Developing Self-Regulated Learning Habits Can Help Residents Be Better Learners

Why doesn't Joe Resident read? Why didn't Jane Resident know the basic steps of a procedure before she walked into your operating room? Why do certain residents regularly score below department standards on the American Board of Surgery In-Training Examination (ABSITE)? And most importantly, what can you, as program directors, faculty advisors, or mentors, do about it? How can we help all residents, and especially those at academic risk, become better learners?

Students matriculating into surgical residencies are at the top of the academic achievement pyramid when compared to the general population. Nonetheless, helping these smart people who were successful in their previous schooling become better at the job of learning during residency training is vitally important. No amount of accessible online curricula, virtual libraries, or face-to-face teaching can transmit all the knowledge they need, in the way they need it, to perform well on their own.

Residents have to become experts at framing their own questions and building their own knowledge bases if they are to grow intellectually throughout their careers. Also, residency presents a richer but trickier learning environment than medical school or college, when instruction was structured and orderly, learning took place in groups (and was often passive in nature), there was time to study, and quizzes and exams provided steady feedback.

During residency training, learners have to work largely on their own to master a large body of new information from disparate sources. Perhaps 95 percent of what is learned during surgical training is acquired in the clinical setting or at home. Specialty conferences, core didactic sessions, grand rounds, morbidity and mortality conferences, and skills labs may account for as many as five hours per week, but topics taught during those hours will not necessarily be appropriate for every postgraduate year (PGY) training level nor relate to cases being seen on rotation. Study time occurs in interrupted fragments and competes with service obligations. To survive, not only do residents have to become strategically opportunistic (i.e., learning from every encounter), but they also have to be more proactive and skilled in their approach to learning. Information may be at their fingertips via the Surgical Council on Resident Education (SCORE) Portal, e-journals, online resource tools, and the plethora of texts that populate most hospital call rooms and libraries, but this treasure trove may prove overwhelming or lie largely dormant if residents do not aggressively direct and regulate their learning.

This article was written for faculty advisors, those facilitating ABSITE study groups, or anyone concerned with resident progress and their ability to retain learned information. It provides some background information on learning and tips that you can give to your residents on studying and test taking. While relevant for any resident, this article may be especially useful for junior residents and residents struggling with the ABSITE.

Self-directed, self-regulated learning (SRL) has been a subject of great interest to educational psychologists for over 100 years. Most educators can easily recognize SRL learners when we see them. They are motivated, confident, diligent, strategic, goal-oriented, resourceful, and persistent.¹ They are aware of how they learn, and they can find ways to learn despite obtuse content, poor teaching, or challenging circumstances. They are not necessarily brighter.² What sets them apart is the degree to which they take ownership for their own learning and their use of a variety of strategies to achieve academic goals. In terms of their education, they are "metacognitively, motivationally, and behaviorally active participants in their own learning."²

Table 1: Characteristics of Self-Regulated Learners

While personality traits come into play, most education theorists consider SRL a learned behavior that is shaped by the environment. How so? Learned behavior is shaped through a combination of cultural norms and expectations; role models; reinforcement (both in the sense that studying "pays off" in higher test scores and that it gains rewards or affirmation from others); the use of particular teaching strategies that engage learners and transfer responsibility for learning to them; and direct instruction.^3,4,5

In surgery, we currently lack good research on the specific nature of learning problems experienced by our residents, other than "lack of time" and fatigue. We hypothesize that if one can rule out psychosocial issues (e.g., clinical depression, substance abuse, specific life stressors) that can affect learning and memory, poor academic performance is most likely due to lack of sufficient SRL. Residents who struggle with the ABSITE at your institution may exhibit some of the attributes listed in Table 2.

Table 2: Anecdotal List of Characteristics of Residents Who Struggle with the ABSITE

There really is no substitute for hard work. Residents need to get a grip on the reality of the learning situation. They need to develop a strategic reading program that covers ABSITE test domains; is based on self-assessment and areas of personal weakness; is sequenced to optimize scheduled teaching events; and involves active, conscious learning. Residents who fall asleep while reading learn no more than residents who fall asleep without reading. Residents should also take the following actions to facilitate learning:

• Establish short- and long-term learning goals.
• Create weekly study schedules that involve new reading and a review of key areas.
• Make plans for how to protect scheduled study time.
• Form contingency and back-up study plans and strategies for emergency learning (e.g., being asked to scrub-in the night before a case; being handed a complex assignment involving unfamiliar topics).
• Devise plans for controlling or screening out distractions (to the extent possible) to achieve better focus. (i.e.: finding a quiet corner with good light at the hospital; using headphones while studying in noisy call rooms; sitting alone or next to quiet people during conferences and taking note).
• Set up an organized study space at home.
• Design a system for organizing study materials. Residents can get creative with electronic filing, set up an actual file drawer, or simply buy a three-ring binder notebook. Lecture notes, questions, ideas, pocket cards, photocopies of chapter excerpts or chapter outlines, links to key articles, practice test items, quiz results, and other materials can be filed in the folder by topic. This notebook (or file drawer or electronic folder) becomes a critical study resource for the ABSITE.
• Think up ways to track study efforts.
• Seek ways to routinely test themselves and follow up on what they don't know.
• Come up with strategies for self-motivation and rewards for "staying with the program."
• Develop a work ethic mantra for when personal and professional responsibilities collide.

Admonishing residents to simply "read more" may not result in the kind of self-regulated learning that is the end goal of teaching. The rest of this article may help you to help your residents become better at the job of learning during an exciting and challenging time of personal and professional development.

Suggested Study and Test-Taking Strategies for Residents

• Read regularly several times every week. It is critical that serious reading be spaced over time. You can't cram all the information in at the end of the year any more than you could bicycle the mountains in the Tour de France after three weeks of training. Expecting to concentrate a week's worth of reading on one day is mentally onerous and generally leads to less total study time than daily reading.
• Expect to read a lot. A study by Hirvela, et al., found that the best predictor of success on the ABSITE (after PGY training year and categorical status were held constant) was the sheer amount of reading residents had done—that is, the number of chapters and the amount of chapters fully read.⁶ This study estimated that residents must read approximately 70 pages a week (two chapters of a standard text) to cover just the ABSITE test domain in a year. That estimate suggests, if you are not setting aside on average five to seven hours per week to study, you are setting yourself up to fail. It is not uncommon for our highest performers to start a rigorous schedule of ABSITE preparation eight to 10 months before the exam and to commit incrementally more hours per week (on top of other studying) leading up to test day.
• Read source material (i.e., textbooks and articles) for learning new material. Do not rely on "outline"-style review books or online resource tools such as Google, Up-to-Date, or Stat Ref to be your primary sources for understanding new information. Predigested material is helpful for review (see next section) and as a memory aid for immediate questions or information that must be memorized, but not for building your knowledge base. It is critical that you understand the difference between these learning resources, as it affects your ability to answer questions that go beyond the review outline or pop-up answer screen.
• Read smart. You must strategically plan what to study as well as when and how. At the very least, this means you should take the following steps:
  • Tailor the content of your reading to reflect your training level and the different emphases within the junior and senior ABSITE. (The junior ABSITE is 60 percent basic science and 40 percent clinical management. The senior ABSITE is 20 percent basic science and 80 percent clinical management.) Read the basic surgical texts if you are studying for the junior exam. When studying for the senior exam, read more than one textbook (to find common ground when authors differ on important topics) as well as selected journal articles.
  • Tailor your reading assignments to focus on areas that you missed in previous exams or were challenging for you in medical school.
  • After identifying readings and review chapters to correspond with the relevant subareas in the ABSITE and your own goals, schedule these readings (to the extent possible) to correspond to topics likely to occur on rotation or to be assigned for weekly core conferences.
  • Read proactively and come to weekly conferences with prepared questions in your mind. Ask those questions during the session and e-mail the faculty member afterward if your question wasn't answered.
  • Read proactively on rotation. Search for and view related video lectures or procedures; make mental notes of things to discuss with faculty during the week. Come to the weekly teaching rounds or patient care meetings with questions.
  • Read before you go into the OR to assist with a new case. Read afterward to amplify or explain what you saw or did. Review operative dictations for procedures and mentally save them for future, similar operations. This process of revisiting topics is very important for building an accessible knowledge base.
• Incorporate regular review and self-assessment into your weekly reading. That is, read and review what you've read and then test yourself. This helps encode new information into long-term memory. However, switch the order of activities to prepare for test taking. This helps with retrieval.

• Shift the ratio of "new reading" to "review + self-test" the closer you get to the next ABSITE. Although you should always incorporate review and assessment along with reading, the balance should change over the year. Think of it like training for a marathon, where you are learning new skills in the early months and increasing the rehearsal, the speed, and the power of those skills leading up to race day.

Consider the months immediately following the ABSITE as a time to read and focus on areas you missed. Over the summer, read more slowly and comprehensively, again paying close attention to areas of weakness. At the same time, keep scanning areas that you know pretty well in order to ensure that you retain them. In the fall, and especially in the months before the ABSITE, switch your diet mainly to material you have thoroughly digested (e.g., your notes, review manuals). Take a practice test or read questions, then review the answers, and then follow up with additional reading to fill gaps or correct misconceptions. In the final weeks prior to the exam, switch entirely to "test preparation" mode. This is the sprint phase where you practice retrieval and get into the mind-set of test-taking. You may find that multi-tasking (e.g., listening to tapes or podcasts while driving the car, running, or working out) at this stage is helpful for continued reinforcement.

This section contains the most important advice for those residents who struggle with comprehension, retention, or retrieval of information. Two things influence how new information gets encoded and moved from short-term "working memory" to long-term memory in retrieval form: How you read (or listen, in the case of lectures; or observe, in the case of watching others) and what you do with what you've read (or heard or seen).

If you remember nothing else from this document, remember this: "Use It or Lose It"

First, you have to be alert. You have to be focused. You have to pay attention, which is not easy in a distracting environment and when one is fatigued. Sitting in a comfortable chair in a warm room after a long day in the hospital is a prescription for disaster. Find tricks to stay awake that work for you (e.g., stock up on caffeine before the cafeteria closes; turn on bright lights; chew gum; study in a cold room; schedule your watch to beep every 20 minutes).

Then, you have to DO SOMETHING with new information to give it meaning, accommodate it with what you already know, and remember it later on. "Deep learning" means getting information encoded in memory in multiple ways. This is most effectively done when you actively do something to interact with the information. In the case of reading, at the very least, this means highlighting, underlining, or jotting notes on the margin of a page. However, before you do that you should do the following:⁷

• Scan an article or chapter section before you read it. What's the big picture? What do you already know about this topic; what is new for you? Read the abstract or chapter introduction and formulate some questions; then read the material to answer those questions.
• Be goal oriented in your reading—that is, read to understand main points. This may actually mean you don't read the entire chapter comprehensively, trying to grasp every detail or memorize every sentence. As you gain clinical experience, it will become easier to pick out key points and concepts and to read more efficiently when time is limited. Over-learning key sections of an article may yield better returns than dogged, literal reading of every word.
• Monitor your comprehension. Halfway through the chapter or section, mentally (if not verbally, out loud) review the main points of what you've just read.

Other active mental processing tips that might work for you:

• Close your eyes and visualize an important table, graphic image, or photo.
• Verbally explain a key point to yourself or someone else.
• Illustrate a principle in your mind's eye with a case you saw on rotation.
• Make mental analogies of new concepts. Compare and contrast similar cases / concepts.
• Diagram the relationship between key points (causes and effects, differential diagnoses, decision trees).
• List terms, definitions, formulas, you need to memorize. Create mnemonics or acronyms to encapsulate a complex rule or principle.
• Draw the anatomy of a procedure and label important parts or steps.
• Write an outline of what you've just read.
• Write a summary of the chapter in your own words (i.e. write your own abstract).
• Create several test items from the chapter and quiz a friend on them.
• Create a note card with questions to pursue in further reading or conversation.

Similar strategies can be adopted for processing information acquired from oral presentations or direct observation.

The best predictor of doing well on the day of testing is the quantity and quality of prior study. You can't pull information from memory if the information isn't there, and you may not remember it (even if it is there) if you haven't been practicing retrieving it under similar practice test conditions.

That being said, some people underperform on the day of testing for a variety of reasons. This section provides some general advice on test taking and summarizes some specific recommendations for the ABSITE. Check with your medical school; most institutions have additional resources for test preparation and test anxiety.

In general, there is a curvilinear relationship between "stress" (heightened awareness, focused attention, readiness to respond) and performance. That is, a certain amount of it is helpful and necessary. Too much of it interferes with focus, reading the questions well, and clicking on answers that you actually know. Some of the more familiar but trustworthy recommendations for being in the right "frame of mind" (i.e., relaxed but alert and focused) include the following:

• Try to rest well the night before. Although the data don't generally show a disadvantage from being on call, residents at risk should try to avoid call duty.
• Eat a good breakfast if you can; do drink caffeine.
• Arrive early to the exam site and get yourself totally settled before the test begins.
• During the exam, relax your body, breathe deeply to relieve stress.
• Pace yourself. Aim to answer half the questions by the time the test period is half over. Do not spend excessive time on questions you really can't answer. You are not penalized for guessing, so pick one option and move on.
• Take short breaks if you lose focus.
• Check for any missed items before submitting the exam.
• Practice positive expectations and affirmations.

The American Board of Surgery's Guide to Multiple Choice Examinations covers elements of test construction and test-taking strategies.⁸ The key points are to do as follows:

• Read test items slowly and carefully, speaking the words silently to yourself if you find yourself jumping ahead to the end.
• Recognize that several of the listed response options may be correct under various circumstances. The point is to choose the best option given circumstances that are embedded in the item itself. Assume that all of the details provided in the item stem are relevant to the answer.
• Recognize also that good test items use gradations in "wrong" answers. At most, one or two of the options will be patently wrong. The others will be reasonable "foils," meaning they look like appropriate answers. Foils force learners to make finer discriminations between similar or competing ideas. Common misconceptions make good foils. Knowing this may help you be especially alert, both in studying and in reading test items, to pay attention to closely similar ideas.
• One strategy to help you focus on the question and select the best response is to cover up the response options and formulate what you think would be the best answer before reading them. Then go through the listed options and see if yours appears. If it is not there, re-read the question. If you still cannot see the best answer, eliminate clearly incorrect answers and decide which of the remaining options is "least wrong." Carefully weighing the alternatives is always a good strategy, even when you have a strong first response regarding the best answer.
• Go through and answer all of the questions you feel certain about and mark those that you wish to return to and review later.
• Keep in mind that your first response is most often the correct one. Don't change your answers unless you are very certain you made an error the first time.

The amount of information within the field of general surgery that could be learned clearly exceeds human capacity to master it. Furthermore, you are not expected to master it all— and certainly not all at once. Part of your success will depend on a realistic, disciplined approach to learning. The other part will depend on remembering why you're doing this, and to embrace the journey. There is a good reason why it takes five years to train clinically and why the rest of your life is called the practice of surgery.

1. Weinstein CE, Husman J, Van Mater Stone G, McKeachie WJ. Teaching students how to become more strategic and self-regulated learners. Ch. 23 in McKeachie's Teaching Tips (12th ed.), WJ McKeachie, MD Svinicki, BK Hofer. Boston (MA): Houghton Mifflin, 2006.
2. Zimmerman BJ. Self-regulated learning and academic achievement: An overview. Educational Psychologist, 1990;25(1):3–17.
3. Zimmerman BJ and Schunk DH. Self-Regulated Learning and Academic Achievement: Theory, Research, and Practice. New York (NY): Springer-Verlag, 1989.
4. McKeachie WJ, Pintrich PR, Lin Y. Teaching learning strategies. Educational Psychologist, 1985;20(3): 153–160.
5. DaRosa DA. Promote residents' responsibility for their own learning. American College of Surgeon's Residency Assist Page, August 11, 2010 (http://www.facs.org/education/rap/darosa0810.html, accessed 8-31-10).
6. Hirvela ER, Becker ER. Impact of programmed reading on ABSITE performance. American Journal of Surgery,1991;162(5):487–90.
7. Robinson F. Effective Study (1972), as summarized in Gover JA and Bruning RH, Educational Psychology: Principles and Applications, 2nd ed. Boston (MA): Little Brown and Company, 1987, p. 87–88.
8. American Board of Surgery, Guide to ABS Multiple-Choice Examinations, (http://home.absurgery.org/default.jsp?examoutlines, accessed 8-19-10).