A-1 Research and scholarship
Last updated: March 10, 2025
Every professional must continually learn and develop their skills across their professional lifetime, often referred to as Continued Professional Development or Self-Directed Learning. Other terms used include lifelong and self-regulated learning. This is needed so the professional can respond and adapt to changes in demands, keep up-to-date with new knowledge or techniques, and maintain and increase their existing knowledge and skills. A competency to ensure this is included in the syllabus because, although its importance is widely acknowledged, I have not found any syllabus mentioning the teaching and training of this skill. Yet, it is a skill that can be taught. This competency is identified in the General Medical Council’s Generic Professional Capabilities framework as Capabilities in Research and Scholarship.
I was once asked to present to the department of psychiatry, where I was a trainee doctor, the evidence on pre-frontal leucotomy as a treatment. This was at St Thomas Hospital, London, where the department arranged many leucotomies and ran large follow-up clinics. I had yet to receive training on finding and collating evidence. I went to a bookshop and bought a book showing evidence of its ineffectiveness and harm. My presentation summarised it. This was not well received, but my seniors produced no contrary evidence! A senior trainee was detailed to show me how to find the evidence needed. I realised that I needed to learn how to find evidence, and that my seniors were not reviewing the evidence about their treatments. In 1975, I had to search through many volumes of Index Medicus. PubMed and Google now make the task easy.
Table of Contents
Competency A1 – Research and Scholarship.
During daily professional work, the trainee identifies information, or a skill needed to improve professional performance and can find sufficient relevant material within 15 minutes to support continuous learning.
Introduction – professionalism.
In 2001, the Lancet published a series of articles about medical education, pointing out the need for change in curricula to reflect the changes occurring in healthcare and society.
Anne Stephenson et al. emphasised the need to teach professional development in medical schools. They referred to the hidden curriculum: “In the hidden curriculum of medical education are the processes, pressures, and constraints, which fall outside of, or are embedded within, the formal curriculum, and that are often unarticulated or unexplored.” The processes are not specified, but one might have been learning to maintain and improve professional knowledge and skills.
The Royal College of Physicians reviewed what characterises professionalism and gives seven central features, one of which is being a learner and teacher. The report, Advancing Medical Professionalism says, “A commitment to lifelong learning underpins the work of all professionals, and the ability to reflect on an event or experience and improve one’s practice defines an effective professional.” It also says, “Lifelong learning includes a commitment to evidence-based practice (while recognising its limitations) and continuous improvement using measurement, reflection and feedback tools.”
Richard Cruess and colleagues give a more striking definition. They start with Miller’s pyramid of developing professional competence: knows, knows how, shows how, does. This may be categorised as knowledge, competence, performance, and action. They add a fifth, top category of “is” (a professional), translated into identity. The characteristic is that the person enacts the attitudes, values, and behaviours expected of someone in a professional role. The person thinks, acts, and feels like a physician (or any other professional).
Thus, a syllabus that only includes clinical knowledge and skills will overlook a substantial part of the professional’s complete education. This competency covers the missing expertise of continuous learning and is therefore the most critical competency in the syllabus.
Professionals and self-directed learning
It should not be surprising that professionals must continue learning through life. Societal changes lead to the emergence of new needs the professional is expected to meet and the disappearance of other requirements. The professional must learn new techniques or knowledge when previous knowledge or skills are superseded. At the same time, they must maintain other knowledge and skills. This is part of all life, not just professional life. This page is written on a computer, but I learned to write using a dip pen, and we had to make the ink.
Professionally, developing electronic databases and software such as PubMed and Google have transformed matters since my early training. Nonetheless, I still see or hear people asking for help with diagnosis or management, when five minutes online would give them an adequate answer.
The General Medical Council regulates all medical professional training and recognises the importance of autonomous scholarship and research. For doctors, it set out a Generic Professional Capabilities framework. Most professions likely have something similar.
The ninth domain is Capabilities in research and scholarship. They provide a list of required behaviours in 12 main items and five sub-items to illustrate the broad scope of ‘research and scholarship’. The capability encompasses
- Continuing Professional Development
- Critical Appraisal skills
- Self-directed learning, and
- A generally broad and curiosity-based approach to clinical practice.
Doctors in training recognise the need to learn self-directed learning skills. Melissa Nothnagle and her colleagues interviewed 13 final-year residents in the US and found that medical trainees:
- understand and value the concept of self-directed learning but undertook limited goal setting and reflection;
- reported a lack of skills to manage their learning, particularly in the clinical setting;
- still valued traditional, teacher-centred approaches even though they were supposedly in a learner-centred culture;
- recognised patient care as the most potent stimulus for learning, but often perceived patient care and learning as competing priorities;
- wanted guidance and training in self-directed learning.
Learning to learn and how to answer questions adequately and quickly is vital. During post-graduate training, professionals become familiar with educational events such as local teaching sessions, grand rounds, seminars, and conferences. Most of these are relatively passive. I suspect that training in self-directed learning is rare. A Google search for courses on self-directed learning only revealed self-directed learning resources on self-directed learning, a somewhat circular phenomenon!
It is a practical skill that can only be acquired through regular use. It cannot be learned as factual knowledge. The professional must practise and use the skill to improve, precisely as our patients improve most through task-specific practice.
Capability and competency.
The overall capability, adapted from the General Medical Council’s Good Medical Practice, is “to develop and maintain your professional performance, applying your knowledge, skills, and experience to your professional practice.”
The competency in this syllabus concerns self-directed learning, which is only a part of the overall capability. It should be relevant in most work areas, easily practised daily, and has a measurable outcome.
Models of learning.
Knowing the theoretical models concerned with self-directed learning may identify where to concentrate one’s attention to help improve the skill. There are several theories and models, but generally, they are similar.
Sawatsky and colleagues proposed a model derived from a qualitative study involving internal medicine trainees. The theoretical basis behind the analysis was a three-factor model encompassing context, personal factors, and the learning process.
Three contextual features were identified. One was the availability of guidance that imposed some structure upon learning. Examples included a curriculum, examinations, peers, more senior doctors, and patients. Closely related to this was the structure and culture of the training programme, such as having time to undertake the activity and the culture or expectation of learning by the trainees.
The context also provided most of the barriers. There was tension in allocating time between patient care, attendance at obligatory teaching or research commitments, leisure and non-work activities, and self-directed learning. A perceived lack of time was frequently mentioned as an obstacle.
Personal factors fell into groups. Motivation and motivating factors were important. For example, low motivation was associated with a lack of autonomy in making patient decisions and unrealistic expectations of achievement. In contrast, previous success and self-confidence were associated with higher motivation. Some residents (trainees) were also motivated to avoid “looking stupid”.
The second personal group acknowledged that a trainee’s approach developed and changed with experience and as the nature of the work changed. For example, textbooks were used more frequently in the early stage of training. The level of knowledge learned altered as the trainee acquired more basic knowledge. The trainee’s personality and learning styles were also essential.
One personal factor is linked directly to the process. The trainee’s level of knowledge determines the new expertise needed because self-directed learning is triggered by a mismatch between the trainee’s ability and what is required. For example, when involved with a patient who has had a stroke, someone familiar with stroke might be triggered to investigate how to rehabilitate someone with prosopagnosia, a rare condition. In contrast, a novice might investigate the expected recovery over the first six months.
Self-directed learning is triggered when someone appreciates that they do not know or understand something they should. However, there is a second, more powerful trigger: curiosity. When a person realises they lack knowledge, they wish to discover to satisfy their interest, even if there is no apparent need to know clinically.
The self-directed learning person’s vital first step is to:
- Realise that there is something they do not know that might be knowable, and
- Be sufficiently curious or concerned to do something about it
The remainder of the process is reasonably straightforward. The person will:
- Formulate some objectives, what they wish to discover and learn;
- Identify and use some appropriate resources to achieve an answer;
- Use the knowledge either in the triggering situation or in a similar case;
- Check that they have reached the learning aimed for.
Influences on self-directed learning
There are many studies on what influences self-directed learning.
Jeong and colleagues undertook a scoping review on what facilitates or inhibits self-directed learning in physicians; 17 articles were included. They analysed the data using the Theoretical Domains Framework, which outlines factors that influence the use of evidence in clinical practice.
They found that four domains (out of 13) had the most influence. The environmental context and resources were, unsurprisingly, the most powerful. This referred to having time available and access to appropriate resources to find and access the information needed. Structured tools to appraise the new information and reflect upon it were significant facilitators.
The social context was a second strong influence. Physicians who engaged in teamwork, collaborative work, interaction with others, and networking were likelier to use self-directed learning. In contrast, they found medicine’s “on-the-job learning” culture a barrier.
The third domain was the physician’s belief in the online programmes used. This only influenced a part of self-directed learning, choosing a specific online programme. The last field, behavioural regulation, is environmental because it concerns the presence of support.
Thus Jeong et al. highlighted the vital role of context, and Joris Berkhout and colleagues investigated this in more detail. They usefully state that “context includes what people do in a context, the roles that people have in a context, interpersonal relationships, and the physical context in which learners learn.”
Their context description implies that it is not a static descriptor of where someone is. Instead, context is dynamic and varies; it arises from interactions and does not solely describe the surroundings. They argue that learning in healthcare professions must be integrated into daily clinical practice to ensure its relevance and integration of learning into daily activity.
There are many theories related to self-directed learning. Berkhout et al. also list and describe the fundamental theories behind self-regulated learning as theories covering achievement goals, a constructivist approach to learning, self-determination, situated learning, workplace affordances, and self-regulated learning.
Improving self-directed learning
If self-directed learning is more effective than other methods, revealed later, it is worth understanding how to improve it.
Van Houten-Schat and her colleagues reviewed the evidence on teaching self-regulated learning (another synonym). From the 18 studies examined, they identified the typical individual, contextual, and social factors influencing self-regulated learning. They concluded that most teaching focused on goal setting and monitoring progress, and none taught self-evaluation. They recommended that education pay more attention to reflection and enable students to use their skills, albeit with support.
Piet van der Keylen and colleagues systematically reviewed studies of the information needs of family doctors to identify their needs and factors that hindered them from being met. They identified five main groups of requirements.
Individual needs.
These were personal needs identified, including the need for continuing medical information and keeping up-to-date; a frequent lack of skill in using the internet and a need to learn (the search covered all years, but most studies were published after 2000); working collaboratively was a valued activity; understanding evidence-based medicine and how to evaluate and interpret evidence; and a preference for paper-based materials.
Access.
The access needs included adequate time, easy-to-use internet resources, cost (paying significant amounts was a large barrier), language (being in a language known to the doctor), and other technical issues.
Quality needs.
These included knowing that the source was trustworthy and the results credible, concise information presentation, such as informative summaries, satisfying the specific needs of the searcher, and being up-to-date.
Utilisation needs.
These covered three separate issues. The first was that the interface should allow easy navigation with well-organised information. The second was a large gap between what was researched and published and the essential information that family doctors needed. Last, if a doctor searched during a clinical encounter, the search needed to improve the doctor-patient relationship.
Implication needs.
This group’s primary need was for information relevant to daily clinical practice. In addition, the necessary information to help educate patients about their condition should justify their clinical practice and decisions, which suggests an uncritical approach to clinical practice.
Effects of active learning.
So, when compared to traditional learning methods, does active learning have an effect, and if so, how much and to what?
Nicolette Harris and Cailee Welch Bacon systematically reviewed the effects of active learning in healthcare professions, identifying 154 studies. They concluded that there was sufficient evidence to warrant Grade A recommendations that active learning techniques were associated with more improvement in lower-order and higher-order cognitive skills than passive learning techniques. Nevertheless, they cautioned that extensive high-quality studies were still needed to investigate whether this translates into clinical practice and work performance.
I know of three systematic reviews of problem-based learning. The first, in 2002, found six controlled studies; there was insufficient evidence to draw any firm conclusion about its effectiveness compared to more traditional teaching methods. The second, in 2014, found 15 studies involving postgraduate doctors, and there was only limited evidence that problem-based learning enhanced professional performance and health outcomes.
The third, in 2022, focused on problem-based learning in medical undergraduates and found 124 relevant publications, but many were small or of low quality. Nevertheless, the evidence showed that this method increased knowledge retention and academic performance as effectively as traditional teaching. Additionally, it improved social and communication skills more effectively than conventional teaching.
Research and scholarship: practical approaches.
Much of the evidence above comes from studies of medical training, probably because medical training is subject to the most scrutiny. Still, there is no reason to think other healthcare professions are different, and the evidence should apply to all healthcare professions. Some practical consequences are set out here, but they are not in any specific order.
Whatever your profession, you must realise that continuous learning is essential, not a luxury, and allocate time to it in your daily work. This competency emphasises two skills when learning. First, you are aiming for something other than perfection; you should aim for a slight increase to be better than before. Second, you should spend at most 15 minutes on the activity; this activity can fit into most working days at some point.
Associated with this “good enough” approach, you need to avoid being overly ambitious about what you learn. Instead, you should set achievable learning targets, such as knowing two effective drugs for controlling neuropathic pain. Learning one thing well is better than having incomplete, patchy knowledge about many things.
You must understand that every day you will encounter things you do not know and could find out. The challenge is not finding something to learn but choosing one of the many arising daily. Choose whichever interests you most or is clinically crucial to you and your patient. These are more likely to motivate you, with curiosity being a vital driver.
You will need to temper curiosity a little to ensure you cover essential areas of knowledge, such as what is required for an examination or following advice from a guideline. Even then, it is better to be curious about a policy, wondering if the evidence supports the recommendation or if there are more risks than acknowledged.
It would be best to foster a local culture of curiosity and self-directed learning among your peers, team members, and colleagues. This can be done, for example, in team meetings or when discussing a clinical problem. Remember that a culture of teamwork, collaborative working, and behaviours such as interacting and networking with others is associated with better learning. You should foster that type of environment.
Last, it would be best to remember that the benefits of self-directed learning extend well beyond learning more facts. It improves your social interactions and communication with others. It also fosters and increases your professionalism so that you and others will recognise that you are indeed a rehabilitation professional.
Conclusion
This competency is crucial, far outweighing any other yet, surprisingly, it is rarely included in a syllabus. The General Medical Council’s General Professional Capabilities framework recognises Scholarship and Research as a vital capability for professional practice. A core competency for this capability is to undertake continuous learning as part of daily work. Evidence suggests self-directed learning is more likely when people work within collaborative, curious teams. Rehabilitation professionals are thus well-placed to develop and use this competency.
