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
Uses active learning strategies (e.g., scans, questions, interprets, analyzes, rephrases, summarizes, elaborates, sorts, classifies, files, reviews, memorizes, rehearses)
Analyzes effects of study efforts on outcomes; revises efforts if they don't produce good outcomes
Achieving goals brings personal satisfaction
Learning fulfills valued self-concept ("I can become a good doctor")
High sense of self-efficacy ("I can master this") is both cause and effect of academic success
Intrinsic interest in subject matter, task
Persistent drive to know the answer(s)
Responsive to external as well as internal motivators
Plans for learning
Organizes learning tasks
Sets goals (realistic, proximal, intermediate)
Selects, structures, creates environments that optimize learning
Exerts controls over time, attention, focus
Seeks advice, information, supports
Devotes significant effort to learning
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
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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:
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 order for learning new information:
Read → review → self-test for comprehension
Suggested order for preparing for test taking:
Self-test → review to reinforce → read areas you missed
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
Other active mental processing tips that might work for you:
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:
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:
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.