-can be understood through these theoretical lenses. Finally, we provide relevant examples from the literature and explore emerging research in this area.

This paper summarises the theory and empirical research on Desirable Difficulties during the learning process, from explaining what they are and why they may be effective to how they have been applied in different contexts. We argue that providing educators and trainees with a comprehensive theoretical and applied understanding of Desirable Difficulty will promote deliberate instructional design decisions and lead to more effective learning.