By Michelle Marlowe; Kyle Atkins, EdS, NRP, FACHDM
The forgetting curve isn’t a willpower problem. It’s a biology problem, and the fix is simpler than you think.
Picture this: You’re on a call. Altered mental status, unknown history, vitals trending the wrong direction. You know you’ve covered this. You’ve sat through the lectures and passed the test. But in the moment, under pressure, the knowledge feels just out of reach.
This isn’t a failure of effort or intelligence. It’s a predictable outcome of the way most education is designed and of how the brain actually works.
The good news: the neuroscience that explains why providers forget also points directly to what helps them remember. And the solution doesn’t require more hours, more lectures, or a bigger curriculum.
| MORE: Applying neuroscience to EMS training
The forgetting curve is real, and it’s not your fault
In the 1880s, German psychologist Hermann Ebbinghaus mapped something most educators still haven’t fully reckoned with: without reinforcement, people forget the majority of new information within days. After a single lecture or training session, retention drops steeply in the first 24 hours and continues to decline thereafter.
This isn’t a character flaw. It’s neurobiology.
Learning is a physical process. Every time you genuinely learn something; not just hear it, but actually process and connect it, your brain changes structure. Neurons that fire together strengthen the synaptic connections between them. Neuroscientist Donald Hebb described this in 1949: “neurons that fire together, wire together.”
The inverse is equally true: neurons that stop firing together eventually disconnect.
When a student only hears content without actively connecting it to what they already know, the pathway that forms is thin, temporary and highly vulnerable to the forgetting curve.
The mechanism underlying durable memory is called long-term potentiation (LTP), a process in which repeated activation of a neural pathway causes structural changes: more receptors, stronger synaptic connections and physical growth of dendritic spines. LTP takes time and repetition. A single exposure, no matter how high-quality, does not produce it.
In an age where the reward for rapid absorption of material is given, students can find themselves more focused on the repetition of knowledge than on learning that commits facts to memory.
Why cramming doesn’t work
The education model, where providers bank hours periodically and test out, is almost perfectly misaligned with how the brain builds durable memory.
Massed practice, studying or reviewing content in concentrated blocks close to a deadline creates the chemical changes associated with short-term memory. Learners feel prepared because the information is briefly accessible. But without the structural changes that come from spaced, repeated activation, that access evaporates quickly after the test.
Dr. Lara Boyd, a neuroscientist at the University of British Columbia, puts it plainly: what you experience as improvement during a single practice session is often not the same as actual learning. Real learning, the kind that supports recall under stress at 2 a.m. on a difficult call, requires structural change in brain tissue. And structural change requires time between practice sessions, not just volume within them.
For EMS providers, this distinction has direct patient safety implications. A paramedic who focused on memorization instead of knowledge has, in a very real neurological sense, less reliable access to that information on a call 3 months later than if they’d reviewed it in small, spaced increments throughout the year.
What actually builds durable memory
The learning science here is consistent and increasingly well-established. Three practices, in particular, produce the kind of structural brain changes that make knowledge durable.
- Spaced repetition. Distributing practice over time (returning to material days or weeks after initial exposure) forces the brain to retrieve and reconstruct information, which deepens neural pathways more than rereading the same material in one sitting. The spacing effect is among the most robust and well-documented findings in the science of learning, with more than a century of research confirming it across ages, subjects and study designs.
- Retrieval practice. Testing yourself on material (answering questions, recalling information from memory rather than re-reading it) produces significantly better long-term retention than passive review. This is sometimes called the “testing effect,” and it works not because testing measures learning, but because the act of retrieval is itself a powerful learning event. Each retrieval attempt strengthens the neural pathway, making future access easier.
- Interleaving and application. Mixing topics and applying knowledge to realistic scenarios, rather than drilling one concept in isolation, forces the brain to discriminate between conditions and builds the kind of flexible, connected understanding that transfers to real calls.
None of these requires more time. They require focused, active attention to the way we process information rather than simple repetition.
How EMS providers can improve knowledge retention
For individual providers, the practical shift is straightforward: replace passive review with active retrieval. Instead of re-reading a protocol manual or rewatching a lecture, use practice questions, scenario-based review or brief self-testing sessions spaced across weeks, rather than crammed into a day or a few days.
Brief, consistent engagement is neurobiologically superior to occasional marathon sessions. A provider who spends 10 minutes actively recalling and applying cardiac protocol information three times a week will have more durable, reliable access to that knowledge than one who spends 2 hours on it the week before recertification.
The keyword is “actively.” Passive exposure, even repeated passive exposure, does not produce LTP. The brain must be working: retrieving, connecting, applying, and sometimes getting it wrong and correcting. Failure, when handled with constructive feedback, is actually a productive learning experience. It activates inhibitory pathways that help the brain distinguish correct from incorrect responses, which strengthens the right pathway in a way that easy, error-free practice does not.
How EMS educators can design training for long-term retention
For those who design educational programs, the forgetting curve is an indictment of the hours-based model as a proxy for competency. Seat time and exposure do not equal retention. The question worth asking isn’t “how many hours does this course require?” but “what features of this program will lead providers to make new connections and keep them?
Building in retrieval practice throughout a curriculum, using scenarios that require application rather than recall alone, spacing review of critical protocols over a recertification period rather than concentrating it: these are course design choices that align education with the biology of memory.
Technology can help here, but the tool matters less than the mechanism. What moves the needle is active retrieval, spaced over time, with feedback that helps learners understand not just what the right answer is, but also why it is right and why the wrong answer is wrong.
Building EMS knowledge that lasts
EMS providers aren’t forgetting information because they don’t care, aren’t trying, or weren’t paying attention. They’re forgetting because the way most education is structured produces exactly the kind of learning the brain discards.
When education is designed around how memory actually forms (through spaced, active retrieval with meaningful feedback), the knowledge providers need for their hardest calls is what sticks.
The neuroscience has been clear for decades. The only question is whether EMS education will catch up to it.
REFERENCES
- Cepeda NJ, Pashler H, Vul E, Wixted JT, Rohrer D. (2006). “Distributed practice in verbal recall tasks: A review and quantitative synthesis.” Psychological Bulletin, 132(3), 354–380.
- Karpicke JD, Blunt JR. (2011). “Retrieval practice produces more learning than elaborative studying with concept mapping.” Science, 331(6018), 772–775.
ABOUT THE AUTHORS
Michelle Marlowe is director of education at Pocket Prep, where she leads content strategy, governance and learning-science-driven design for certification preparation across more than 155 certification exams. With over a decade in education and assessment, Marlowe writes on AI literacy, assessment validity, and how learning systems can protect critical thinking as generative AI reshapes the way knowledge is produced and accessed.
Kyle Atkins is senior EMS curriculum specialist at Pocket Prep, where he leads curriculum strategy for national EMS certification exam prep. A paramedic and EMS educator with more than a decade of frontline and leadership experience across EMS operations, clinical education and CQI, he specializes in connecting learning science and data-informed instruction to real-world provider performance. He is a co-author on national position papers addressing the responsible use of AI in healthcare.
