Introduction

The transition from medical school to residency brings an abrupt increase in responsibilities and a shift from structured teaching to the less predictable clinical learning environment.¹ While transition-to-residency courses improve clinical knowledge, they may not fully address time management and self-directed learning (SDL) skills.² Given that SDL typically occurs outside of clinical duties, residents often rely on internal motivation, which can be difficult to maintain given the demands of residency. The Fogg Behavior Model (FBM), a widely used framework in health and education,^3-7 proposes that behavior depends not just on motivation, but also on prompts (external triggers) and ability (ease of action).⁸

While targeted interventions such as faculty coaching and structured curricula can enhance SDL in residents, these often require significant time and institutional resources.^9-11 Some interventions support motivation without addressing the environmental or individual factors that shape learning habits. Garrison’s SDL model, for instance, emphasizes self-management, self-monitoring, and motivation, but offers limited guidance for building consistent study routines.¹² In contrast, the FBM explicitly accounts for these barriers, emphasizing how well-timed prompts and simplified tasks can drive behavior even when motivation is low.⁸

We applied FBM principles to design an SDL intervention aimed at increasing study engagement among first-year obstetrics and gynecology (OB/GYN) residents. Since motivation alone might be insufficient during residency, we hypothesized that enhancing prompts and ability components of the model would improve both SDL activity and In-Training Examination (ITE) performance.

Methods

This quasi-experimental study was conducted at the University of Missouri–Kansas City (UMKC) OB/GYN residency program from 2016 to 2021. All postgraduate year (PGY) 1 residents participated, with each incoming class consisting of approximately 8 residents per year. All participants followed the SDL program implemented in 2016, including assigned reading topics and curated study materials, which residents were expected to review independently. A shared Google Drive spreadsheet was used to track individual study sessions and topic completion. Residents were asked to log each study session with a timestamp and topic studied. A study session was defined as any independent learning activity related to the assigned materials, such as reading, completing question sets, or reviewing notes. No structured follow-ups were conducted, but residents were told that logged study sessions would be monitored weekly by the program director. In 2019, an FBM-based workshop was introduced, defining the intervention group (2019-2021), while the control group (2016-2018) followed the original SDL program. Both groups used the same topic list, tracking system, and monitoring process.

The FBM-based workshop, conducted during orientation week, had 3 components (Table 1): a self-reflection exercise where residents identified prior study motivations and strategies for overcoming lapses in motivation; a didactic session on FBM principles categorized study tasks into low-energy (reading, podcasts), moderate-energy (flashcards, multiple-choice), and high-energy (active recall, teach-back) activities; and a “10-minute minimum” option to mitigate procrastination in times of very low motivation.¹³ The last component of the workshop involved hands-on application of the FBM, personalizing SDL prompts using “Whenever I… (prompt), I will… (study activity based on energy level).” They documented these intentions on 3x5 cards for home display.

Table 1 Fogg Behavior Model Workshop Components

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The primary outcome was the difference in mean ITE scores between groups. The ITE is norm-referenced, with a mean score of 200 (SD=20), ranking residents nationally. To ensure comparability, scores were analyzed within PGY levels. A power analysis (n=24 per group) determined 80% power to detect a 10-point difference in scores (P<.05), based on prior program data. The ITE was administered approximately 5 months after the FBM-workshop, and the SDL program continued until the ITE was administered for both groups. Only PGY-1 ITE scores were included in the analysis. The secondary outcome was SDL engagement, measured by number of study sessions logged per week and percentage of assigned topics completed at 6 months. Demographic data were extracted from the residency program onboarding records. The study was institutional review board (IRB) exempt (UMKC IRB# 2092667).

Results

Baseline characteristics were comparable between groups (Table 2), with similar United States Medical Licensing Examination (USMLE) Step 1 (230.8±7.6 vs 227.9±7.6, P=.59) and Step 2 scores (250.5±6.4 vs 247.8±6.4, P=.55). The intervention group had a higher, though not statistically significant, percentage of women (22 of 24, 92% [95% CI, 74.2-97.7] vs 19 of 24, 80%, [95% CI, 59.5-90.8], P=.28).

Table 2 Baseline Characteristics

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The intervention group significantly outperformed the control group in ITE scores (206±3.13 vs 194±3.11, P=.006), with a mean difference of 12 points (95% CI, 10.24-13.77). They also logged a higher average number of study sessions per week (4.8±1.2 vs 3.2±1.0, P=.02) and completed a greater proportion of assigned reading topics at 6 months (104 of 120, 87% vs 74 of 120, 62%, P=.01). compared to the control group (Table 3).

Table 3 Primary and Secondary Outcomes

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Discussion

Our study suggests that this FBM-based intervention enhances SDL engagement and ITE performance among first-year OB/GYN residents. Even in high-demand training environments, prioritizing prompts and ability over motivation alone can improve study engagement and outcomes. The structured planning methods, such as implementation intentions (eg, “When I receive a prompt, I will complete a 10-minute review”), reinforce SDL habits, making learning initiation more consistent.

These findings align with existing research on FBM’s role in enhancing engagement and study habits in higher education,¹⁴ and our study extends its application to medical training. In SDL, prompts serve as external cues for initiating learning, while ability encompasses cognitive capacity and resource accessibility. This approach integrates well with prior studies that underscore the importance of structured planning and external cues in enhancing educational outcomes.¹⁵ By integrating implementation intentions with prompts, individuals can enhance habit formation and goal-directed learning.¹⁶

This 6-year study allowed a well-powered comparison between cohorts. The FBM-based approach, easily scalable and requiring minimal resources, is feasible for broad implementation across educational settings. While our results demonstrate the potential benefits of this intervention, several limitations must be considered. The lack of randomization may introduce bias due to unmeasured baseline differences, though similar USMLE scores and demographics between groups help mitigate this issue. Additionally, we did not assess residents’ prior study habits or SDL experience, which may have influenced how individuals engaged with the intervention. Cohort effects could also impact outcomes, though no significant faculty or curriculum changes occurred during the study. Furthermore, the self-reported SDL data may be subject to inaccuracies, and the single-site design restricts the generalizability of our findings.

Future studies should explore the use of randomization and objective tracking tools to reduce reliance on self-report. It is also essential to assess the impact of individual FBM components (eg, prompts vs ability) on SDL behaviors and to track the sustainability of these learning strategies longitudinally beyond the first PGY. This could help confirm the effectiveness of the FBM-based intervention across different medical specialties and training environments.

Conclusions

This FBM–based intervention that emphasized prompts and ability improved ITE scores and study session frequency among first-year OB/GYN residents.