Self-regulated learning evolving and deepening into lifelong learning is best understood using the Dreyfus model for skill development.¹⁵ This is in keeping with the foundational framework from which the milestone frameworks have been structured to assess residents/fellows in surgical disciplines.¹

DREYFUS MODEL FOR SKILL DEVELOPMENT

The Dreyfus model for skill development identifies five levels of skill development^15–17:

On this continuum, learners pass from one level to the next as skills are acquired. At each level, there are “recognizable, qualitatively different ways of acting and performing in the process of learning a given skill. Individuals at a given level do better than individuals at the previous level.”¹⁸ Table 1-2 presents the five levels of the Dreyfus model with the addition of delineating each level along four characteristics of skill development: knowledge; decision-making; perception of context; and autonomy.^19–23 Increasing understanding, confidence, and independence associated with these characteristics is in keeping with higher levels of competency with the skill being measured. This delineated view demonstrates in a granular way how a learner progresses and performs differently at each level. Based on criteria, it is clear why not every learner reaches the highest level. The criterion-based foundation of the Dreyfus model makes it a widely adapted process for assessment.^23,24

2 At the novice level, learners largely have textbook familiarity with a skill. After having advanced to the expert level, learners have extensive experiential knowledge with a skill and are seen to be highly intuitive. We understand self-regulated learning to be a skill that can be learned, will progressively grow and deepen over time, is carried out differently at each successive level, and ought to be carried out in the workplace. As the skill is honed and becomes habitual, self-regulated learning transitions into lifelong learning. This progression in skill development makes the Dreyfus model highly appropriate for understanding, teaching, and assessing self-regulated learning.

DREYFUS MODEL OF SKILL DEVELOPMENT APPLIED TO SELF-REGULATED LEARNING IN SURGERY

The attributes and practice of self-regulated learning change as learners transition from one level to the next. In other words, as learners attain greater levels of responsibility, the goals they set for themselves, insights adopted about learning, feedback they require, and adjustments they make based on successes and failures will be different from one level to the next. This is in line with gradually more mature forms of reflection and insightful learning plans learners develop for themselves. Self-regulated learning will be described at each level in terms of the learner’s skills, but also includes suggestions for educators on how to teach at the level of the learner and establish scaffolds to support the learner advancing to the next level.^23,24

Novice

The novice learner is focused on figuring out how textbook knowledge applies to the current experience. The goals learners set for themselves are about making sense of uncertain or unfamiliar content by connecting it to existing familiar sets of knowledge. At this point, the learner adheres to step-by-step rules, regardless of context. Working through a methodical line of reasoning without situational awareness or discretion makes it difficult for the trainee to deal with exceptions and complexity.²⁴ The learner searches for absolute answers. Tendencies toward binary sets of knowledge reveal that learners at this level often do not know what they do not know (unconscious incompetence), suggesting they have an incomplete development of self-assessment.²⁵ After routine-guided observations of procedures being performed, novice learners are incrementally moved to close supervision with explicit instruction in order to complete tasks. Reflecting on their behavior during experiential opportunities along with the feedback received from faculty or more senior residents and fellows causes learners to revisit the knowledge they believed to be universally true and adjust their goals and views on learning.

Educators must be deliberate and specific in the feedback that is provided, even being explicit about the phases of effective self-regulated learning that should be developed. Educators become a resource as trainees learn to develop appropriate goals and establish a plan forward. Determining the existing level of the learner and learning preferences of the trainee is essential for educators so that they can guide the learner toward suitable challenges that will scaffold him/her to the next level.

Advanced Beginner

For the advanced beginner, emphasis is on gaining practical experiences and knowledge. The balance tilts from taking textbook knowledge and applying it to the context, to better understanding the context, patient indicators, and beginning to discern and apply rules. Although perception is improving, judgments are still quite limited. The advanced beginner continues to be rational and analytic, but now sees actions as related rather than a series of independent steps.²⁴ Developing an understanding of connectedness helps learners realize the complexity of situations and with that comes an appreciation for how much they do not know (conscious incompetence).²⁵

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