Sample and Setting

Pragmatism is a research paradigm that focuses on what works to address real-world problems. It values practical outcomes, blends methods, and emphasizes the usefulness of results for stakeholders and society.^14,15 Guided by a pragmatic orientation, this study was conducted within a midsize IM residency program, starting in October 2022. Residents who scored below the 35th percentile on the IM-ITE were required to participate in the academic coaching program, while other residents could choose to participate voluntarily. Based on the American Medical Association Coaching Implementation Workshop, the program aimed to enhance residents’ SDL.¹⁶ The intervention started with structured workshops, with participants developing individualized learning plans (ILPs) in a specific, measurable, achievable, relevant, and time-bound (SMART) goal format for the academic year.¹⁷ Thirteen faculty coaches from IM and related specialties volunteered and received training via a 1-hour faculty development session that covered reflective practice frameworks, scripts, and contracts. These coaches met bimonthly with assigned residents, independently of advisor meetings, and received monthly check-in emails. While the meeting format (in-person or virtual) was flexible, academic coaching materials focused on enhancing residents’ SDL skills.⁶

Design and Intervention

The academic coaching program aimed to facilitate the development of SDL by equipping residents with the skills to independently assess their learning needs, set meaningful goals, and identify the resources and strategies required for success. The workshops included formative exercises that focused on critiquing and developing SMART goals. Based on these goals, each resident created an ILP that guided their learning throughout the academic year.

Data Collection

We performed a secondary analysis of qualitative data collected to explore the impact of the academic coaching program on residents’ SDL.⁶ Residents who had met with their assigned coach at least once were invited to participate in semistructured interviews conducted virtually via Google Meet in October 2023 (interview guide provided as online supplementary data). The interviews explored residents’ experiences with the academic coaching program, focusing on their perceptions of the relationship between coaching and SDL, and the strategies and resources they employed in their SDL journeys. The authors digitally recorded, transcribed, and verified all interviews for accuracy. Data collection for the primary analysis continued until we achieved thematic sufficiency for our initial study question, ensuring a rich, comprehensive dataset for analysis; in this analysis, we did not perform additional interviews but did critically analyze the data from the existing interviews to ensure it was sufficient to robustly address our research question. We reached this consensus through discussion with all authors that involved mapping our final themes to our research question.¹⁸

Data Analysis

We analyzed interview data using thematic analysis following Braun and Clarke’s 6-step approach.¹⁹ Four authors independently coded transcripts using open, inductive coding. While we developed a codebook to track codes between authors, this codebook was not predetermined and continued to evolve in an iterative fashion with each round of analysis. Coding remained open throughout each round so that authors could continue to analyze and reflect upon the meanings that each drew from the data, and the outcome of our analysis was theme development and refinement.^19,20 The team held frequent discussions throughout the analytic process to iteratively reflect upon insights and connections made, and we used memos to process and record our approaches, assumptions, and thoughts during the primary analysis.

In this secondary analysis, one author (K.M.B.) reviewed the coded data to identify specific strategies and resources residents used to support SDL. Four additional authors (J.D.H., H.M., M.E.K., K.R.W.) independently reviewed the coded data to capture all relevant passages. The research team then met to refine and develop themes aligned with the research question, focusing on how residents’ learning strategies and resource utilization interacted with cognitive load.

Guided by cognitive load theory, our analysis examined how residents managed intrinsic, extraneous, and germane cognitive load when engaging in SDL. We specifically explored how academic coaching influenced their ability to optimize cognitive resources, mitigate unnecessary cognitive burden, and enhance meaningful learning. This approach allowed us to contextualize residents’ SDL strategies within the cognitive demands of medical training, providing insight into how academic coaching can support their development as autonomous learners.

Reflexivity

K.M.B., the residency program director, co-developed the academic coaching program with K.R.W., the associate program director. Given K.M.B.’s primary goal of evaluating how residents engage in their SDL, the research team adopted a pragmatic approach to data analysis. M.E.K., a general pediatrician and former program director with expertise in qualitative research, and H.M., a health education researcher specializing in coaching and qualitative methods, brought critical methodological knowledge to the study. M.R.K. and E.J. conducted interviews with residents required to participate in the academic coaching program to minimize potential biases and enhance participant comfort.⁶

The study received ethical approval from the Wright-Patterson Medical Center Human Research Protection Program under protocol #FWP20230008N, with a “Not Research” designation.

Personalization and Structure in Learning

Residents in the academic coaching program created personalized study plans tailored to their specific needs, such as focusing on organ systems, responding to IM-ITE feedback, or preparing for board examinations. One resident shared, “Part of the academic coaching program also had individualized learning plans. So, I created a spreadsheet and an individualized learning plan for what I was going to study…on this date, I reviewed this, and if I had to, then modified the plan afterward.” (Resident 2) Another resident highlighted the balance between structure and flexibility, saying, “That learning plan was the 30 000-foot overview of what I needed to do. But, the methods I could use were flexible depending on my schedule.” (Resident 1) Residents often adapted their learning plans to fit their clinical schedules, using lighter clinical months to address more learning objectives. Ultimately, the structured ILPs helped residents transition from initial disorganization to increased confidence and more effective learning. As one resident reflected, “It was nice to have everything in one place…just having it in one place and then kind of checking it off as I moved along.” (Resident 7)

Diverse Learning Strategies With Emphasis on Retrieval Practice

Residents employ various learning methods to maintain engagement and reinforce knowledge, tailoring their approaches to individual preferences and needs. These methods include reading textbooks (eg, Harrison’s Principles of Internal Medicine²¹), answering board-style questions, listening to podcasts, watching online videos, using UpToDate (Wolters Kluwer Health), and participating in structured didactics. Retrieval practice is a key strategy for assessing progress, primarily through question banks such as the Medical Knowledge Self-Assessment Program (MKSAP) and UWORLD’s question banks.

One resident explained, “Early in residency, it was very much Harrison’s and reading textbooks, and that was not efficient… I started transitioning more to online videos…or other forms of audio podcasts, which are things that I could try to do while doing something else to promote learning.” (Resident 1) This allowed residents to multitask, utilizing passive review methods, such as listening while exercising or driving, to address their learning objectives. Another resident shared the value of adapting active learning methods: “I focused a lot on question banks, which is the way I learned best, but…being a chief now has opened my eyes to what I missed in the problem-based learning sessions by not being active in my learning.” (Resident 9) This suggests that, while question banks were effective, incorporating additional active learning modalities, such as project-based learning, could deepen understanding.

Residents also emphasized the importance of flexibility in their SDL approaches. As one stated, “When I think of self-directed learning, I think of very much what am I doing on my own time to further my education, whether that’s reading UpToDate at work, reading MKSAP, listening to podcasts, or watching YouTube videos to learn.” (Resident 5) This adaptability enables residents to stay engaged and continuously assess and adjust their learning strategies.

Deliberate Repetition and Spaced Learning for Retention

Residents in the academic coaching program developed effective strategies that held them accountable for their learning, operationalizing accountability through regular self-assessment and structured review. They consistently assessed their performance using metrics such as question bank completion and topic mastery, prioritizing gaps for review. As one resident stated, “Repetition is the key to learning…hammer things over and over again to make it stick, spending less time on each pass.” (Resident 6) This approach helped residents identify areas needing improvement and track their progress, ensuring they focused on mastering key concepts.

Spacing out learning and revisiting topics at set intervals also played a significant role in reinforcing retention. As another resident explained, “I test what I gain through doing questions online or flashcards,” (Resident 4) emphasizing the role of active recall in solidifying knowledge and preventing forgetting. One resident further shared, “And then I also have started integrating Anki decks into my studying, and so I’m creating those myself. Based on my reading and what I feel are high-yield topics from my reading and areas that I know I’m weak in,” (Resident 5) underscoring their proactive approach to customizing study tools. Using tools like flashcards and question banks (eg, MKSAP, UWORLD), residents revisited missed content and tracked their progress over multiple attempts. Gradually decreasing review time allowed them to optimize SDL while increasing efficiency.

Through self-assessment and consistent review, the academic coaching program’s structured approach to accountability empowered residents to actively engage in their learning and develop the skills necessary for lifelong SDL. By tying learning strategies to measurable progress and ensuring regular revision, the program helped residents prepare more effectively for high-stakes assessments.