Authors: Annahieta Kalantari, DO; Eric Lee, MD; David Zodda, MD
Editor: Simiao Li-Sauerwine, MD, MSCR

A Case

Melissa is a new emergency medicine intern. Her medical school grades and evaluations were excellent and she is well-liked by colleagues, faculty, and staff. However, since starting residency, Melissa has struggled with regard to her clinical performance. 

After some critical shift evaluations, her residency director meets with her. When asked what abilities and characteristics make a good doctor, Melissa has a hard time coming up with specific attributes. She states that learning was easier in medical school as she was able to monitor her success through her performance on regular quizzes and exams. Now, in residency, there are no grades and the expectations are higher. She wants to step up and succeed but she is not sure where to start.

 We can all relate to the difficulties Melissa is facing. Many of us can also relate to the challenges her residency director faces as they work to help Melissa achieve her goals. In this chapter, we will take a look at education theory and take a deep dive into the key elements of self-regulated learning. We will discuss how self-regulated learning techniques can be utilized by both residents and educators to achieve their academic goals.

Background

Self-regulated learning theory is often confused with metacognition and self-directed learning. Metacognition was first introduced by Flavell and described as thinking about one’s own thinking. Although this is an essential component of self-regulated theory,³ it differs in that self-regulated theory incorporates knowledge of cognition in addition to self regulatory mechanisms and self efficacy. Moreover, self-regulated learning theory differs from self-directed learning because in self-regulated learning, instructors provide a scaffolding and guidance for learning. In self-directed learning, the process is entirely learner independent.²

Regulatory agents

The first stage of self-regulated learning is the planning phase. This is primarily done by setting goals. Goal setting is most effective when goals are specific, individuals are committed to reach them, individuals possess task knowledge, and individuals receive feedback on goal progress.¹ In Melissa’s case, her medical school goal was to score well on exams. She was able to develop study plans, sustain motivation, and assess her progress in achieving goals with each exam. Her residency goal is to be a good doctor. This is not specific enough. Because it lacks specificity, she is unable to develop an effective learning plan and is unable to assess her progress effectively.

Regulatory mechanisms

Regulatory mechanisms are under the control of the learner and are the crux of self-regulated learning. They are:

• Planning – Allows trainees to think through steps on how to achieve goals. Many are not planned out far in advance as the plan usually evolves as the task is carried out
• Monitoring – Provides awareness of one’s knowledge level. Accurate monitoring enhances the regulation of learning and reveals what the learner knows and where they need to focus resources.
• Metacognition – This differs from monitoring as it incorporates not only awareness of knowledge but understanding one’s own thought processes.
• Attention – Degree to which trainees maintain cognitive focus and concentration during training.
• Learning strategies – Useful for breaking a task into smaller parts and reorganizing parts and building knowledge structures that are meaningful and can be stored in long term memory.
• Persistence – How effort is devoted despite boredom and failures. Function of outcome expectancy. Goal setting, self-efficacy, and feedback all have positive effects on persistence.
• Time management – Study schedules and allocating time, meeting deadlines. Opposite of procrastination.
• Environmental structuring – choosing study location supportive of learning, removing distractions from study area. Imperative for online training.
• Help seeking – degree to which trainees ask assistance when they have difficulty understanding concepts. Knowing when, why and from whom to ask for help.
• Motivation – willingness to engage in learning and desire to learn. Beliefs about incentives or values of learning have direct effect.
• Emotion control – limits intrusion of performance anxiety. Trainees can engage in relaxation exercises, self encouragement and self talk. Facilitates performance by keeping off-task concerns at bay
• Effort – amount of time devoted to learning. Regulate effort by monitoring behavior and feedback on performance. If detect negative discrepancy, will increase effort to reduce discrepancy.

As learners engage in goal achievement, self efficacy will redirect which regulatory mechanisms should be incorporated or require adjusting.¹

Regulatory appraisals

Regulatory appraisals involve determining where a learner is in the goal achieving process and identifying which factors are contributing or preventing goal achievement.

There are three main components of regulatory appraisal.

• Self evaluation – assessing goal progress by comparing one’s current level of knowledge/performance to the targeted goal. Metacognition plays are large role in self-evaluation.³
• Attributions – If not meeting goals, attributions are deemed the reasons why. Effective self regulators generally attribute failure to low effort and poor use of learning strategies.
• Self efficacy – refers to trainees belief regarding their capability to succeed. Motivation and self efficacy are big drivers of self regulated learning.

Modern takes on this Theory

The emergence of FOAM and digital resources have the potential to greatly contribute to self-regulated learning theory. Traditionally, learners read through textbooks and deciphered what was relevant and essential to learning. Blogs and podcasts attempt to curate essential information. Online testing resources allow learners to independently assess their medical knowledge progress as well. What FOAM cannot provide are the essential steps of the planning phase but this can be done with academic coaching. 

Academic coaching is a process wherein a learner meets regularly with a faculty member to create goals, develop learning strategies and further develop professional identity. The goals should be consistent with the S.M.A.R.T format: specific, measurable, attainable, relevant and timely. Coaching will allow the learner to reflect and develop SMART goals. Once these goals have been created, FOAM and online resources can be used for regulatory mechanisms and regulatory appraisals. 

Coaching can also guide the learner’s selected resources. For example, as a novice learner, Melissa may not know which resources to use to further her learning. Her coach can provide her with a list of relevant resources that align with her level of training. She will continue to meet with her coach and appraise her progress. As she successfully achieves her goals, she and her coach can gradually increase the complexity of her learning goals and her coach can provide more advanced FOAM resources. 

Other examples of where this theory might apply

The clinical setting is a new frontier for many medical students and residents as they transition from tests to clinical performance. Those who came from a problem-based learning curriculum have been shown to use more self-regulated learning skills in their clinical performance.⁸

Limitations of this Theory

It is essential to stress that self-regulated learning is not an entirely learner independent process. This learning theory requires an instructor to help build foundational elements required for success. 

Novices and experts view their learning in different ways. It is more difficult for novices than experts to engage in self-regulated learning because novices are more reliant on external feedback and direction at the beginning of their training.⁷ Self-regulated learning may be harder to develop in interns as opposed to senior residents.

This can be overcome with appropriate coaching and guidance. With appropriate guidance, a learner can set goals that are appropriate to his/her level of training. Educating the learner about the different regulatory mechanisms will assist them with goal achievement. Using an inquiry and advocacy framework will assist the learner in developing the skills of self reflection that are required for regulatory appraisal. 

Returning to the case…

Melissa is an emergency medicine intern struggling to achieve her goal of becoming a good doctor. She is smart and motivated and recognizes that she needs to specify exactly what she means by becoming a good doctor. Her residency director introduces her to the educational theory of self-regulated learning in an effort to help Melissa achieve her professional goals.

Together, Melissa and her residency director develop an action plan focusing on three main academic areas: medical knowledge, patient care, and professionalism. Melissa develops a self-study plan composed of peer-reviewed FOAM resources and weekly question bank expectations. Self-study sessions take place during protected time in the hospital library to reduce distractions and include a mechanism for regular performance monitoring by her residency director.

Help seeking, motivation, planning, persistence, goal setting, and environmental structuring are all key elements of the self-regulated learning strategy. Baked into Melissa’s action plan are self-regulatory appraisals such as scheduled performance monitoring by her residency director. To further enhance her learning, Melissa also chooses to include regular self-evaluation via personal journaling, social media posting, and self-reflection. 

Fast forward just a few months later and Melissa is excelling in her intern year. Her weekly quiz score leads her class. Her shift cards continue to rack up positive comments on patient care and professionalism. Self-regulated learning has made a real difference in Melissa’s development and success. As she gains more experience and insight, she will be able to independently set new goals, develop plans, determine progress, and titrate adjustments in her learning.

References

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