Internal Medicine Residents' Acceptance of Self-Directed Learning Plans at the Point of Care

Research has highlighted the chasm between what is known and what is practiced in medicine,1–6 and it is widely appreciated that physician competence after completion of residency benefits from the application of self-directed learning (SDL) skills situated in the practice context. Current trainees will face a practice world in which SDL must be documented as part of maintenance of certification and licensure.7,8 Requisite skills of SDL include recognition of knowledge and proficiency gaps through self-assessment. After the implementation of strategies to fill the gaps, a reflective process is used to determine the learning endeavor's success.9 SDL is one component of life-long learning.

Teaching and evaluation of the skills for lifelong learning are required of all residency training programs in the United States and is included in the competencies of practice-based learning and improvement (PBLI) and professionalism.10 Many have suggested that self-directed learning skills are a specific skill set11 and should be taught during training.12–15 However, there is limited knowledge on the acceptability of sustained use of self-directed learning plans by residents.

To teach residents self-directed learning skills, in 2004, we implemented an ongoing curriculum integrated with their clinical practice. Residents record one clinical question monthly that forms the basis of a structured exercise. They document the patient encounter triggering the question, describe resources used and the answer found, and reflect on its effect on patient management. Residents discuss their self-directed learning plans (SDLPs) monthly at the preclinic conference, where only their postgraduate year (PGY) cohorts (PGY-1 versus PGY-2 and PGY-3 residents) are present. The purpose of this report is to describe perceptions and attitudes of residents in internal medicine using SDLPs conceived in the resident-patient encounters.

In November 2006, 17 months after curricular implementation, we invited all residents (N  =  37) in our program to complete a questionnaire administered anonymously at the residents' noon conference. We did not collect individual identifiers because of the small size of our program. A second invitation was made 2 weeks later by placing the questionnaires in the residents' mailboxes. Explicit instructions were given to participants to complete the questionnaire only once. Data collection was completed during November and December of 2006.

The questionnaire was developed by the investigators and was tested on a small convenience sample. It consisted of 17 items to assess the residents' perceptions and self-reported behaviors relevant to the use of SDLPs, self-identified knowledge gaps, the effect of SDLPs on their practice, and the intent to use SDLPs after residency.

The study was approved by the institutional review board.

Descriptive statistics were used to report the findings. All the results were presented as proportions and percentages. Respondents rated the items concerning their attitudes toward SDLPs, the effect of doing SDLPs on their knowledge gaps, and their critical appraisal skills on a 5-point Likert scale from “strongly agree” to “strongly disagree.” We dichotomized the responses (strongly agree or agree responses and disagree and strongly disagree were combined).

Most (16 of 17) upper-level residents (94%) had completed 5 or more SDLPs. Half of all respondents spent 30 minutes or less, and the other half spent more time, up to 2 hours, to complete an SDLP.

Most (24 out of 26) of the residents (92%) responded that SDLPs had helped them to identify and fill their knowledge gaps (table) without a significant difference between upper- and lower-level residents. However, more upper-level residents indicated that they benefited from listening to others' SDLPs (15 of 17 [88%] versus 6 of 9 [67%]) and that the use of SDLPs improved their ability to search for evidence, (15 of 17 [88%] versus 6 of 9 [67%]).

Most (23 out of 26; 88%) indicated that completing the SDLPs was an opportunity to practice framing questions in a systematic format. Similarly, residents responded that it improved their ability to look for evidence (21 out of 26; 81%), and helped them practice their critical appraisal skills (20 out of 26; 77%).

Residents predominantly used electronic resources including PubMed and UpToDate (22 out of 26; 85%).

Although one-third of residents responded that the outcome was to confirm their present clinical practice, the rest (17 out of 26; 65%) indicated that the most common outcome was either a meaningful change in their current practice or a direction for further learning.

Most of the residents (23 out of 26; 88%) indicated that they plan to integrate SDLPs into their practice habits.

Most residents reported that completing SDLPs enabled them to recognize and fill knowledge gaps, and they noted enhancement of their literature searching and appraisal skills. These findings are consistent with systematic reviews of the evidence-based medicine (EBM) literature, which showed clinically integrated curricula result in a change in physicians' EBM skills, attitudes, and behaviors.16,17 

Practicing physicians and trainees have many clinical questions arising during their patient care.18–20 Our residents reported formulating and finding answers to questions in practice resulted in a change in patient management or provided direction for further learning, consistent with findings in other publications.21–25 Learning embedded in patient encounters may represent the single greatest motivator for meaningful physician learning.26,27 The challenge lies in incorporating the habit into a busy practice.

Our residents used primary research articles and summary sources, such as electronic textbooks and synthesized and preappraised sources of evidence to complete their SDLPs. They reported most commonly using PubMed and UpToDate to answer questions, comparable to other studies that concluded that summary resources often fulfill information needs at point of care.28 

Our curriculum with its regular practice and faculty guidance should increase learners' self-efficacy in clinical question follow-up, thereby perpetuating further learning episodes. We also found that more upper-level residents indicated that they benefitted from listening to SDLPs presented by their cohorts (15 of 17 [88%] versus 6 of 9 [67%]). This may reflect the greater sophistication of the SDLPs of the upper-level groups making their discussions more useful.

In addition, residents accepted the SDLP format and endorsed its value and ease of use for documenting clinical questions and learning activities, consistent with the findings of others.8 Self-directed learning skills will be important to residents in their continuous professional development and licensure, because continuing medical education (CME) credits, which are required for licensure renewal, are available through organizations such as American College of Physicians' Physician Information and Education Resource for similar activities.29 In addition, the American Board of Internal Medicine is offering an Internet-based learning portfolio as an optional exercise toward maintenance of certification (MOC), based on a pilot in which the portfolio was well received as a CME activity due to its relevance to practice.8 Self-directed learning skills will be important in a resident's future MOC.

Residents reported acceptance of SDLPs as a point-of-care learning method, and embedding SDLPs in the preclinic conference has ensured sustainability and has enabled us to demonstrate teaching of PBLI. The process of residents formally discussing their clinical questions and their learning with peers and faculty reinforces the importance of PBLI in practice. It establishes the relevance of “situated learning,” which has been shown to be important in “deep learning” and the “construction of knowledge.”30,31 

Our study has several limitations. The small sample size in a single institution may limit the generalizability of our findings. Also, given the nearly universal success of this learning method with our learners, and the lack of specific information about each participant's learning style, we could not draw conclusions about the few residents for whom this learning method was not effective.

The responses of most residents reflected their acceptance of point-of-care learning in the form of an SDLP. The SDLPs helped the residents to identify and fill knowledge-base gaps, enhanced their literature searching and critical appraisal skills, and promoted reflection on their learning outcomes.