AMBULATORY PEDIATRICS Volume 5, Number 5298Copyright q 2005 by Ambulatory Pediatric Association September–October 2005

Are Residents Ready for Self-Directed Learning? A Pilot Program ofIndividualized Learning Plans in Continuity Clinic

Elizabeth Stuart, MD, MSEd; Theodore C. Sectish, MD; Lynne C. Huffman, MD

Changes in training and certification requirements demand that trainees and practitioners take charge of planning anddocumenting their ongoing learning. Individualized learning plans (ILPs) have been proposed as a tool to guide thisprocess. We report on a pilot program using ILPs as part of the pediatric continuity clinic experience.

Objective.—The goal of the project was to explore residents’ and faculty members’ reactions to using ILPs whenILPs were offered as an optional tool.

Methods.—A group of 42 residents and 13 faculty members volunteered to use ILPs in continuity clinic. Nine monthsinto the intervention, residents and faculty completed questionnaires about their experiences using ILPs. We performeda content analysis of questionnaire responses to identify perceived benefits and barriers to using ILPs.

Results.—ILP users reported that the program was helpful in providing a framework and focus for learning and inamplifying their awareness of the learning process. Barriers to using ILPs included lack of time and difficulty establishingand working with learning goals.

Conclusions.—Our results suggest that residents are unaccustomed to taking active roles in planning their ownlearning. To prepare trainees for lifelong learning and continuous professional development, residency programs needto provide explicit education in the process of self-directed learning.

KEY WORDS: competency-based education; continuous professional development; individualized learning plan;practice-based learning and improvement; self-directed learning

Ambulatory Pediatrics 2005;5:298 301

The focus of medical education has undergone sig-nificant change over the past decade. Increasing de-mand for physician accountability and rapid ad-

vances in medical knowledge and technology haveprompted a new emphasis on outcomes- and competency-based education as well as a heightened awareness thattrue professional ‘‘competence’’ requires a commitment tolifelong learning.

Recent and upcoming changes in training and certifi-cation requirements reflect this shift in focus. The broaderconcept of continuous professional development (CPD)has supplanted Continuing Medical Education (CME).1

Certification will soon require explicit demonstration ofongoing learning and application of that learning to prac-tice.2 At the residency training level, the AccreditationCouncil on Graduate Medical Education Outcome Projectincludes lifelong learning as an element of two of theGeneral Competencies, Professionalism, and Practice-Based Learning and Improvement (PBLI).3 To managetheir own professional development, residents must haveskills in each of the steps of self-directed learning (SDL):identifying learning needs, finding resources to meet thoseneeds, and evaluating and documenting their achieve-ments. Traditional approaches to residency education,which are based largely on a passive, apprenticeship-like

From the Department of Pediatrics, Stanford University, PaloAlto, Calif.

Address correspondence to Elizabeth Stuart, MD, MSEd, Divisionof General Pediatrics, Stanford University, 750 Welch Rd #325, PaloAlto, CA 94304 (e-mail: aestuart@stanford.edu).

Received for publication June 18, 2004; accepted June 3, 2005.

model, have not deliberately addressed the developmentof SDL skills.4 To rise to the standard of a competency-based educational paradigm, programs must look for waysto prepare trainees for the task of directing their ownlearning.

One potentially useful tool is the learning contract, orindividualized learning plan (ILP). In its simplest form, alearning contract is a guide to learning, collaborativelydeveloped by teacher and learner at the beginning of alearning experience. Contracts specify goals for learning,resources and strategies for achieving goals, and evidenceto be gathered to demonstrate achievement. After estab-lishing an initial contract, teacher and learner meet peri-odically to review the learner’s progress toward goals andto revise the contract, if necessary.

Learning contracts have been used in a variety of healthprofessions’ training programs and offer actual and theo-retical educational advantages, including skill building inSDL.5–12 Though the method seems well-suited for use inresidency education there are few published reports ofcontract learning in US residency training.13,14

We describe the implementation of a pilot program us-ing ILPs in pediatric continuity clinic. Our objective wasto explore residents’ and faculty members’ reactions tousing ILPs when ILPs were offered as an optional edu-cational tool.

METHODS

Setting and Participants

Residents in our program attend continuity clinic 1 half-day per week throughout their 3 years of training. Two-thirds of our 57 residents are assigned to our hospital-

AMBULATORY PEDIATRICS Individualized Learning Plans 299

based primary care clinic, where they work in teams of7–9 residents, supervised by 2–3 faculty members. Forthe purposes of the ILP program, each resident in the hos-pital-based clinic was assigned to work with 1 primarypreceptor. The remaining third of our residents work offsite, with individual preceptors in private practice or com-munity clinic settings.

In June 2000, we invited all continuity faculty (N 522) to an orientation workshop and dinner. Thirteen of the14 faculty members who attended agreed to participate inthe ILP program with their continuity residents (N 5 42).

Intervention

ILP

The form for our learning contract, or ILP, providedspace to record residents’ goals, learning strategies, andevidence of goal achievement (form available from au-thors). The ILP form also prompted residents and facultyto establish an explicit schedule for follow-up meetings toreview progress toward goals and update learning plansas necessary. A progress review form was provided torecord the content of follow-up meetings.

Intervention Group Preparation

Two authors (E.S. and T.S.) led the 2-hour facultyworkshop. The first part of the workshop covered basicprinciples of teaching and adult learning, with a focus onpromoting reflection and awareness of learning. The sec-ond part of the workshop introduced the ILP program. Wediscussed the rationale for using learning contracts withresidents and offered guidelines and written tools for de-veloping ILPs with residents.

We recommended a schedule of progress reviews(meetings between resident and faculty preceptor) at 6- to8-week intervals. We sent informal reminders about theprogram every 3–4 months by electronic mail.

Preceptors were advised to use the materials providedat the faculty workshop to orient their residents to the ILPprogram at the beginning of the academic year (July2000).

Program Evaluation Measures

We developed a learning plan program questionnaire(LPPQ) to determine participants’ actual use of ILPs andto elicit their reactions to the program. Nine months afterthe start of the program, LPPQs were mailed to all resi-dent and faculty participants. The questionnaire includedyes–no and open-ended questions. To discover how close-ly participants followed guidelines for using ILPs, we per-formed a descriptive analysis of responses to yes–no ques-tions on the LPPQ and reviewed a subset of residents’completed learning plans.

Open-ended items on the LPPQ addressed perceivedadvantages to using ILPs, problems encountered, and sug-gestions for improving the program. We performed a con-tent analysis of data from these items to identify commonthemes and categories of responses. Each of the authorscoded the data independently; disagreements were re-

solved by consensus. Coded data were analyzed descrip-tively using SPSS15 and Microsoft Excel.16

Stanford’s Administrative Panel on Human Subjects inNon-Medical Research reviewed and approved the pro-gram and its evaluation.

RESULTS

Response rates for the LPPQ were 55% and 69% forresidents and faculty, respectively.

Actual Use of ILPs

Of the 23 intervention group residents who returned theLPPQ, 2 (8.7%) reported that they had not used ILPs withtheir preceptors; 7 (30.4%) had ‘‘sort of’’ used an ILP;14 (60.9%) had ‘‘definitely’’ used an ILP.

One hundred percent of the 21 resident respondentswho used an ILP ‘‘sort of’’ or ‘‘definitely’’ reported thatthey had discussed an initial set of goals with their pre-ceptors. Eighty-five percent had recorded these initialgoals on an ILP form. Eighty percent had discussed goalsagain after developing an initial ILP. Twenty-five percentkept a written record of progress.

Sixteen ILP forms were available for content review.The mean number of goals listed was 3.23 (range: 1–7).Seventy-one percent of the goals listed were linked tostrategies for learning. Twenty-five percent of goals hadassociated entries outlining evidence of achievement.

Perceived Benefits and Barriers to Using ILPs

Thirty-five percent of resident respondents and 56% offaculty respondents indicated that the ILP program washelpful in providing a focus or framework for learning.Thirty percent of residents reported that using ILPs helpedto enhance their awareness of the learning process, byhelping them identify and discuss their learning needswith preceptors and by making teaching and learning apriority in clinic.

Forty-three percent of residents and 33% of faculty not-ed that insufficient time was a barrier to using ILPs. Twen-ty-two percent of residents and 33% of faculty reporteddifficulty establishing or working with goals. Seventeenpercent of resident respondents mentioned tiredness, pas-sivity, or lack of motivation as obstacles.

Twenty-six percent of residents and 78% of faculty sug-gested that the program could be improved by providingmore structure, in the form of suggested learning goals,dedicated time for progress review, or external reinforce-ment of the process (eg, formal reminders).

Sample resident and faculty responses to open-endedquestions on the LPPQ are presented in the Table.

DISCUSSION

Knowles17 described the learning contract as, ‘‘withoutquestion the single most potent tool I have come acrossin my more than half-century of experience with adulteducation.’’ Given this strong endorsement and reports ofbenefits of using learning contracts in a variety of healthprofessions’ training settings, we set out to explore the

AMBULATORY PEDIATRICS300 Stuart et al

Sample Comments on Benefits, Barriers, and Suggestions for Im-provement

Resident comments

In what ways was using a Learning Plan helpful?

● Identifying a specific thing/skill to focus on as a new intern. (PL-1)*● It helped me to identify areas in which I could use more expe-

rience and learning. (PL-2)● Alters focus of clinic to having discrete goals of learning for exam/

history rather than just ‘‘get through clinic’’ approach. (PL-2)● Allowed my preceptor to know what I wanted to get out of his

clinic. (PL-2)● Motivating us to have regular discussions about topics of interest.

(PL-3)

What problems did you encounter?

● I often don’t know what to work on. (PL-1)● Clinic is fast-paced, busy, good for learning lots, but not easy to

actually sit and discuss how learning relates to goals. (PL-2)● Never enough time (PL-3)● Sometimes I’m too tired or busy to really focus on my goals.

(PL-3)

Suggestions

● Recommendations for specific goals would be helpful. (PL-1)● Set time allocated for meeting with our preceptor throughout the

year. (PL-3)● Initiating the program as an intern appears to be beneficial and

establishes a residency-long routine/expectation. (PL-3)

Faculty comments

In what ways was using a Learning Plan helpful?

● Lending focus. Stimulating more purposeful learning.● Allows me to re-evaluate the learning needs of the resident to

cover areas that are not well represented in my practice.

What problems did you encounter?

● Our goals have been important but broad topics. It’s hard to eval-uate progress toward completion.

● A few of the residents were interested, but a few shied away,even with pursuit of a faculty member. Initially, PL-1s were morereceptive because of more concrete needs. Senior residents wereless receptive and more patronizing. It varied around each resi-dent’s personality type.

● Thinking of this as residents directing their own learning is in-teresting. I have my own ideas about what they should learn.

● Deep down, the learning happens 1) how we model it, and 2)how it walks in the door. Eventually, we teach to what walks inthe door.

● Whose responsibility is it to take charge [of learning]? If it’s thehouse staff’s responsibility, then there is the problem of experi-ence/apprenticeship type of training and how much time needs tobe logged before they are qualified?

Suggestions

● Formal reminders.● Commitment for quarterly or semiannual review, with time set

aside for doing so.● Tie the individual’s program to a structured schedule.● A list of specific goals per year of residency.● Start with PL-1s. Harder with PL-2s and PL-3s.

*PL indicates postgraduate level.

advantages and limitations of using ILPs as part of thepediatric continuity clinic experience.

The large proportion of residents who used ILPs re-ported developing learning goals, recording those goals,and returning to a discussion of those goals later in theirtraining. Residents who used ILPs described an enhancedawareness of learning needs—an important initial step in

self-directed learning. At the same time, residents reporteddifficulty establishing and planning ways to achieve goals.The fact that only 25% of goals listed were linked toentries for evidence of achievement suggests that this as-pect of the process was particularly troublesome. Facultyappreciated the structure that the program offered, butthey felt limited in their ability to help residents developand follow their ILPs. Although the theoretical power ofthe ILP approach lies with its emphasis on self-directionand individualization of learning, both resident and facultyparticipants in our program wanted more guidance, stan-dardization, and structure.

Our results echo findings from previous reports. Man-ning et al18 found that physicians using learning plans tomanage CME were reluctant to define their own learningobjectives and relied heavily on the guidance of ‘‘educa-tion specialists’’ in developing their plans. Schwiebert etal19 found that nearly all students using learning contractsduring a family medicine clerkship opted to select pre-written goals rather than create their own learning planentries. Both groups argued that learners accustomed tothe passive learning approaches that characterize tradi-tional medical training require considerable structure andsupport as they are introduced to independent learningactivities.

Our evaluation of the learning plan program had severallimitations. Our faculty participants were a self-selectedgroup of volunteers, survey response rates for the LPPQwere low, and the program involved a small group ofresidents and faculty at a single institution. Nevertheless,we feel we have gathered important information about res-idents’ readiness for SDL and PBLI. Our participants’ re-actions to using ILPs suggest that the transition to SDLis challenging and that residency training programs mayneed to take an active approach to ensuring competencyin PBLI.

Our program has not previously included formal self-directed learning exercises in its curriculum. We believethat ongoing practice using ILPs, with additional guidanceand support from the residency program leadership, mightserve as an effective means to train residents in PBLI,lifelong learning, and CPD. To maximize the benefit ofthe process, we offer the following recommendations tothose considering similar educational interventions:

● Skill building in SDL and PBLI should be an explicitgoal of working with ILPs. Residents and facultyshould focus energy as much on the process of devel-oping learning plans as on the content of the plansthemselves. Specific learning objectives of the ILP ex-ercise need to include: analyzing or reflecting on prac-tice to identify learning needs, locating resources forlearning, assessing learning achievements, and docu-menting application of new learning to practice.

● The residency program should offer tools (eg, detailedand user-friendly examples of ILP entries) and remind-ers to ensure that participants are successful in design-ing and working with ILPs. As the process becomes

AMBULATORY PEDIATRICS Individualized Learning Plans 301

familiar, we expect that the need for this external sup-port would decline.

● Residents and faculty need to have dedicated time todevelop and discuss their ILPs. Balancing the manydemands and limitations on residents’ time is a constantchallenge for training programs. Identifying ILPs as atool for teaching PBLI might help justify the time need-ed to use them. Alternatively, work with ILPs could beundertaken outside clinical training hours, during edu-cation time not limited by duty-hours regulations.

When we began our pilot program, we hoped to gen-erate and document positive effects on residents’ educa-tional experiences in continuity clinic. In the end, we feelthe most meaningful outcome of the project, particularlyin the context of new requirements for training and main-tenance of certification, has been to draw attention to thechallenges of moving residents and faculty to self-direct-ed, independent learning. We hope our results will guidefuture efforts to prepare residents to be lifelong learners—and truly competent practitioners.

ACKNOWLEDGMENTSWe thank the 2000–01 continuity clinic residents and faculty at

Lucile Salter Packard Children’s Hospital at Stanford for their par-ticipation in the Learning Plan Program and members of the Divi-sion of Medical Education, University of Southern California KeckSchool of Medicine for their guidance and support.

REFERENCES1. Sectish TC, Floriani V, Badat MC, Perelman R, Bernstein HH.

Continuous professional development: raising the bar for pedi-atricians. Pediatrics. 2002;110:152–156.

2. Program for Maintenance of Certification in Pediatrics. Amer-ican Board of Pediatrics.

3. ACGME Outcome Project: General Competencies. Accredita-tion Council for Graduate Medical Education; 2001.

4. Pencheon D. Paradigms in Learning. May 8, 1999 ed. Availableat: BMJ.com. Accessed February 25, 2004.

5. Fox RD, West RF. Developing medical student competence inlifelong learning: the contract learning approach. Med Educ.1983;17:247–253.

6. Ghazi F, Henshaw L. How to keep student nurses motivated.Nurs Stand. 1998;13:43–88.

7. McDermott MM, Curry RH, Stille FC, Martin GJ. Use of learn-ing contracts in an office-based primary care clerkship. MedEduc. 1999;33:374–381.

8. Parsell G, Bligh J. Contract learning, clinical learning and cli-nicians. Postgrad Med J. 1996;72:284–289.

9. Parsell G. Handbooks, learning contracts, and senior house of-ficers: a collaborative enterprise. Postgrad Med J. 1997;73:395–398.

10. Renner JJ, Stritter FT, Wong HD. Learning contracts in clinicaleducation. Radiol Technol. 1993;64:358–365.

11. Richardson S. Implementing contract learning in a senior nurs-ing practicum. J Adv Nurs. 1987;12:201–206.

12. Chan SW, Chien WT. Implementing contract learning in a clin-ical context: report on a study. J Adv Nurs. 2000;31:298–305.

13. Cohen EB. Electronic learning contracts. Acad Med. 1996;71:528–529.

14. Bravata DM, Huot SJ, Abernathy HS, Skeff KM. The devel-opment and implementation of a curriculum to improve clini-cians’ self-directed learning skills: a pilot project. BMC MedEduc. 2003;3:7.

15. SPSS for Windows. 12.0 ed. Chicago: SPSS Inc; 2003.16. Microsoft Excel. Redmond, Washington: Microsoft Corpora-

tion; 2002.17. Knowles M. The Adult Learner: A Neglected Species. 4th ed.

Houston, TX: Gulf Publishing; 1990:139.18. Manning PR, Clintworth WA, Sinopoli LM, et al. A method of

self-directed learning in continuing medical education with im-plications for recertification. Ann Int Med. 1987;107:909–913.

19. Schwiebert LP, Crandall SJS, Brown DS. Incorporating goal-setting into a third-year family medicine clerkship: a pilot pro-ject. Teach Learn Med. 1991;3:239–244.