Sawatsky et al.

BMC Medical Education (2017) 17:31

DOI 10.1186/s12909-017-0869-4

RESEARCH ARTICLE Open Access

A model of self-directed learning in internal

medicine residency: a qualitative study
using grounded theory
Adam P. Sawatsky1*, John T. Ratelle2, Sara L. Bonnes1, Jason S. Egginton3 and Thomas J. Beckman1

Abstract
Background: Existing theories of self-directed learning (SDL) have emphasized the importance of process, personal,
and contextual factors. Previous medical education research has largely focused on the process of SDL. We explored
the experience with and perception of SDL among internal medicine residents to gain understanding of the personal
and contextual factors of SDL in graduate medical education.
Methods: Using a constructivist grounded theory approach, we conducted 7 focus group interviews with 46 internal
medicine residents at an academic medical center. We processed the data by using open coding and writing analytic
memos. Team members organized open codes to create axial codes, which were applied to all transcripts. Guided by a
previous model of SDL, we developed a theoretical model that was revised through constant comparison with new
data as they were collected, and we refined the theory until it had adequate explanatory power and was appropriately
grounded in the experiences of residents.
Results: We developed a theoretical model of SDL to explain the process, personal, and contextual factors affecting
SDL during residency training. The process of SDL began with a trigger that uncovered a knowledge gap. Residents
progressed to formulating learning objectives, using resources, applying knowledge, and evaluating learning. Personal
factors included motivations, individual characteristics, and the change in approach to SDL over time. Contextual
factors included the need for external guidance, the influence of residency program structure and culture, and the
presence of contextual barriers.
Conclusions: We developed a theoretical model of SDL in medical education that can be used to promote and assess
resident SDL through understanding the process, person, and context of SDL.
Keywords: Adult learning theory, Graduate medical education, Self-directed learning

Background is part of lifelong learning, and is an important compe-

Self-directed learning (SDL) is considered a component tency for physicians to develop and maintain [3].
of physicians’ professional identities [1]. The Accreditation SDL originates from the adult education literature
Council for Graduate Medical Education [2] requires that with Houle, Tough, and Knowles [4]. Knowles incorpo-
“residents and faculty members must demonstrate an rated SDL into his adult learning theory by emphasizing
understanding of their personal role in…attention to “the learners’ self-concept of being responsible for their
lifelong learning,” by developing skills and habits “to own decisions” and stating that “the most potent motiva-
continuously improve patient care based on constant tions [for learning] are internal pressures,” which contrib-
self-evaluation.” This “personal role” suggests that SDL ute to “the transition from dependent to self-directing
learners” [5]. Knowles [6] defined SDL as “a process in
* Correspondence: [email protected] which individuals take the initiative, with or without the
Presented at the annual meeting of the Society of General Internal Medicine, help of others, in diagnosing their learning needs, formu-
Toronto, Ontario, Canada, April 22-25, 2015.
1
Division of General Internal Medicine, Mayo Clinic, 200 First St SW,
lating goals, identifying human and material resources for
Rochester, MN 55905, USA learning, choosing and implementing appropriate learning
Full list of author information is available at the end of the article

© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Sawatsky et al. BMC Medical Education (2017) 17:31 Page 2 of 9

strategies, and evaluating learning outcomes.” One review we sought to explore the person, process, and context of
of SDL in medical education scholarship identified that SDL during residency training.
many studies lacked a definition for SDL, highlighting that
there is limited understanding of SDL and that clearer Methods
definitions and theories of SDL are needed to advance To build on existing theory and develop a framework of
SDL research in medical education [7]. SDL in medical education, we used a constructivist
Starting with Knowles’ definition, theories of SDL grounded theory approach to explore the experience of
have been developed to encompass three key components: SDL during internal medicine residency training at
process, personal attributes, and context. Brockett and Mayo Clinic, Rochester, Minnesota, USA, from October
Hiemstra [8] developed a Personal Responsibility Orienta- 2014 to January 2015. Study investigators had experience
tion model of SDL with two dimensions: SDL (process) and in qualitative medical education research and residency
learner self-direction (motivation). Candy [9] subdivided education. To explore various experiences and to learn
these dimensions into four phenomena: personal au- from the social interaction of participants, we collected
tonomy, self-management, learner control in academic data using focus groups. This study was approved by the
settings, and the individual, noninstructional pursuit Mayo Clinic Institutional Review Board. All participants
of learning opportunities in the “natural societal set- provided informed consent.
ting.” Garrison [10] outlined three similar dimensions: The Internal Medicine Residency Program at Mayo
self-management (task control), self-monitoring (cog- Clinic includes 144 categorical residents and 24 preliminary
nitive responsibility), and motivation (entering and residents. Sixty percent of the residents for this academic
task). More recently, Hiemstra and Brockett [11] proposed year were men. We invited all residents to participate
that previous models underemphasized the effect of context in 1-h focus groups, which were moderated by an expe-
on SDL and proposed a “Person, Process, Context” model, rienced facilitator (J.S.E.) who had no connection to the
highlighting the equal importance of each of these three residency program. The primary investigator (A.P.S.)
dimensions. They define person as the “characteristics of observed each session to provide initial data summaries.
the individual,” such as “critical reflection, enthusiasm, life All residents who volunteered to participate were included
experience, motivation, and self-concept,” whereas process in the study. We conducted 7 focus groups with 5–9 par-
includes skills and abilities to carry out SDL [11]. This ticipants per group; each group discussion lasted 60 min.
model added to their previous model the importance of The focus group discussions were audio recorded and
context, which they defined as encompassing the “en- transcribed verbatim. Transcripts were de-identified
vironmental and sociopolitical climate, such as culture, before data analysis.
power, learning environment, political milieu…” [11]. We developed the focus group guide through established
This theoretical model highlights the complexity of methods, including a comprehensive review of the literature
SDL, incorporating the personal and contextual factors and review with a panel of residency faculty members [16].
that affect the process of SDL. Throughout data collection and analysis, we revised the
Given the relevance of SDL to adult learning, under- interview guide to optimize saturation of themes within
standing the application to medical education is critically our theoretical model. We have included the focus
important. Murad et al. [12] demonstrated that SDL was group guide as a representation of possible questions,
effective for knowledge acquisition in health professions but emphasis may have been placed on different ques-
education but identified that few studies reported SDL tions to ensure rich discussion and theory development
components consistent with Knowles’ definition. This (see Additional file 1, Box).
suggests a misunderstanding of SDL in medical education We used a constructivist grounded theory approach to
and implies that clear definitions and the application of develop a theoretical model for how residents engage in
SDL theory can focus and clarify ongoing medical educa- SDL [17]. We chose this approach because we wanted to
tion scholarship in this area [7, 13]. develop a theoretical model of SDL that was unique to the
Slotnick [14] studied SDL among physicians, which residency learning environment, but was informed by previ-
resulted in a 4-stage model of the process of SDL: ous SDL theory. We therefore used Hiemstra and Brock-
scanning, deciding, learning, and gaining experience. ett's “Person, Process, Context” model as our theoretical
Similarly, Li et al. [15] developed a model for the lens to guide analysis and frame our research findings [11].
process of SDL in residency. Although these models We analyzed data after each focus group discussion was
outlined the process of SDL in medical education, they transcribed. Using open-coding and writing analytic
did not explore the components of people or context memos, we identified major themes. After the first two
of SDL. To our knowledge, a comprehensive model of focus groups, team members categorized dominant themes
SDL in medical education—which incorporates process, to create axial codes, which were applied to all transcripts
person, and context—does not currently exist. Therefore, using NVivo (QSR International) [18].
Sawatsky et al. BMC Medical Education (2017) 17:31 Page 3 of 9

We developed a theoretical model that was revised as learning objectives, use resources, apply knowledge, and
new data were collected. Through constant comparison, evaluate learning. This serves to build the resident’s know-
we refined the theory until it had adequate explanatory ledge framework and triggers additional learning, which
power and was appropriately grounded in the experi- makes SDL cyclical. The person of SDL includes motiva-
ences of residents. This process also allowed the study tions, individual characteristics, and change over time.
team to assess theoretical saturation, which was achieved The context of SDL includes external guidance, residency
after seven focus groups. To test the trustworthiness of program structure and culture, and barriers. We will
our theory, we invited all 46 study participants to par- discuss each element below. (Quotations given are followed
take in one of two member check sessions, and 18 resi- by the group number of the participant.)
dents (39%) participated. In these sessions, we presented
the theoretical model and discussed the process, per- The Process of SDL
sonal aspects and contextual factors of SDL. Participants The center of the theoretical model contains the process
were given the opportunity to make comments and of SDL practiced by residents (Figure, gray boxes); Table 1
discuss the model. During these sessions, the study par- contains additional supporting quotations. The starting
ticipants endorsed the nature of our findings and sug- point and main goal of SDL was building a knowledge
gested minor changes to the model. framework required to be a physician. Residents described
the requisite knowledge gained through training as “what
Results I need to know to come out of residency [having] a broad
We conducted seven focus groups of 46 residents total: 20 and deep knowledge base” (group 2). On this knowledge
postgraduate year-1 residents, 10 year-2 residents, and base, residents developed a framework that supported
16 year-3 residents. Thirty-one residents (67%) were men. comprehension of medical knowledge and application to
We developed a broad theoretical model of resident patient care, until residents understand concepts “in
SDL that encompassed the major themes within the depth” (group 3).
categories of person, process, and context of SDL (see Triggers for SDL were external events that exposed
Fig. 1). The process of resident SDL is at the center of gaps in the resident’s current knowledge framework.
the model, beginning with a trigger for learning that Triggers arose when residents were “presented with a
acts on the resident’s knowledge framework to uncover new unfamiliar scenario” (group 1), like “when a ques-
a knowledge gap and stimulates the resident to formulate tion comes up with the care of a patient” (group 6).

Fig. 1 Theoretical Model of Resident Self-Directed Learning (SDL). This model highlights the person, process, and context of SDL in medical education,
captured by the dotted lines. The gray boxes at the center represent the process of resident SDL. The white boxes represent personal factors that affect
the process of SDL. The black boxes represent contextual factors that affect the process of SDL
Sawatsky et al. BMC Medical Education (2017) 17:31 Page 4 of 9

Table 1 Supporting quotations for themes in the process of resident SDL

Theme Explanation Participant quotationsa
Knowledge framework The main goal was building a knowledge “In a perfect world I’d spend 2 h every day going through topics
framework required to be a physician categorically and have this nice wide knowledge base and really
have a good comprehensive understanding” (group 5).
“To formulate a framework on my own that works for me … I was
able to synthesize my own kind of format” (group 4).
“Every time I have a patient that comes in with a problem that
I don’t necessarily grasp, and I have to pull up whatever resource,
that’s SDL, …I’m going to remember that framework that I’m starting
to develop” (group 4).
Triggers External events started the process of SDL Faculty and senior residents who “ask the right questions” (group 2)
can trigger SDL by making it “clear an area I’m weak in, and that’s
the area I go try and fill the void. …So I like people asking me
questions because that tells me where I’m weak and helps me get
stronger in those areas” (group 4).
Uncover knowledge gap The trigger uncovered a gap in the “SDL is the process of identifying your weaknesses and your goals
resident’s current framework for learning” (group 5).
“It’s about filling in your own gaps of knowledge. …I’m taking care
of a patient and they have [a problem] so you go read about it. …
you’re filling in your own gaps of knowledge” (group 4).
“You get a concise and a clear question and say, ‘We’re trying to
decide between these two drugs, which one is better?’ That’s a clear
and concise question that’s directly [clinically] relevant and easy to
The gap in knowledge led residents answer” (group 4).
Formulate learning objectives
to identify objectives to fill the gap “It’s such an open, broad, vast sea of stuff that I could be studying.
Triaging what I should study, what order I should study it, how
much time I should dedicate to it. The system, …I consider it to
be SDL” (group 6).
“Knowing what resources give you what information and what
amount of time you’ll take to find it” (group 1).
Based on their specific learning objective, “So for example, when you’re trying to figure out how to treat a
Use resources specific condition, a well-written review article can be very high
residents chose appropriate resources
yield. …I’ve had to go through a lot of trial and error to find out
what resources I like for what topics and in what situations and
I’ve had some guidance” (group 3).
“A lot of this learning is not so much learning the topic but learning
where to find information, how to access the right information at
the right time, and what resources are available to us. …Those
things are much more important to learn” (group 2).
Apply knowledge Residents applied the knowledge “If I read something and I don’t apply it anywhere for a few months,
gained through SDL then it won’t stay with me, but applying it clinically and seeing it
in a patient, making some difference with what you learned, is a
very important factor in making it stay with you” (group 7).
“I’ve found that I learn the best when I have to teach someone about
something…when I have to actually read and understand everything
fully so I can teach it to others” (group 7).
“You need some external assessment; it’s really hard to assess yourself.
You definitely need some external evaluation of your performance
because you’re not objective about yourself” (group 4).
Residents used self-reflection and
Evaluate learning external feedback to evaluate their “I don’t really feel convinced that I’ve learned anything until I encounter
learning through SDL the same scenario again and feel more comfortable with it…or if you
feel like you’re thinking about other things than you would have the
first time around, those are some of the clues that make me feel like
I’ve learned something” (group 3).
“I didn’t realize I learned everything first year until I got an intern
second year. … You always just feel like you are struggling to stay
afloat. But when you get someone below you, that’s when I actually
found out that it was working” (group 3).
Abbreviation: SDL self-directed learning
a
Quotations given are followed by the group number of the participant
Sawatsky et al. BMC Medical Education (2017) 17:31 Page 5 of 9

Triggers included patient care, clinical teaching, peer connections to a topic area, personal mistakes, and the
interaction, media reports, email notifications, and prepar- need for self-preservation. Previously successful SDL
ation for examinations. Once the gap in knowledge was was a powerful motivator: “there are a few moments
exposed, residents identified specific learning objectives. that I can pinpoint…a case where it was almost palpable,
Objectives often took the form of a specific clinical ques- where you started to dig into the details, and you discov-
tion, and residents identified several objectives for any ered a linchpin that made everything flow together, and you
trigger. Residents triaged objectives by prioritizing objec- knew exactly what was going on…at a very deep level that’s
tives that pertained to “common conditions” and that will what keeps me going” (group 7). These “aha moments”
“change my practice” (group 1). (group 1) made SDL enjoyable and drove future learning.
To accomplish their learning objectives, residents sought Additionally, residents were extrinsically motivated by
resources, including clinical summaries, journal articles, patients, peers, faculty members, and examinations.
Internet searches, colleagues, and faculty. Resource selec- Residents also discussed factors that reduced motivation
tion was influenced by the objective, and residents learned to pursue SDL. First, unrealistic expectations “can impede
which resources helped achieve different types of objec- your desire to participate [in SDL] because you don’t feel
tives, searching for the most high-yield resources. Once a you can accomplish that goal” (group 3). Second, when
learning objective was achieved, the knowledge or skill was residents experienced little autonomy or responsibility for
applied to the SDL trigger, a critical step in solidifying patient care, “that doesn’t help our SDL when the [faculty
knowledge and evaluating the learning process. members] are not [involving] the residents [in patient
Residents used self-reflection and external assessment care]” (group 7). These factors eroded motivation for SDL.
to evaluate their learning. Self-reflection was often aided
by external cues or feedback. External cues included know- Individual characteristics
ledge application, comfort with patient care, efficiency, Residents discussed several individual characteristics that
performance on clinical questions, and gauging themselves affected the process of SDL. First, residents have different
against their peers. Feedback came through faculty evalu- levels of confidence with SDL, which affected how they
ation and performance on examinations (eg, In-Training approached SDL: “Everybody comes into residency with
Examination). Although residents sought external feed- varying levels of confidence regarding SDL, and they
back, sometimes self-evaluation was based on a feeling: “I should teach you how to do SDL” (group 2). Second, resi-
don’t know, to me it’s just a gut feeling. I know I’ve read dents identified variations in preferences that could influ-
enough, and if I read more, it’s just going to be useless” ence SDL: “learning styles are important, because to some
(group 2). At the same time, there was another sentiment: people SDL is more important than to others” (group 1).
“It’s part of our profession…I can’t imagine getting to a Personal styles affected how residents structured SDL:
point where I would say I’m totally comfortable” (group 6). “There may be an element of personality that carries over
Self-evaluation drove future learning, thereby creating a into how you learn. Do you need it to be more structured
continuous cycle of SDL. or more free-flowing?” (group 6). The approach to choos-
ing and using resources can also differ based on “styles of
The Person of SDL learning…some people can picture things and other
Residents described multiple personal aspects of SDL, people learn in other ways” (group 7). Although individual
including their motivations, individual characteristics, characteristics affected how and when residents partici-
and their change in approach over time. pated in SDL, it still followed the same basic process.

Motivations Change over time

Several types of motivation moved residents through the Residents’ approach to SDL changed over the course of
process of SDL. The foundational motivation for SDL their training, as residents developed confidence in SDL
was intrinsic: “I equate [SDL] to intrinsic learning; it’s and sophistication in their knowledge framework: “As
your own intrinsic motivation to learn outside of a defined you progress in medicine, you’re able to deal with the
curriculum” (group 4). Extrinsic motivation was also im- nuance better, and that’s where experience comes into
portant for SDL during residency training: “Extrinsic moti- play” (group 7). A more advanced framework had smaller
vators are very good, because there are certain things that gaps and led to more specific learning objectives. As learn-
I’m not that interested in intrinsically” (group 2). ing objectives changed, residents used different resources,
Intrinsic motivations included personal interest, curiosity, progressing from textbooks to clinical reviews to original
enjoyment of learning, competence, personal responsibility, research. Over time, residents become more confident in
improved patient care, and professional identity formation their ability to identify and use the appropriate resource
(see Table 2). Residents also described emotional moti- for a given objective: “it gets more efficient because you
vations, including fear of “looking stupid,” personal find different resources for different situations” (group 7).
Sawatsky et al. BMC Medical Education (2017) 17:31 Page 6 of 9

Table 2 Motivations for resident SDL with supporting quotations

Motivation Participant quotationsa
Personal interest “It’s unlikely to come up on the board exam, but I still think it’s interesting so I’ll read about it, but
that [is one of the] main things I consider as SDL” (group 1).
Curiosity “I find that a lot of my SDL is a result of curiosity. It’s usually triggered by a patient encounter that
makes me raise a question, and I keep probing until there comes a point when it gets uninteresting
and I don’t have questions anymore” (group 6).
Enjoyment of learning “The true essence of SDL is enjoyment. If you’re learning something without knowing that you’re
learning it, then it’s probably SDL because you’re doing it without even thinking about it” (group 7).
Patient care “Am I here because I like to be called a doctor or am I here because I want to know how to take
care of patients the best I possibly can? I think that makes the biggest difference between SDL and
doing the bare minimum” (group 6).
Competence “At the end of the day, when you sit in a room with a patient, how competent are you” (group 6)?
“It’s important to demonstrate competence in areas that you may not be so interested in so that
you can still provide excellent care” (group 4).
Personal responsibility “Being in the position where I had no safety net, I realized that only I could help in the situation,
and so immediately I became more resourceful than I typically would have been in a situation
like that, in how I perused resources and created an initial therapy plan. That was very instructional
because when you’re put in that position you become more resourceful than you think you’re
capable of, and to me that was like the crux of SDL” (group 6).
Identity formation “Once you start figuring out your specific niche, you become more interested in that pathology
and literature, and it’s interesting because your peers will come to you and ask about specific cases.
It motivates you to really be on top of the area in which you’re going” (group 3).
Fear of looking stupid “I’m afraid of looking dumb in front of the med students…patients…yeah, including yourself…
there’s a constant fear of looking dumb” (group 5).
Emotional connection “SDL is important when we’re emotionally tied to a specific topic. If we have a family member
who is struggling from a specific illness, we might have a self-directed drive to learn more about that,
or if we have an emotional connection to a patient we might go deeper just because there’s an
emotional connection” (group 2).
Self-preservation “When I have a rough day, I go back at the end of the day and I’m like, ‘Man why was I slogging
through everything, why was it such a pain?’ Then I go, ‘Well, I didn’t know this.’ I should look that
up so that next time I can have that discussion much more easily, and that’s one of the ways in
which I drive myself to do SDL” (group 1).
Faculty inspiration “In terms of motivation from consultants, you meet so many world-famous leaders in fields on a
daily basis, and that’s really inspirational for me. Like the people around me really motivate me, and
[faculty members] are a big part of that” (group 3).
Social pressure “To be honest with you, for me it’s a lot of [my peers]. I mean, these guys are always learning, and
I feel like if I don’t, I’ll be left behind” (group 3).
Examinations “All the residents care about is, ‘Is this coming up on my boards, is this coming up on Step 3?’ I feel
that is really big” (group 4).
Mistakes “I find that I learn the best from my own mistakes. If I did something and I was like, ‘Oh crap,
I screwed up,’ that stays with me and I become the unofficial expert in that thing because I messed
it up” (group 4).
Previous success “The moments are fleeting, but when they do occur it’s fun, but when you see a patient and you
think about it more and you’re like, ‘I’ve seen this before and I know this,’ and you figure it out.
That’s what makes it enjoyable—the aha moments” (group 1).
Abbreviation: SDL self-directed learning
a
Quotations given are followed by the group number of the participant

The context of SDL Residents described guidance for SDL as different from
Residents discussed multiple contextual aspects affecting “other-directed learning, learning that is constructed by
SDL, including the need for external guidance for SDL, others…when we’re seeing our patients, at home thinking
the influence of residency program structure and cul- at night, investigating what we find interesting…that really
ture, and contextual barriers. is SDL” (group 1). They identified sources of guidance for
SDL, including the residency curriculum, individual fac-
External guidance ulty members, peers, patients, and examinations. External
Although the process of SDL was characterized by in- guidance helped focus SDL and provided support for con-
ternal motivation and choice about learning, residents also tinued learning, and residents saw the benefit of being
identified the need for external guidance (see Table 3). provided with a structure “to guide your learning, and
Sawatsky et al. BMC Medical Education (2017) 17:31 Page 7 of 9

Table 3 External guidance for resident SDL with supporting quotations

Step in SDL process Type of external guidance Participant quotationsa
Framework External sources helped provide “For everything that’s key, they need to provide a framework and
a framework for learning the key things that you have to know. Then provide the resources
for those that are interested in going deeper” (group 4).
Uncover knowledge gaps External sources uncovered residents’ “I like people asking me questions, and I like people giving me a
knowledge gaps hard time because that tells me where I’m weak, and that helps
me get stronger in those areas” (group 4).
Formulate learning objectives External sources helped identify “Sometimes they help us identify an objective, you know, something
and focus learning objectives to learn” (group 1).
“Sometimes when you’re doing SDL and you don’t have something
to guide you, it’s very easy to miss out on what is really important. …
If someone with clinical experience were teaching you, they could
say the main things here are X, Y, and Z, but it’s easy to miss out on
those things when you’re reading on your own” (group 4).
Use resources Residents used people as a primary “There are guidelines, but their 40 years of working has given them
resource experience, and having that explanation is very helpful so we can
understand from their experience what setting you would use this”
(group 2).
“Faculty can overrefer you to resources instead of just telling you the
answer” (group 3).
External sources provided resources “It can be really helpful; I’ve had consultants that say this review article
is really good for this topic” (group 1).
External sources taught how to use “It’s good to know what’s available for resource and if someone tells
resources you that ahead of time, then you can already sort that out without
having to figure it out yourself. It’s nice to have the program say,
‘These are the resources’” (group 1).
Apply knowledge Residents applied knowledge outside “The main one for me by far is having had the chance to apply this
of themselves in clinical practice” (group 7).
Evaluate learning Residents sought feedback from “We have the In-Training exams every year. They give you a percentage
multiple external sources of how many questions you got right and wrong and you can compare
yourself to your peers” (group 1).
“The reason we are here is to get feedback to make ourselves better
and I’m really appreciative of those people who take that step” (group 4).
Abbreviation: SDL self-directed learning
a
Quotations given are followed by the group number of the participant

then you can get feedback on how your search went evaluation (“a lot determined by what your peers know”
and how you can do better next time” (group 4) and [group 5]), and social identity (balance between trying to
“maximize your self-directed gain” (group 5). “make your own area and claim your stake” and trying
to “fit in” [group 4]).
Residency program learning environment
Residency program learning environment, including the Barriers
structure and culture, also influenced SDL. Residents Barriers to SDL were mostly contextual. A major barrier
recognized that the residency program needed to pro- to SDL was having adequate time in the setting of com-
vide “time and resources to be able to pursue interests” peting demands: “The nature of being a resident is there
(group 2) because “every rotation is a good time to be are millions of things on every patient that you could
adding more nuggets of wisdom on SDL” (group 2). look up, and we don’t have the time because we’re busy”
Time was necessary because “to really understand a sub- (group 3). The main demand on time was the balance
ject, I have to go back when I’m not stressed out, where between patient care and SDL: “You can’t choose when
I have time to sit and actually think about what I’m the patient comes in; you try to fit in learning, and the
reading” (group 6). Residency programs can also pro- fact that your schedule is crammed impedes how much
mote SDL by attempting to “cultivate a culture of learn- learning you can do” (group 1). Obligations, including
ing among the residents …. SDL should be something research and other learning opportunities, were barriers
that we start from day one of intern year, teaching you to SDL. Maintaining personal well-being could detract
how to do it and making it an expectation” (group 3). from SDL: “if we have some time, that’s not what we
Culture also related to social aspects of SDL, including want to spend our time doing, in order to have a balance
motivation (“keeping up with the colleagues” [group 2]), and sanity” (group 5). Striking this balance was discussed
Sawatsky et al. BMC Medical Education (2017) 17:31 Page 8 of 9

as a barrier to SDL but was seen as necessary “to not get personal motivation for SDL. Personal growth can influ-
burned out, because if you get burned out then there’s ence the process of SDL as residents progress through
nothing much you can do …. That ties into how you their training. Context can greatly affect the process and
manage your time and energy level” (group 1). person aspects of SDL.
Difficulty with any step of the process also served as a SDL is felt to be integral to resident learning and identity
barrier to SDL overall. For example, residents who have formation [1]. Residency programs have implemented indi-
difficulty identifying knowledge gaps, translating them vidualized learning plans to augment SDL [22–24]. Despite
into learning objectives, and quickly identifying appro- these efforts, residents have identified difficulty with SDL
priate resources may struggle with SDL: “I don’t know and desired guidance from faculty [19, 20, 25]. We are
what my weaknesses are to say I have these goals for hopeful that our model—which exposes important context-
learning” (group 4) or “there’s so much I don’t know that ual factors and provides an overarching definition of SDL
my list of things to read is so ridiculously long that I within graduate medical education—will address existing
have no idea where to start” (group 2). limitations by providing residents with an improved under-
standing of SDL and providing faculty with better insights
Discussion regarding their roles in helping residents learn.
We present a broad theoretical framework of SDL in This study has some limitations. It was conducted at a
medical education that includes aspects of process, person, single institution, which may limit transferability to other
and context. The process begins when external triggers settings. Additionally, these findings may not describe SDL
expose gaps in residents’ knowledge framework, which in different environments, such as surgical subspecialties or
stimulates them to engage in a cycle of formulating learning undergraduate medical education. Future research should
objectives, identifying learning resources, applying know- focus on how SDL differs across the spectrum from under-
ledge to clinical problems, evaluating their learning, reinfor- graduate to continuing medical education. Finally, these
cing their growing framework, and possibly triggering data represent residents’ perceptions of SDL, which should
further SDL. The person aspect, which includes a complex prompt future research regarding observed practices.
interplay of individual comfort with and motivation for
SDL, develops over the course of residency training. Finally, Conclusions
context, encompassing individual faculty members and resi- Guided by existing SDL theory, we developed a theoretical
dency structure and culture, affects the process of SDL. model of resident SDL that highlights the personal (eg,
This study builds on previous theoretical models for motivations, individual characteristics) and contextual
SDL in medical education, contextualizing broader theory (eg, residency program structure, external guidance,
of SDL [11] to the residency training environment. In con- and barriers) factors that affect the process of SDL.
trast to practicing physicians [14], residents spend less time This model may improve understanding of SDL in
planning and react to clinical problems in real time. This graduate medical education, allow residency programs
may reflect the evolution of learning in the online environ- to achieve an appropriate balance between SDL and other
ment, in which information is immediately available. We learning opportunities, and provide a framework for fu-
also identified similar personal and contextual barriers to ture research on developing instruments to assess SDL.
SDL as those identified by Li et al. [15, 19] and have inte-
grated them into our conceptual model. Additionally, our Additional file
findings are congruent with previous work suggesting the
need for external guidance for SDL; we have also included Additional file 1: Box. Interview guide for the study entitled: “Self-
these contextual factors in our model [20]. Directed Learning in Internal Medicine Residency: A Qualitative Study”.
(DOC 45 kb)
We utilized previous theoretical models from general
education research to enhance our understanding of
Abbreviation
SDL during residency [8–11]. There is a growing under- SDL: Self-directed learning
standing that SDL is influenced by context, and there
has been a call for more qualitative inquiry into the role Acknowledgments
We thank the residents who participated in the study.
of context and SDL in medical education [21]. This
study underscores distinct triggers for learning and the Funding
value of applying knowledge in medicine. We elucidate This study was funded by the Mayo Clinic Division of General Internal
Medicine Small Grant Program funded by the Mayo Clinic CTSA through
how personal and contextual factors affect SDL among grant number UL1TR000135 from the National Center for Advancing
residents and demonstrate how these factors influence Translational Sciences (NCATS), a component of the National Institutes of
learning. For example, contextual factors, like the resi- Health (NIH). Its contents are solely the responsibility of the authors and do
not necessarily represent the official views of the NIH. This funding body
dency learning environment, including culture and pro- played no role in study design, data collection and analysis, or drafting the
gram expectations, can affect both the process of and manuscript.
Sawatsky et al. BMC Medical Education (2017) 17:31 Page 9 of 9

Availability of data and materials 10. Garrison DR. Self-directed learning: toward a comprehensive model. Adult
Transcribed interviews from this study will not be shared because of the Educ Q. 1997;48(1):18–33.
presence of potentially personally-identifiable information. We did not obtain 11. Hiemstra R, Brockett RG. Reframing the meaning of self-directed learning:
informed consent from our participants for data sharing. an updated model. Adult Education Research Conference, June 1, 2012,
Paper 22, 155-161. [cited 2016 Jul 14.] Available from: http://newprairiepress.
Authors’ contributions org/aerc/2012/papers/22/.
APS contributed to the conception and design of the study, participated in 12. Murad MH, Coto-Yglesias F, Varkey P, Prokop LJ, Murad AL. The effectiveness of
data collection, coding and analysis, and prepared the draft of the manuscript. self-directed learning in health professions education: a systematic review.
JTR participated in the coding and analysis of data and critical review of the Med Educ. 2010;44(11):1057–68.
manuscript. SLB participated in the coding and analysis of data and critical 13. Mazmanian P, Feldman M. Theory is needed to improve education, assessment
review of the manuscript. JSE conducted all of the focus groups and participated and policy in self-directed learning. Med Educ. 2011;45(4):324–6.
in data analysis and critical review of the manuscript. TJB contributed to the 14. Slotnick HB. How doctors learn: physicians’ self-directed learning episodes.
conception and design of the study, participated in data collection, coding and Acad Med. 1999;74(10):1106–17.
analysis, and provided critical review of the manuscript. All authors read and 15. Li ST, Paterniti DA, Co JP, West DC. Successful self-directed lifelong learning
approved the final manuscript. in medicine: a conceptual model derived from qualitative analysis of a
national survey of pediatric residents. Acad Med. 2010;85(7):1229–36.
16. Krueger RA, Casey MA. Focus groups: a practical guide for applied research.
Author information
4th ed. Los Angeles: Sage; 2009.
APS is an Assistant Professor of Medicine in the Division of General Internal
17. Charmaz K. Constructing grounded theory. 2nd ed. Thousand Oaks: Sage; 2014.
Medicine, Mayo Clinic, Rochester, Minnesota.
18. NVivo qualitative data analysis software. QSR International Pty Ltd.
JTR is an Assistant Professor of Medicine in the Division of Hospital Internal
Version 10; c2012.
Medicine, Mayo Clinic, Rochester, Minnesota.
19. Li ST, Tancredi DJ, Co JP, West DC. Factors associated with successful
SLB is an Assistant Professor of Medicine in the Division of General Internal
self-directed learning using individualized learning plans during pediatric
Medicine, Mayo Clinic, Rochester, Minnesota.
residency. Acad Pediatr. 2010;10(2):124–30.
JSE is a Senior Health Services Analyst in the Center for the Science of Health
20. Nothnagle M, Anandarajah G, Goldman RE, Reis S. Struggling to be self-directed:
Care Delivery, Mayo Clinic, Rochester, Minnesota.
residents’ paradoxical beliefs about learning. Acad Med. 2011;86(12):1539–44.
TJB is a Professor of Medical Education and Medicine in the Division of
21. Jennings SF. Personal development plans and self-directed learning for
General Internal Medicine, Mayo Clinic, Rochester, Minnesota.
healthcare professionals: are they evidence based? Postgrad Med J.
2007;83:518–24.
Competing interests 22. Bravata DM, Huot SJ, Abernathy HS, Skeff KM, Bravata DM. The development
The authors declare that they have no competing interests. and implementation of a curriculum to improve clinicians’ self-directed
learning skills: a pilot project. BMC Med Educ. 2003;3:7.
Consent for publication 23. Nothnagle M, Goldman R, Quirk M, Reis S. Promoting self-directed learning
Not applicable. skills in residency: a case study in program development. Acad Med. 2010;
85(12):1874–9.
Ethics approval and consent to participate 24. Smith SJ, Kakarala RR, Talluri SK, Sud P, Parboosingh J. Internal medicine
This study was approved by the Mayo Clinic Institutional Review Board. residents’ acceptance of self-directed learning plans at the point of care.
All participants provided informed consent. J Grad Med Educ. 2011;3(3):425–8.
25. Li ST, Favreau MA, West DC. Pediatric resident and faculty attitudes toward
Author details self-assessment and self-directed learning: a cross-sectional study. BMC Med
1
Division of General Internal Medicine, Mayo Clinic, 200 First St SW, Educ. 2009;9:16.
Rochester, MN 55905, USA. 2Division of Hospital Internal Medicine, Mayo
Clinic, Rochester, MN, USA. 3Robert D. and Patricia E. Kern Center for Science
of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.

Received: 7 September 2016 Accepted: 24 January 2017

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