This project was reviewed and approved by the Harvard Medical School Program in Medical Education Scholarship Review Committee and was exempt from formal IRB review. The study population included 169 students enrolled in their first year of preclinical training at Harvard Medical School. Among first-year medical students who participated in the study there were differences in educational backgrounds. Some students had science-based undergraduate majors such as biology or chemistry, while other held degrees in humanities, language, math, art, or other areas of study.
The intervention was piloted in the setting of a flipped classroom curriculum which necessitates student engagement in several hours of dedicated preparatory work prior to class sessions. The preclinical curriculum in this format also focuses heavily on case-based collaborative learning, in which a problem or scenario is used to stimulate the acquisition of knowledge amongst learners within a small group. For many students, case-cased learning is a new format of education. More traditional, lecture-based learning may place greater emphasis on memorization and routine performance on exams. This intervention was designed to aid students in the application of self-regulated learning in the context of case-based learning, a format of education which requires perspective and reflection to facilitate growth and improvement. The intervention design was based on the Social-Cognitive Theory as proposed by Zimmerman et al. . This model incorporates three stages of self-regulated learning, including 1) the planning and forethought phase which involves setting goals, 2) the learning and performance phase which encompasses the implementation and experimentation of learning strategies and 3) the evaluation and self-regulation phase, consisting of reflection on performance . For the purposes of the intervention, and to make the steps of self-regulated learning more relatable and actionable for medical students, the three phases were simplified to represent the core principles of self-regulated learning including 1) goal setting, 2) applying evidence-based learning strategies, and 3) reflection. This simplified model has also been used in prior studies involving self-regulated learning among medical students . In this study, evidence-based learning strategies refers to methods for learning which have been shown to improve long-term retention of learned material including self-quizzing, consolidation, and interleaving .
Research has suggested beneficial effects of student engagement in the cyclical process of self-regulated learning delivered through a diversity of formats. The majority of prior studies have involved the implementation of coaching and instructional small or large group guidance. There have been notable differences in measured outcomes depending on SRL intervention design [12, 15, 19]. Incorporating the intervention utilizing both the large group format as well as in an individualized coaching setting, allowed for the assessment and comparison of students’ experiences in both settings and formats.
Intervention 1: classroom session methods
The classroom session was carried out as a quality improvement project. Anecdotal evidence from students suggested a need for enhanced education regarding self-regulated learning. Professional development content centered around self-regulated learning was developed, and all 169 first-year students were invited to participate in the session regardless of prior performance and experience with self-regulated learning. The initial component of the intervention took place during medical students’ first semester of the preclinical curriculum. Prior to attending the in-class session, students watched a series of four brief videos designed to introduce the concept of SRL, as well as the different SRL domains including goal setting, evidence-based learning strategies, and reflection.
Students attended a 90-minute, faculty-led class session on SRL skill development and application. The session consisted of a brief lecture and small group discussions based on the SRL concepts introduced in the videos. The class also included time for individual reflection and goal setting. All students were provided with a personal journal in which to address prompts for reflection. As a part of the classroom intervention, students filled out two questionnaires (see Additional file 1). The first questionnaire was completed after watching the videos, prior to the classroom session. This pre-class survey included questions regarding students’ current use of SRL skills and inquired about how one might advise a fellow medical student to apply self-regulated learning and potential barriers they anticipate their colleague may encounter. Following the class session, students completed a second survey and responded to questions regarding anticipated use of skills in SRL, potential barriers to future application of skills and specific examples of how they may incorporate the use of these strategies into their own routine.
Intervention 2: academic coaching sessions methods
The academic coaching intervention was carried out as a pilot study and session content was delivered during the sessions for a total of 15 first-year medical students. The purpose of the pilot was to determine feasibility, required material, and resources necessary for a potential larger scale intervention. All first-year medical students were invited via email to participate in a series of two individualized academic coaching sessions led by one of the medical school’s learning specialists (RG), and 15 students were randomly selected to participate. Each meeting with the academic coach was 40 minutes, with sessions spaced approximately 2 weeks apart.
The initial coaching session (see Additional file 1 for coaching guide) consisted of four primary objectives including 1) establishment of a relationship between the coach and coachee, 2) development of an individualized learning plan and/or goals based on student-reported strengths and areas for growth 3) discussion of evidence-based learning strategies and key psychological principles in learning (i.e. growth mindset) and finally 4) real-time practice using new learning strategies based on content and examples extracted from the first-year basic science curriculum. The second coaching session included 1) a discussion of progress and/or challenges in implementation of the learning plan, 2) provision of objective feedback and suggested solutions to learning challenges from the learning coach, and 3) revision and adjustment of learning goals for the remainder of the semester. Following the second coaching session, each student took part in a virtual interview. A broad, open-ended semi-structured interview protocol was used to guide the discussion (see Additional file 1). One test interview was conducted.
Quantitative pre and post survey data from the classroom intervention was analyzed using the statistical software STATA Version 16 (Stata Corp, College Station, Texas. StataCorp. 2019). Chi-square tests were used to determine statistical significance of differences between students’ pre and post survey responses.
Interviews from the academic coaching session were video recorded, transcribed verbatim, and de-identified. Both data from the transcribed interview responses and qualitative short answer survey responses from the classroom session were stored and organized using Dedoose Version 9.0.46 (Sociocultural Research Consultants, Los Angeles, California). Two authors (TB and AA) who did not engage with students in the classroom or coaching sessions carried out the qualitative analysis. Students’ short responses from the surveys and transcribed interviews were read through in entirety and an inductive approach was employed using the Framework Method for qualitative analysis . Memoing was completed, followed by open coding and codebook development. Descriptions and illustrative quotes for every code were discussed and discrepancies resolved prior to application of codes to the entire data set. Intercoder reliability was established through coding identical texts and resolving differences of opinion through discussion. Final themes were determined through an iterative process of constructing level 1 and level 2 categories from coded excerpts. Coders met throughout the coding process to ensure full agreement and discussion of uncertainties in coding. Emerging themes were discussed with the entire research team twice during committee meetings.