1. Planning

2. Learning

3. Assessment

4. Adjustment

Planning is about setting personal goals, establishing desired outcomes, and having the belief in one’s

ability to achieve those goals. In this phase, intrinsic motivation and extrinsic motivation are important

considerations in the setting and reaching of learning goals. While extrinsic motivation is embedded in

graduate medical education (e.g., passing certifying oral examinations), it is intrinsic motivation that is

“key to the development of autonomy” and “autonomy is key to lifelong learning.”12 Therefore, during

the planning phase, learners develop a sense of urgency for their own learning and an ability to plan

and act on goals.

During the Learning phase, learners need clarity about how they learn most effectively. This includes

developing awareness about one’s personal beliefs toward acquiring knowledge, preferred ways of

learning (e.g., visual, auditory), learning strategies (e.g., where and when studying happens), and

finally aligning learning expectations with those of the educator.

Assessment requires timely, specific, and regular formative feedback (e.g., from supervisors,

colleagues, medical students) as well as internal monitoring that compares one’s progress against the

goal that was set. Together these sources of feedback guide the learner’s next steps toward reaching the

goal.

Finally, Adjustment is where the learner synthesizes what has been gained through the planning,

learning, and assessment phases and makes adjustments either in the nature of the goal or in the

strategies needed to reach the goal. How learners integrate information about successes or failures

could be seen as a matter of attribution – how performance is accounted for ranging from ability to

effort. Examining the performance feedback that has been gathered to date, considering the validity of

the information, and then determining how to make sense of it in relation to what they already know is

a complex process of reflection.13

Through explicit teaching and practice at each phase, learners are guided toward sustaining strategies

for ongoing, more effective self-regulated learning. Sustainable strategies form the basis for lifelong

learning. White et al.12 underscore sustainable strategies as a key to continuing medical education

(CME) for the practicing surgeon and point to the link between CME and quality health care.

LIFELONG LEARNING

If the phases of self-regulated learning solidify for the trainee, they become habitual characteristics of

effective lifelong learning. In the broadest sense, lifelong learning is about ongoing learning from cradle

to grave. However, in the context of entering the workplace after graduate medical education, we look

at physicians and lifelong learning more closely as the “ability to guide their own learning throughout

their lives and in the wide variety of situations they will encounter after leaving formal education.”14

This ongoing reflexive process of lifelong learning includes five characteristics

14:

1. set goals

2. apply appropriate knowledge and skills

3. engage in self-direction and self-evaluation

4. locate required information

5. adapt their learning strategies to different conditions

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These characteristics are meant to extend the physician’s concept of ongoing learning from “lifelong

schooling” to “life-wide learning” so that personal inquiry can happen, for example, at the bedside or in

the community and is not constrained to formal educational opportunities.14

As a trainee transitions through different levels in residency, the nature of self-regulated learning will

also change depending on the learner’s needs. As learners meet increasingly more complex patient care

milestones, the practice of self-regulated learning transforms accordingly. Solidifying the phases of selfregulated learning during graduate medical education feeds into establishing effective characteristics for

lifelong learning that become a critical part of a physician’s everyday practice (Table 1-1). As such,

medical education programs have a social and professional obligation to further develop and deepen

characteristics of self-regulated learning among learners so that graduating surgeons pursue professional

learning throughout their careers.5 It is critically important that a robust curriculum be established

within graduate medical education for teaching, engaging with, and assessing practices for lifelong

learning.

Table 1-1 Relationship Between Self-Regulated Learning and Lifelong Learning

Self-regulated learning evolving and deepening into lifelong learning is best understood using the

Dreyfus model for skill development.15 This is in keeping with the foundational framework from which

the milestone frameworks have been structured to assess residents/fellows in surgical disciplines.1

DREYFUS MODEL FOR SKILL DEVELOPMENT

The Dreyfus model for skill development identifies five levels of skill development15–17:

1. Novice

2. Advanced Beginner

3. Competent

4. Proficient

5. Expert

On this continuum, learners pass from one level to the next as skills are acquired. At each level, there

are “recognizable, qualitatively different ways of acting and performing in the process of learning a

given skill. Individuals at a given level do better than individuals at the previous level.”18 Table 1-2

presents the five levels of the Dreyfus model with the addition of delineating each level along four

characteristics of skill development: knowledge; decision-making; perception of context; and

autonomy.19–23 Increasing understanding, confidence, and independence associated with these

characteristics is in keeping with higher levels of competency with the skill being measured. This

delineated view demonstrates in a granular way how a learner progresses and performs differently at

each level. Based on criteria, it is clear why not every learner reaches the highest level. The criterionbased foundation of the Dreyfus model makes it a widely adapted process for assessment.23,24

2 At the novice level, learners largely have textbook familiarity with a skill. After having advanced to

the expert level, learners have extensive experiential knowledge with a skill and are seen to be highly

intuitive. We understand self-regulated learning to be a skill that can be learned, will progressively

grow and deepen over time, is carried out differently at each successive level, and ought to be carried

out in the workplace. As the skill is honed and becomes habitual, self-regulated learning transitions into

lifelong learning. This progression in skill development makes the Dreyfus model highly appropriate for

understanding, teaching, and assessing self-regulated learning.

Table 1-2 Dreyfus Model of Skill Development: Novice to Expert Levels for Self44

Regulated Learning

DREYFUS MODEL OF SKILL DEVELOPMENT APPLIED TO SELFREGULATED LEARNING IN SURGERY

The attributes and practice of self-regulated learning change as learners transition from one level to the

next. In other words, as learners attain greater levels of responsibility, the goals they set for

themselves, insights adopted about learning, feedback they require, and adjustments they make based

on successes and failures will be different from one level to the next. This is in line with gradually more

mature forms of reflection and insightful learning plans learners develop for themselves. Self-regulated

learning will be described at each level in terms of the learner’s skills, but also includes suggestions for

educators on how to teach at the level of the learner and establish scaffolds to support the learner

advancing to the next level.23,24

Novice

The novice learner is focused on figuring out how textbook knowledge applies to the current

experience. The goals learners set for themselves are about making sense of uncertain or unfamiliar

content by connecting it to existing familiar sets of knowledge. At this point, the learner adheres to

step-by-step rules, regardless of context. Working through a methodical line of reasoning without

situational awareness or discretion makes it difficult for the trainee to deal with exceptions and

45

complexity.24 The learner searches for absolute answers. Tendencies toward binary sets of knowledge

reveal that learners at this level often do not know what they do not know (unconscious incompetence),

suggesting they have an incomplete development of self-assessment.25 After routine-guided observations

of procedures being performed, novice learners are incrementally moved to close supervision with

explicit instruction in order to complete tasks. Reflecting on their behavior during experiential

opportunities along with the feedback received from faculty or more senior residents and fellows causes

learners to revisit the knowledge they believed to be universally true and adjust their goals and views

on learning.

Educators must be deliberate and specific in the feedback that is provided, even being explicit about

the phases of effective self-regulated learning that should be developed. Educators become a resource as

trainees learn to develop appropriate goals and establish a plan forward. Determining the existing level

of the learner and learning preferences of the trainee is essential for educators so that they can guide

the learner toward suitable challenges that will scaffold him/her to the next level.

Advanced Beginner

For the advanced beginner, emphasis is on gaining practical experiences and knowledge. The balance

tilts from taking textbook knowledge and applying it to the context, to better understanding the

context, patient indicators, and beginning to discern and apply rules. Although perception is improving,

judgments are still quite limited. The advanced beginner continues to be rational and analytic, but now

sees actions as related rather than a series of independent steps.24 Developing an understanding of

connectedness helps learners realize the complexity of situations and with that comes an appreciation

for how much they do not know (conscious incompetence).25

Faculty provide trainees with structured opportunities and directly observe their skills. Under this

closely guided practical experience, trainees assist with performing a procedure and receive some

opportunities to try simpler tasks on their own. There is a high likelihood these trainees will be able to

accomplish these simpler tasks successfully. With the learner starting to see steps as related, this is an

opportunity for the educator to give feedback that will push the learner to be aware of more complex

connections. Learners still require supervision for the procedure largely because they continue to have

difficulty with troubleshooting. Educators should provide challenges just at the edge of the learners

comfort level. The trainee’s performance will help the educator identify where emphasis needs to be

placed in the next educational encounter. It is important to debrief this experience with the learner so

s/he can reflect back on emotions, thinking, and skills and establish subsequent goals. Educators

simultaneously assess how much scaffolding learners require to extend them to the next level while also

removing scaffolds as the learner demonstrates task competence.

Competent

At the competent level, the learner has well-developed conceptual models and fund of knowledge in a

specialty. Although still primarily rational and analytic in decision-making, the learner is largely led by

guidelines that are specific to the given context. In other words, through deliberate planning and

judgment, the trainee can see the larger context and handle complex situations.24 Trainees recognize

what they know, for example, the limits of what they are able to troubleshoot on their own, and also

know when to ask for guidance or help (conscious competence).25 Safely progressing in a high-stakes

environment while knowing when to slow down or stop is indicative of being able to reflect while in

the moment. A competent level learner will reflect on actions and develop long-term goals.

Educators recognize that learners are able to complete an entire procedure independently to an

optimal level. Nevertheless, educators still provide direct supervision to guide refinement, efficiencies,

and standardization of procedures. With increasingly complex skills, educators will model specific

methods. Learners at the competent stage ask for feedback and the response of the educator becomes

less about general principles and more about fostering specific opportunities for individualized growth.

While still under direct supervision, individualized instruction allows faculty to release greater degrees

of responsibility for the full spectrum of patient care to residents/fellows so they can begin to take

ownership and think ahead in developing a care plan.

Proficient

The proficient level represents a learner who sees context, actions, and interactions holistically.

Physician core competencies (e.g., Patient Care and Professionalism), as outlined by the ACGME, are

understood and enacted in an integrated way into the roles and responsibilities of the learner.6 It is in

46

seeing the bigger picture that the trainee is able to filter out extraneous materials and focus on essential

information that results in less labored decision-making and consistently high levels of performance.24

Residents/fellows are able to apply the depth of knowledge they have acquired in their specialty and

increasingly become more intuitive with less dependence on rules (unconscious competence).25 Trainees

continue to be guided by maxims and rationale approaches to address unusual problems or deviations

from expected patterns. The trainee reflects on personal performance with the goal of being able to

efficiently merge intuitive and rationale approaches in complex situations.

Proficient residents/fellows have demonstrated that they reliably perform at an acceptable standard;

therefore, there is a greater degree of indirect supervision. The role of faculty is to provide

opportunities for learners to take full responsibility for performing a procedure, as well as work

through uncommon cases. The feedback provided to learners is specific and formative (i.e., not scored)

in helping them reach self-identified goals, as well as extend their critical thinking to unique problems

and situations.

Expert

At the expert level, individuals have deep holistic understanding in their specialty. Depth of knowledge

has provided them with intuitive understanding, confidence in decision-making, and ability to

successfully manage complex situations with ease.24 When faced with novel situations, they are able to

seamlessly proceed with alternative approaches, consciously draw on guidelines and maxims, and

consider innovative possibilities. Internal creative inquiry challenges these individuals to raise questions

to themselves, put the mental brakes on what is familiar, and set goals that extend the field in new

directions.26 Experts are thought to be authorities in their specialties.

Individuals at this level rarely receive feedback unless they ask for it.27 They adjust and adapt their

learning with regular review of current literature, participating in CME, and pursuing and publishing

research. As surgeons who independently perform procedures without any supervision, experts also rely

on patient outcomes – by reflecting in action (e.g., adapting to unexpected conditions) and reflecting on

action (e.g., follow-up care with patient) – as forms of feedback to inform practice.13,28 The expert level

does not represent completion in learning, rather it signifies that a learner has the skills to continue to

stay informed through workplace-based learning. This transition into habitual, ongoing, life-wide

learning illustrates that a learner has solidified skills for lifelong learning.

SELF-REGULATED LEARNING AND LIFELONG LEARNING IN

SURGERY EDUCATION

3 4 The purpose of this discussion is to show that skills for self-regulated learning can be learned,

developed, and transformed into lifelong learning. The Dreyfus model provides an accessible model for

visualizing the development and progression of skills from self-regulated learning into lifelong learning.

The implications for overlooking development of lifelong learning skills are less obvious while under

the observation and guidance of a Surgery Education program. However, if the goal of Surgery

Education programs is to produce surgeons who are able to practice independently, actively pursue safe

patient care with up-to-date knowledge and skills, then the development of skills for lifelong learning

cannot be easily overlooked while still in training. As such, the role of faculty educators to model and

explicitly teach about self-regulated learning and lifelong learning is essential.

Educators of residents/fellows at early levels of skill development must be explicit and concrete when

explaining how to set independent goals for advancing abilities, as well as provide specific instructions

on how to pursue inquiry on their own. As trainees deepen their skills and apply those more routinely,

the responsibility for stimulating habitual inquiry begins to shift from the faculty to the trainee. The

faculty now looks for the ways in which surgeons in training seek, receive, and provide feedback as

indicators of the awareness learners have about where they need to focus their attention for growth.29

With still further development of self-regulated learning, learners will likely transition into lifelong

learners.

5 When advancing in training and moving into careers as experts, there is a great deal of familiarity

with procedures, processes, and knowledge. When there is unconscious competence or deep

understanding, automaticity sets in. Individuals at this level have ingrained skills and habits that

routinely incite internal creative inquiry causing them to challenge these familiar patterns. The lifelong

learner purposefully “makes unconventional linkages (…) in order to reveal unseen aspects.”26 The

47

lifelong learner also seeks, applies, and makes new meaning. These are the surgeons who are prepared

to deal with the problems of today, but even better prepared to deal with complexities that are yet to

be encountered.

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