Original Article

Self-Directed Learning among Internal Medicine Residents in the Information Age

Authors: Matthew Kelleher, MD, MEd, Rebecca E. Miller, MD, Ashley Duckett, MD, Paul O’Rourke, MD, MPH, Lindsey Hall, MPH, Miao-Shan Yen, MS, Stephanie A. Call, MD, MSPH, Steven E. Bishop, MD, Sean Tackett, MD, MPH


Objectives: The revolution in information technology and a rapidly expanding evidence base are changing residency training. Understanding the habits and preferences of trainees’ self-directed learning (SDL) has never been more important. Our goal was to provide a contemporary description of residents’ SDL practices.

Methods: Internal medicine residents at four university-affiliated programs were surveyed in Spring 2017. Residents estimated the number of hours in their typical week spent in SDL on service and after hours when on inpatient and noninpatient rotations, how often they used specific educational resources for SDL, and the percentage of time that they used four different modes to access resources.

Results: Of 384 residents, a total of 254 (66%) responded. Residents spent more total hours in SDL on noninpatient services (median 11, interquartile range 8–17) than on inpatient services (median 7, interquartile range 4–10) and the same median number of hours in SDL on clinical duty as off hours for both inpatient (median 3 hours) and noninpatient (median 5 hours) rotations. Nearly all of the respondents (99%) reported using online point-of-care resources for SDL at least once per week. Most (77%) never used printed textbooks. Desktop/laptop was the most commonly used (47% of the time) medium to access resources.

Conclusions: Although the resident learning environment and resource use are changing, residents engage in as much or more time in SDL as in previous studies, with a large proportion occurring during clinical service. Understanding residents’ current SDL habits will better prepare educators to support and guide our trainees.

This content is limited to qualifying members.

Existing members, please login first.

If you have an existing account please login now to access this article or view your purchase options.

Purchase only this article ($15)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.


1. Yao DC, Wright SM. National survey of internal medicine residency program directors regarding problem residents. JAMA 2000;284:1099–1104. 2. Hawkins RE, Lipner RS, Ham HP, et al. American Board of Medical Specialties Maintenance of Certification: theory and evidence regarding the current framework. J Contin Educ Health Prof 2013;33(suppl 1):S7–S19. 3. Kassirer JP. Does instant access to compiled information undermine clinical cognition? Lancet 2010;376:1510–1511. 4. Ericsson KA. Acquisition and maintenance of medical expertise: a perspective from the expert-performance approach with deliberate practice. Acad Med 2015;90:1471–1486. 5. Duran-Nelson A, Gladding S, Beattie J, et al. Should we Google it? Resource use by internal medicine residents for point-of-care clinical decision making. Acad Med 2013;88:788–794. 6. Bullock A, Dimond R, Webb K, et al. How a mobile app supports the learning and practice of newly qualified doctors in the UK: an intervention study. BMC Med Educ 2015;15:71. 7. Hardyman W, Bullock A, Brown A, et al. Mobile technology supporting trainee doctors' workplace learning and patient care: an evaluation. BMC Med Educ 2013;13:6. 8. Asch DA, Nicholson S, Srinivas S, et al. Evaluating obstetrical residency programs using patient outcomes. JAMA 2009;302:1277–1283. 9. Knowles MS. Self-Directed Learning: A Guide for Learners and Teachers. New York: Association Press; 1975. 10. Accreditation Council for Graduate Medical Education. Common program requirements. www.acgme.org/Portals/0/PFAssets/ProgramRequirements/CPRs_2017-07-01.pdf. Published 2017. Accessed January 21, 2019. 11. Nothnagle M, Anandarajah G, Goldman RE, et al. Struggling to be self-directed: residents' paradoxical beliefs about learning. Acad Med 2011;86:1539–1544. 12. Sawatsky AP, Ratelle JT, Bonnes SL, et al. A model of self-directed learning in internal medicine residency: a qualitative study using grounded theory. BMC Med Educ 2017;17:31. 13. Smith SJ, Kakarala RR, Talluri SK, et al. Internal medicine residents' acceptance of self-directed learning plans at the point of care. J Grad Med Educ 2011;3:425–428. 14. Li S-T, Tancredi DJ, Co JPT, et al. Factors associated with successful self-directed learning using individualized learning plans during pediatric residency. Acad Pediatr 2010;10:124–130. 15. Li S-T, Favreau MA, West DC. Pediatric resident and faculty attitudes toward self-assessment and self-directed learning: a cross-sectional study. BMC Med Educ 2009;9:16. 16. Edson RS, Beckman TJ, West CP, et al. A multi-institutional survey of internal medicine residents' learning habits. Med Teach 2010;32:773–775. 17. Lai CJ, Aagaard E, Brandenburg S, et al. Brief report: multiprogram evaluation of reading habits of primary care internal medicine residents on ambulatory rotations. J Gen Intern Med 2006;21:486–489. 18. Oxentenko AS, Manohar CU, McCoy CP, et al. Internal medicine residents' computer use in the inpatient setting. J Grad Med Educ 2012;4:529–532. 19. Accreditation Council for Graduate Medical Education. The ACGME 2011 Duty Hour Standard. Enhancing quality of care, supervisor and resident professional development. https://www.acgme.org/Portals/0/PDFs/jgmemonograph[1].pdf. Published 2011. Accessed January 31, 2019. 20. Sy A, Wong E, Boisvert L. Learning behaviour and preferences of family medicine residents under a flexible academic curriculum. Can Fam Physician 2014;60:e554–e561. 21. Lott JP, Roy B, Venkatesh AK. Temporal trends in accessing online medical information. J Hosp Med 2014;9:525–526. 22. Aakre CA, Pencille LJ, Sorensen KJ, et al. Electronic knowledge resources and point-of-care learning: a scoping review. Acad Med 2018;93 (11S Association of American Medical Colleges Learn Serve Lead: Proceedings of the 57th Annual Research in Medical Education Sessions):S60–S67. 23. Amber KT, Dhiman G, Goodman KW. Conflict of interest in online point-of-care clinical support websites. J Med Ethics 2014;40:578–580. 24. McDonald FS, Zeger SL, Kolars JC. Factors associated with medical knowledge acquisition during internal medicine residency. J Gen Intern Med 2007;22:962–968. 25. Isaac T, Zheng J, Jha A. Use of UpToDate and outcomes in US hospitals. J Hosp Med 2012;7:85–90. 26. Seelig CB. Changes over time in the knowledge acquisition practices of internists. South Med J 1993;86:780–783. 27. Pastötter B, Bauml K-HT. Retrieval practice enhances new learning: the forward effect of testing. Front Psychol 2014;5:286. 28. van Houten-Schat MA, Berkhout JJ, van Dijk N, et al. Self-regulated learning in the clinical context: a systematic review. Med Educ 2018;52:1008–1015. 29. Saks K, Leijen A. Distinguishing self-directed and self-regulated learning and measuring them in the e-learning context. Procedia Soc Behav Sci 2014;112:190–198. 30. Fletcher KE, Visotcky AM, Slagle JM, et al. The composition of intern work while on call. J Gen Intern Med 2012;27:1432–1437. 31. Sullivan GM. A mile wide but 1 cell thick: the need to prioritize learning in graduate medical education. J Grad Med Educ 2016;8:488–491.