Unveiling Self-Regulated Learning Practices in Surgical Residents: A Scoping Review

Unveiling Self-Regulated Learning Practices in Surgical Residents: A Scoping Review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Unveiling Self-Regulated Learning Practices in Surgical Residents: A Scoping Review Ye Lim Lee, Mandeep Kaur, Brandon Cowan, Aileen Gozali, Jacquelyn Knox, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6960218/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Purpose Self-regulated learning (SRL) is a proactive approach that can help surgical residents maximize learning among their many competing demands. While the literature reports frameworks for SRL in surgical education, a comprehensive list of strategies is needed for practical use. We conducted a scoping review to map SRL strategies used by surgical residents into a single collated resource. Methods We searched five electronic databases (PubMed, Embase, Web of Science, Cochrane, CINAHL) on July 16, 2024. Two team members independently reviewed abstracts, and six team members reviewed full texts in pairs with an initial calibration process and iterative conflict resolution. We characterized resident behavior by the three phases of Zimmerman’s model of SRL–forethought, performance, and self-reflection. Results Twenty-three articles were included from 4493 screened abstracts. For forethought: (1) Preoperatively identify and communicate learning goals to faculty via email or educational timeouts; (2) Review procedural steps and relevant anatomy in preparation for cases. For performance: (3) Verbalize observations, next steps, and challenges intraoperatively; (4) Seek help, including the expertise of supervisors, other healthcare professionals, and near peers. For self-reflection: (5) Make written, oral, or mental reflections of one’s performance and experiences to identify key learning points, areas of improvement, and reactions to clinical events. Conclusion Our scoping review identified specific strategies that surgical residents use to maximize SRL inside and outside of the operating room. The outlined SRL behaviors can help residents engage in practice-based learning and improvement by evaluating their current practices and considering new positive habits. Figures Figure 1 INTRODUCTION Self-regulated learning (SRL) is a proactive, learner-driven process in which individuals take ownership of their education by managing their cognition, behavior, and emotions [ 1 , 2 ]. Several theoretical models describe SRL, and among them, the framework created by Zimmerman is one of the most widely used [ 2 , 3 ]. Zimmerman proposes a cyclical model that divides SRL into three iterative phases: the forethought phase, where learners set goals and assess their motivations and capabilities; the performance phase, where they implement learning strategies and monitor progress; and the self-reflection phase, where they evaluate their performance and adapt future learning accordingly [ 4 ]. In medical education, SRL is strongly associated with achieving success in both academic and clinical settings. Learners who engage in SRL tend to perform better on exams, excel in clinical assessments, and experience better mental health [ 5 – 10 ]. These outcomes underscore the importance of understanding how SRL develops and manifests, particularly for graduate medical learners such as residents, who must master complex knowledge while applying it in high-stakes, real-world situations. Surgical residents stand to benefit significantly from SRL. Much of their learning occurs outside of protected educational time and instead takes place through experiential workplace learning or independent study. Given the variability in clinical exposure and surgical case volume, SRL can help residents develop intentional learning behaviors—such as preparing for procedures, setting case-specific goals, monitoring progress in the operating room (OR), and reflecting on their performance afterwards—to proactively identify and address gaps in training [ 11 ]. Surgical residency demands comprehensive mastery of both technical and non-technical skills, all within a high-pressure, time-constrained environment, creating an appropriate context for self-regulation [ 12 , 13 ]. In 2019, Johnson et al. proposed a conceptual model outlining how surgical trainees should appraise, regulate, and refine their learning strategies in every clinical environment [ 11 ]. Through Delphi consensus, their framework emphasized the importance of planning, goal tracking, and adaptive behaviors—core components that mirror Zimmerman’s model of SRL. While this framework offers valuable structure, there remains a need for a comprehensive, updated synthesis of specific SRL strategies used by surgical residents across diverse learning settings. This scoping review aims to fill that gap by mapping the literature of SRL strategies utilized by surgical residents, using Zimmerman’s model as an organizing framework. Our goal is to create a unified resource that identifies actionable strategies that may support trainees' development into safe, autonomous surgeons through the application of SRL. METHODS We followed the five stages of the Arksey and O’Malley framework to guide our scoping review [ 14 ]. Stage 1: Identifying the research question Our research question was: “What SRL strategies do surgical residents use?” Stage 2: Identifying relevant studies In collaboration with a librarian, we developed search strategies for five electronic databases: PubMed, Embase, Web of Science, Cochrane, and CINAHL. The search included all articles published up to July 16, 2024. The full search strategy developed for PubMed, which was subsequently adapted for use in the other databases, is provided in Appendix 1. Stage 3: Study selection Articles were included if they were: available in English, targeted postgraduate learners in surgical specialties, and focused on self-reported strategies or tested interventions that promoted SRL. Papers were excluded if they: (1) lacked a focus on SRL strategies, (2) included multiple types of learners without distinguishing results specific to surgical residents; (3) described strategies that could not be self-initiated, or (4) lacked empirical data and rather drew SRL-related conclusions outside the context of specific strategies or interventions. We included program- or faculty-led interventions if the skills taught could be transferable to residents’ independent practice beyond structured didactics (e.g. goal setting, reflection). Two reviewers (YL and MK) independently screened all titles and abstracts. Prior to screening, a calibration exercise was conducted by reviewing a uniform set of 50 abstracts to establish consistency in applying inclusion and exclusion criteria. The reviewers met regularly throughout the screening process to resolve conflicts. When consensus could not be reached, a third team member (BC), a surgical resident, provided adjudication based on relevance to SRL in surgical training. For full-text review, six team members (YL, MK, BC, PO’S, AG, JK) were paired to determine inclusion of screened articles. A calibration exercise using two full-text articles established consistency across all reviewers. Each pair reviewed a subset of full-text articles and met to reach consensus for study inclusion or exclusion. Unresolved conflicts were brought to the full team for discussion. Stage 4: Charting the data We developed and iteratively refined the extraction form on Qualtrics®. The extracted data included: article title; primary author; publication type; statement of purpose; study design; methodological framework; data collection method; number, location, level of training, and specialty of participants (if specified); SRL strategy or intervention; Zimmerman’s model categorization; primary conclusion; and additional references to search. Stage 5: Collating, summarizing and reporting the results We categorized each study and its strategy by one or more of the three phases outlined in Zimmerman’s model of SRL: forethought, performance, and self-reflection. RESULTS A total of 4,493 articles were screened after duplicate removal. Based on titles and abstracts, 4,423 were excluded. The full texts of 70 articles were reviewed, and 23 met the inclusion criteria for this scoping review (Fig. 1). Table 1 Summary of Characteristics of Included Studies Related to Self-Regulated Learning in Surgical Residents Location Number of Studies North America 19 (83%) Europe 3 (13%) Australia 1 (4%) Publication Type Number of Studies Original research report 20 (87%) Review 3 (13%) Research Design Number of Studies Qualitative 11 (48%) Causal / Experimental 4 (17%) Descriptive 3 (13%) Mixed Methods 1 (4%) Program Evaluation 1 (4%) Specialty Number of Studies General Surgery 16 (80%) Orthopedic Surgery 3 (15%) Otolaryngology 3 (15%) Obstetrics Gynecology 2 (10%) Urology 2 (10%) Cardiothoracic Surgery 2 (10%) Plastic Surgery 1 (5%) Neurosurgery 1 (5%) Ophthalmology 1 (5%) Oral Maxillofacial Surgery 1 (5%) Forethought Phase Among the included studies, 16 articles addressed the forethought phase with heavy emphasis on preoperative preparation and goal setting [ 15 – 30 ]. Strategic planning—identifying what to study, when, and how—were explored in seven studies [ 15 – 21 ]. Table 2 summarizes the common topics residents reviewed preoperatively and the corresponding resources they used to prepare. While there is a plethora of resources, one study surveyed 108 otolaryngology residents nationwide in the U.S. and found that textbooks, surgical education websites, and atlases were the three most used items among all respondents, and journal articles and personal notes were more often utilized by residents who rated the effectiveness of their preparation highly [ 18 ]. Residents also considered multiple factors such as case complexity, familiarity, expected level of autonomy, and attending surgeon when deciding how much time to devote to preparation [ 15 , 16 ]. One study described that some residents addressed time constraints by creating a personalized surgical guide that consolidated frequently referenced information [ 15 ]. Several studies noted that residents associated preoperative preparation with greater engagement in the OR and, at times, increased intraoperative autonomy [ 17 , 19 , 20 ]. Strategic planning also took place in simulations, where residents found it helpful to break down their tasks into manageable steps easier to train for and master [ 21 ]. Table 2 Preoperative Preparation Topics and Resources Identified in Included Studies Topics Resources Used Studies Technical Skills Simulations Review prior notes on errors made Review recordings 15, 18, 19 Procedural Steps, Anatomy, Complications Textbooks Surgical atlas Websites (UpToDate, Medscape, E-medicine, Google) Videos (The Society of American Gastrointestinal and Endoscopic Surgeons, YouTube) Journal articles 15, 16, 18, 19, 20 Patient-Specific Factors Patient chart, including labs and imaging 15, 16, 17, 19 Surgeon Preferences Ask the attending surgeon Review old operative notes Ask peers 15, 17, 20 Four studies highlighted a preparation strategy that extends beyond physical resources—mental rehearsal [ 17 , 21 – 23 ]. This technique involves visualizing procedural steps without physically performing them. Skervin and Scott found that most of their survey respondents (91.9% of surgical trainees) engaged in mental rehearsal independently to prepare for complex cases [ 22 ]. Through this strategy, residents identified potentially challenging steps and addressed these gaps using supplemental resources such as videos [ 21 , 23 ]. Goal setting was another commonly reported forethought strategy across eight articles [ 17 , 19 , 20 , 23 , 24 – 27 ]. While many emphasized the importance of establishing goals preoperatively, Ranney et al. also underscored the value of explicitly sharing these goals with attending surgeons [ 20 ]. Three studies tested interventions that structured this dual process. Fieber et al. introduced resident-initiated, inquiry-based preoperative briefing (R-PROB), in which residents sent two to four learning goals to their attendings at least 24 hours before the procedure and discussed them face-to-face [ 24 ]. Lillemoe et al. implemented educational timeouts (ETOs), during which residents and attendings met preoperatively to review: 1) learning goals tied to a specific operative step, 2) the resident’s current autonomy level in that step, and 3) strategies to advance toward the resident’s goals [ 25 , 26 ]. Goal setting was not limited to the OR. One study described how surgical residents identified their strengths and weaknesses to develop a six-month individualized learning plan using the SMART (specific, measurable, achievable, relevant, and time-bound goal) framework [ 27 ]. These goal setting practices highlight the proactive engagement residents employ to shape their learning trajectories within surgical training. Performance Phase Ten articles described strategies used by residents during a learning activity, most commonly while operating [ 19 – 21 , 27 – 33 ]. The strategies largely fell into two categories: verbalization and help-seeking behaviors. Five studies named verbalization as a common strategy used in the OR [ 19 – 21 , 31 , 32 ]. Residents verbalized their thought processes and observations as they progressed through the procedure—for example, identifying anatomic structures as they appeared, proposing plans, and requesting instruments for the next step [ 19 – 21 , 31 ]. Communicating uncertainties was also critical. When facing a challenging step, residents often articulated what they were attempting, what they perceived to be going wrong, and how they planned to address it [ 19 , 20 , 31 ]. Nieboer et al. conducted a conversation analysis of verbal exchanges between trainees and supervisors during a total hip replacement and identified four ways residents sought guidance from supervisors: residents (1) explicitly asked for input, (2) evaluated the task before soliciting an opinion (“This is what I think. What do you think?”), (3) requested confirmation of their assessment (“This is what I think. Do you agree?”), and (4) offered an evaluation of the ongoing activity without seeking feedback [ 32 ]. While attending surgeons were the primary source of support during operations, Woelfel and Kunze recognized that residents also seek help from other personnel [ 31 , 33 ]. For instance, residents consulted seasoned scrub technicians, gaining insight into the preferences and workflow of attending surgeons on a new rotation [ 31 ]. Senior residents also served as near-peer mentors, helping junior residents navigate patient care and systems-based practices such as the electronic medical record, OR logistics, and procedural techniques. In shared cases, seniors could identify operative learning opportunities for their juniors [ 31 , 33 ]. Self-Reflection Phase Ten articles described topics and practices used by residents to reflect on a learning activity [ 20 , 21 , 27 – 30 , 33 – 37 ]. Common themes of reflection included clinical decision making in evaluation and management of the patient, technical skills, complications and mistakes, and interpersonal dynamics within the surgical team [ 34 – 36 ]. Reflection methods varied. For example, Morrill et al. reported that many residents engaged in daily reflection, most often mentally and shortly after cases [ 36 ]. A summary of additional reflection methods is presented in Table 3 . Table 3 Methods of Reflection Identified in Included Studies Reflection Method Description Mental Re-living experience with step-by-step mental review, internal narration [ 36 ] Written Note-taking, reading literature, re-reading patient charts, journaling, artistic endeavors [ 36 ] Monthly written reflections with guiding questions [ 35 ] Verbal Postoperative discussion with attending about struggles, dictating operative notes [ 20 ] Conversations with peers/family [ 36 ] Chart stalking Following patient chart over time to observe changes in management plans, orders, and outcomes [ 37 ] Multiple studies emphasized identifying personal strengths and weaknesses as a core objective of reflection [ 20 , 35 , 36 ]. For instance, DeVries et al. noted that complications often served as memorable primers for reflection, prompting adaptive behaviors in future scenarios [ 34 ]. Other times, residents felt driven to evaluate their own performance out of the spirit of competing against themselves, especially in settings such as simulations where they could gamify their learning tasks [ 21 ]. Reflective questions—such as how a learning point aligns with existing knowledge, its broader applicability, contributing factors, or how the situation could have been better managed—can help structure this process [ 35 ]. Reflections can guide goal formation, as demonstrated by O’Connor et al., whose intervention began with residents’ self-assessments of strengths and weaknesses that led to the creation and monitoring of individualized learning plans [ 27 ]. External Scaffolding of SRL While the learner is the primary agent of SRL, many strategies identified in the literature involved external influences, including attending surgeons and peers. For example, both resident-initiated, inquiry-based preoperative briefing and educational timeouts in the forethought phase required attending participation [ 24 – 26 ], and senior residents were frequently cited as resources for preoperative preparation and clinical learning [ 15 , 17 , 33 ]. Three studies discussed how all three phases of SRL—forethought, performance, and self-reflection—could be socially mediated through interactions with mentors and peers [ 28 – 30 ]. Carlson and Tannyhill explained that residents regularly extend their SRL efforts by involving faculty, peers, patients, and other healthcare professionals in co-regulated learning environments [ 29 ]. Similarly, Aho et al. implemented a curricular model in which residents met with a faculty mentor at the beginning, middle, and end of a six-week simulation lab rotation to set goals, receive technical advice and feedback, and review learning curves. All participants (n = 6) demonstrated improvement in laparoscopic tasks and reported increased practice when supported by faculty mentors in contrast to doing it alone [ 28 ]. The impact of learning with peers was exhibited in the study conducted by Sonnadara et al., which found that residents in student-led groups outperformed their instructor-led counterparts after practicing technical skills with their peers by collaboratively exploring concepts and knowledge, identifying learning strategies, and exchanging feedback with minimal involvement from instructors [ 30 ]. Barriers and Challenges to SRL Implementation The included studies identified several challenges to implementing SRL strategies. Authors in multiple studies commonly cited time constraints as a barrier to preoperative preparation, goal discussion, and postoperative case reflection [ 15 – 18 , 20 , 24 ]. Furthermore, studies noted a lack of structural support for residents to adopt these behaviors; some residents reportedly developed preoperative preparation systems through trial and error and struggled to locate adequate resources [ 15 , 16 ]. Jabbour et al. illustrated this challenge when they reported residents’ average self-rated preparation effectiveness at 3.53 and efficiency at 3.19 on a 5-point Likert scale [ 18 ]. Additionally, the literature revealed instances where residents demonstrated limited understanding of certain SRL strategies, such as being unaware of mental rehearsal’s potential for skill acquisition beyond case preparation [ 23 ]. Another study, by Nieboer et al., questioned whether residents’ intraoperative verbal cues for input were deliberate, pre-planned learning strategies, suggesting instead that these behaviors might represent spontaneous requests or “reflection in action” [ 32 ]. DISCUSSION Our scoping review illuminates the landscape of SRL strategies adopted by surgical trainees, demonstrating a clear emphasis in the literature on the forethought phase. Residents engage in diverse preoperative preparations, including mental rehearsal and goal setting, which are perceived to enhance confidence, reduce stress, and improve preparedness for cases. This review also identified crucial strategies within the performance phase, such as verbalizing intraoperative thoughts, as well as varying methods of self-reflection. Furthermore, our findings highlight that help-seeking is a pervasive and continuous strategy across all SRL phases, involving a wide array of colleagues and supervisors. This review therefore provides a foundational understanding of how surgical residents actively regulate their learning, predominantly through anticipatory actions but also through ongoing self-monitoring and reflection. SRL is a highly valued construct in education and an essential component of modern medical training. A recent systematic review aimed at identifying core competencies for lifelong learning across educational disciplines found that self-regulation and self-direction were the most frequently represented attributes, appearing in 65% of included studies [ 38 ]. This emphasis on self-regulation is echoed in the ACGME’s Surgery Milestones, where the practice-based learning and improvement (PBLI) competency explicitly requires residents to identify learning needs, seek performance data, apply feedback, and update learning plans [ 39 ]. While the Delphi study by Johnson et al. established what factors constitute SRL in surgical education, our review complements their framework by illustrating concrete examples of how surgical residents operationalize these behaviors in practice and by providing insight into the lived application of SRL across its phases [ 11 ]. While our review extensively captured the cognitive and behavioral facets of self-regulation, a notable absence emerged concerning its motivational and emotional components. Within the forethought phase, Zimmerman distinguishes between task analysis (goal setting and strategic planning) and self-motivation beliefs. He underscores that the value of SRL skills inherently diminishes without a learner’s motivation to engage, as factors like perceived self-efficacy, outcome expectations, and intrinsic or extrinsic value driving behaviors are deeply intertwined with goal setting and learning initiation [ 40 ]. Similarly, our review revealed a distinct lack of papers discussing self-satisfaction or residents’ emotional reactions to their performance, which contribute to a critical feedback loop influencing future behavior and goal adjustment within the self-reflection phase. The limited attention to these emotional and motivational dimensions in our review signals a need for future research to explore these potentially under-examined areas for a more holistic understanding of SRL within surgical residents. While identifying effective SRL strategies is a critical first step, our review highlights that implementing them meaningfully presents significant challenges for surgical residents. As evidenced by multiple studies, barriers such as pervasive time constraints hinder residents from consistently incorporating strategies into their daily workflow. Crucially, gaps remain in understanding how much time these strategies cost residents, precisely when residents engage in such activities, and how residents manage to find time for them amidst their demanding schedules. These observed difficulties in translating knowledge into deliberate action, coupled with concerns raised in the literature regarding residents' awareness and optimization of SRL behaviors, pose important questions about the true extent of residents’ engagement in these habits. Recognizing that the development of sophisticated metacognitive processes, like real-time self-evaluation, requires time and experience, it becomes evident that supporting residents to overcome these barriers is paramount. These challenges to implementation underscore the need to formally incorporate SRL into surgical education curricula. To begin, further research is essential to bridge the knowledge gaps identified in our review. This includes exploring surgical residents’ self-motivational beliefs, emotional regulation, and practicalities of time management. Beyond this, introducing the SRL framework to both residents and faculty in diverse instructional settings (e.g., grand rounds, simulation, faculty development meetings) can foster a mutual understanding of its principles to guide teaching and learning. This awareness may benefit residents by encouraging intentional practice, while clarifying faculty’s pivotal role in scaffolding these habits [ 41 ]. Educators can also create structured opportunities for SRL across all phases of learning. For example, providing program-approved resource databases for case preparation, establishing routine preoperative goal-setting discussions, and facilitating robust postoperative and post-simulation debriefs with guiding questions may promote efficient integration of SRL into trainees’ daily workflow. Furthermore, other SRL domains, particularly mental rehearsal, may benefit from didactics, providing the impetus for residents to learn how to meaningfully engage with and effectively hone these skills over time [ 42 , 43 ]. This scoping review has several limitations. First, while efforts were made to conduct a comprehensive search, some relevant articles may have been missed due to variability in how SRL-related concepts are described in literature and exclusion of studies that included other participant groups (e.g., medical students, non-surgical residents) alongside surgical residents but did not stratify results by learner level or specialty. Second, many of the included studies were qualitative or descriptive in nature, with limited data on the outcomes or effectiveness of the SRL strategies reported. Third, while some strategies may be generalizable, others may not apply across all training environments, and there may be variations in learning styles and resources suited for that particular surgical specialty. Lastly, as many behaviors were self-reported, there remains uncertainty regarding the depth, consistency, or intentionality of their use, which limits the ability to assess how well SRL is operationalized in practice. CONCLUSION This scoping review highlights the diverse ways in which surgical residents engage in SRL across the forethought, performance, and self-reflection phases, supported by external scaffolding. In collating specific SRL strategies into a single resource, it also aims to provide guidance for both residents and mentors working on integrating SRL into daily practice. Despite growing recognition of SRL as a vital competency for surgical training, gaps remain in ensuring these behaviors are applied intentionally, effectively, and consistently. Future work should focus on developing targeted, longitudinal interventions to explicitly teach and reinforce SRL strategies within the surgical curriculum. Empowering residents with the tools and structure to regulate their learning has the potential to not only enhance skill acquisition but also foster reflective and adaptive surgeons equipped for and committed to lifelong learning. Declarations Conflict of Interest: On behalf of all authors, the corresponding author states that there is no conflict of interest. Data Availability Statement: The data extracted and analyzed during this review include information from published studies, a subset of which is presented in the manuscript and its appendix. Additional extracted data (e.g., reflexivity statements, methodological framework, primary conclusions, etc.) are not included in the manuscript to prioritize relevance and clarity but may be obtained from the corresponding author upon reasonable request. 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The road to mastery: an analysis of goal orientation in the transition from medical school to surgical residency. J Surg Educ . 2023;80(11):1574‑1581. https://doi.org/10.1016/j.jsurg.2023.08.017 Van den Broeck L, De Laet T, Dujardin R, Tuyaerts S, Langie G. Unveiling the competencies at the core of lifelong learning: a systematic literature review. Educ Res Rev . 2024;45:100646. https://doi.org/10.1016/j.edurev.2024.100646 Accreditation Council for Graduate Medical Education. ACGME program requirements for graduate medical education in general surgery. Chicago, IL: ACGME; 2019. Zimmerman BJ. Attaining self‑regulation: a social cognitive perspective. In: Boekaerts M, Pintrich PR, Zeidner M, eds. Handbook of Self‑Regulation . San Diego, CA: Academic Press; 2000:13‑39. Papanagnou D, Corliss S, Richards JB, Artino ARJ, Schwartzstein R. Progression of self‑directed learning in health professions education: clarifying terms and processes. Acad Med . 2024;99(2):236‑? https://doi.org/10.1097/ACM.0000000000005191 Wallace L, Raison N, Ghumman F, Moran A, Dasgupta P, Ahmed K. Cognitive training: How can it be adapted for surgical education? The Surgeon . 2017;15(4):231‑239. https://doi.org/10.1016/j.surge.2016.08.003 Souiki T, Benzagmout M, Alami B, et al. Impact of mental imagery on enhancing surgical skills learning in novice’s surgeons: a pilot study. BMC Med Educ . 2021;21(1):545. https://doi.org/10.1186/s12909-021-02987-z Supplementary Files Appendix1.docx Appendix2.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 20 Jul, 2025 Reviewers invited by journal 07 Jul, 2025 Editor invited by journal 04 Jul, 2025 Editor assigned by journal 01 Jul, 2025 First submitted to journal 25 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6960218","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":481800954,"identity":"cdc7bbad-b004-400d-a507-30f6ac74859d","order_by":0,"name":"Ye Lim Lee","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3ElEQVRIiWNgGAWjYJACZgYGCwYG+cMHgGw5IE4gSosEELGBlBqTpIXHgDgt8u1nH34uYJCQ45fu+Sbx448BAz97jgFeLQZn0o2lZzBIGEvOObtNsrfNgEGy5w0BLQxpDNI8DBKJGw7kbpNmbPjDYHCDgC3y/c+YfwO11O8/kPNMmgHoMHtCWhhupLGBbEkwkMhhk2ZgM2AAMgg47MYzNmseAwnDGWeOGVsC/cIjceZZAQGHpTHf5qmwkedvb354AxhicvztyRvwOwxiF4LJQ4TyUTAKRsEoGAWEAABeHztuMuuIXAAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0009-0000-9218-019X","institution":"University of California San Francisco School of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Ye","middleName":"Lim","lastName":"Lee","suffix":""},{"id":481800955,"identity":"70b55d49-9c15-4df0-b1c8-41a551272f3c","order_by":1,"name":"Mandeep Kaur","email":"","orcid":"","institution":"University of California San Francisco School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Mandeep","middleName":"","lastName":"Kaur","suffix":""},{"id":481800956,"identity":"9b22eb2a-05c5-4880-9357-f6e0d03592dc","order_by":2,"name":"Brandon Cowan","email":"","orcid":"","institution":"University of California San Francisco Department of Surgery","correspondingAuthor":false,"prefix":"","firstName":"Brandon","middleName":"","lastName":"Cowan","suffix":""},{"id":481800957,"identity":"02d4d0df-81a9-4d8a-94f4-013bd8a82219","order_by":3,"name":"Aileen Gozali","email":"","orcid":"","institution":"University of California San Francisco Department of Surgery","correspondingAuthor":false,"prefix":"","firstName":"Aileen","middleName":"","lastName":"Gozali","suffix":""},{"id":481800958,"identity":"81c6cf8d-e2bb-4cd9-8cea-b901fc1cce92","order_by":4,"name":"Jacquelyn Knox","email":"","orcid":"","institution":"University of California San Francisco Department of Surgery","correspondingAuthor":false,"prefix":"","firstName":"Jacquelyn","middleName":"","lastName":"Knox","suffix":""},{"id":481800959,"identity":"7aa0b267-f158-47fe-8f20-4188f6baba34","order_by":5,"name":"Hueylan Chern","email":"","orcid":"","institution":"University of California San Francisco Department of Surgery","correspondingAuthor":false,"prefix":"","firstName":"Hueylan","middleName":"","lastName":"Chern","suffix":""},{"id":481800960,"identity":"2f586cb3-a543-4679-8581-37acb500134c","order_by":6,"name":"Shareef Syed","email":"","orcid":"","institution":"University of California San Francisco Department of Surgery","correspondingAuthor":false,"prefix":"","firstName":"Shareef","middleName":"","lastName":"Syed","suffix":""},{"id":481800961,"identity":"cb648a51-48d9-4a7f-892c-4bda7198c109","order_by":7,"name":"Patricia O’Sullivan","email":"","orcid":"","institution":"University of California San Francisco Department of Surgery","correspondingAuthor":false,"prefix":"","firstName":"Patricia","middleName":"","lastName":"O’Sullivan","suffix":""}],"badges":[],"createdAt":"2025-06-24 00:22:31","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6960218/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6960218/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":86420763,"identity":"c2f4b398-9928-4bd6-b6f4-1e62f4694a85","added_by":"auto","created_at":"2025-07-10 12:47:43","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":184017,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA flow diagram illustrating the study selection process for the scoping review Of the 23 included studies, the majority were conducted in North America (n=19, 83%) and published as original research (n=20, 87%), with 11 (48%) using a qualitative design. General surgery was the most frequently represented specialty (n=16, 80%), and there were more junior-level residents (n=251) than senior-level residents (n=166) among studies that specified the number and training level of participants. Table 1 provides a summary of the included studies by location, publication type, research design, and surgical specialty, summarizing the percentage and number of studies in each category.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6960218/v1/e3f40cddf57aa49d5a1ea17a.png"},{"id":86422104,"identity":"47910ce6-03fd-4482-a3f2-ad3bd82f9e5f","added_by":"auto","created_at":"2025-07-10 12:55:49","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":813223,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6960218/v1/c0064b8a-d71f-4b61-8d27-6f5620962df6.pdf"},{"id":86420770,"identity":"bdf43c86-4b4b-4582-baa2-2d092004f40e","added_by":"auto","created_at":"2025-07-10 12:47:45","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":14334,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix1.docx","url":"https://assets-eu.researchsquare.com/files/rs-6960218/v1/21489c9469ca5eab5717b082.docx"},{"id":86420772,"identity":"4890deef-0bb5-4a39-9778-109f2f418163","added_by":"auto","created_at":"2025-07-10 12:47:45","extension":"docx","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":25403,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix2.docx","url":"https://assets-eu.researchsquare.com/files/rs-6960218/v1/5cea72e650f6dc44a265f86d.docx"}],"financialInterests":"","formattedTitle":"Unveiling Self-Regulated Learning Practices in Surgical Residents: A Scoping Review","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eSelf-regulated learning (SRL) is a proactive, learner-driven process in which individuals take ownership of their education by managing their cognition, behavior, and emotions [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Several theoretical models describe SRL, and among them, the framework created by Zimmerman is one of the most widely used [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Zimmerman proposes a cyclical model that divides SRL into three iterative phases: the \u003cem\u003eforethought\u003c/em\u003e phase, where learners set goals and assess their motivations and capabilities; the \u003cem\u003eperformance\u003c/em\u003e phase, where they implement learning strategies and monitor progress; and the \u003cem\u003eself-reflection\u003c/em\u003e phase, where they evaluate their performance and adapt future learning accordingly [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In medical education, SRL is strongly associated with achieving success in both academic and clinical settings. Learners who engage in SRL tend to perform better on exams, excel in clinical assessments, and experience better mental health [\u003cspan additionalcitationids=\"CR6 CR7 CR8 CR9\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. These outcomes underscore the importance of understanding how SRL develops and manifests, particularly for graduate medical learners such as residents, who must master complex knowledge while applying it in high-stakes, real-world situations.\u003c/p\u003e\u003cp\u003eSurgical residents stand to benefit significantly from SRL. Much of their learning occurs outside of protected educational time and instead takes place through experiential workplace learning or independent study. Given the variability in clinical exposure and surgical case volume, SRL can help residents develop intentional learning behaviors\u0026mdash;such as preparing for procedures, setting case-specific goals, monitoring progress in the operating room (OR), and reflecting on their performance afterwards\u0026mdash;to proactively identify and address gaps in training [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Surgical residency demands comprehensive mastery of both technical and non-technical skills, all within a high-pressure, time-constrained environment, creating an appropriate context for self-regulation [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn 2019, Johnson et al. proposed a conceptual model outlining how surgical trainees should appraise, regulate, and refine their learning strategies in every clinical environment [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Through Delphi consensus, their framework emphasized the importance of planning, goal tracking, and adaptive behaviors\u0026mdash;core components that mirror Zimmerman\u0026rsquo;s model of SRL. While this framework offers valuable structure, there remains a need for a comprehensive, updated synthesis of specific SRL strategies used by surgical residents across diverse learning settings. This scoping review aims to fill that gap by mapping the literature of SRL strategies utilized by surgical residents, using Zimmerman\u0026rsquo;s model as an organizing framework. Our goal is to create a unified resource that identifies actionable strategies that may support trainees' development into safe, autonomous surgeons through the application of SRL.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eWe followed the five stages of the Arksey and O\u0026rsquo;Malley framework to guide our scoping review [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStage 1: Identifying the research question\u003c/h2\u003e\u003cp\u003eOur research question was: \u0026ldquo;What SRL strategies do surgical residents use?\u0026rdquo;\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eStage 2: Identifying relevant studies\u003c/h3\u003e\n\u003cp\u003eIn collaboration with a librarian, we developed search strategies for five electronic databases: PubMed, Embase, Web of Science, Cochrane, and CINAHL. The search included all articles published up to July 16, 2024. The full search strategy developed for PubMed, which was subsequently adapted for use in the other databases, is provided in Appendix 1.\u003c/p\u003e\n\u003ch3\u003eStage 3: Study selection\u003c/h3\u003e\n\u003cp\u003eArticles were included if they were: available in English, targeted postgraduate learners in surgical specialties, and focused on self-reported strategies or tested interventions that promoted SRL. Papers were excluded if they: (1) lacked a focus on SRL strategies, (2) included multiple types of learners without distinguishing results specific to surgical residents; (3) described strategies that could not be self-initiated, or (4) lacked empirical data and rather drew SRL-related conclusions outside the context of specific strategies or interventions. We included program- or faculty-led interventions if the skills taught could be transferable to residents\u0026rsquo; independent practice beyond structured didactics (e.g. goal setting, reflection).\u003c/p\u003e\u003cp\u003eTwo reviewers (YL and MK) independently screened all titles and abstracts. Prior to screening, a calibration exercise was conducted by reviewing a uniform set of 50 abstracts to establish consistency in applying inclusion and exclusion criteria. The reviewers met regularly throughout the screening process to resolve conflicts. When consensus could not be reached, a third team member (BC), a surgical resident, provided adjudication based on relevance to SRL in surgical training. For full-text review, six team members (YL, MK, BC, PO\u0026rsquo;S, AG, JK) were paired to determine inclusion of screened articles. A calibration exercise using two full-text articles established consistency across all reviewers. Each pair reviewed a subset of full-text articles and met to reach consensus for study inclusion or exclusion. Unresolved conflicts were brought to the full team for discussion.\u003c/p\u003e\n\u003ch3\u003eStage 4: Charting the data\u003c/h3\u003e\n\u003cp\u003eWe developed and iteratively refined the extraction form on Qualtrics\u0026reg;. The extracted data included: article title; primary author; publication type; statement of purpose; study design; methodological framework; data collection method; number, location, level of training, and specialty of participants (if specified); SRL strategy or intervention; Zimmerman\u0026rsquo;s model categorization; primary conclusion; and additional references to search.\u003c/p\u003e\n\u003ch3\u003eStage 5: Collating, summarizing and reporting the results\u003c/h3\u003e\n\u003cp\u003eWe categorized each study and its strategy by one or more of the three phases outlined in Zimmerman\u0026rsquo;s model of SRL: forethought, performance, and self-reflection.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA total of 4,493 articles were screened after duplicate removal. Based on titles and abstracts, 4,423 were excluded. The full texts of 70 articles were reviewed, and 23 met the inclusion criteria for this scoping review (Fig. 1).\u003c/p\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eSummary of Characteristics of Included Studies Related to Self-Regulated Learning in Surgical Residents\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eLocation\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNumber of Studies\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNorth America\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19 (83%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eEurope\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (13%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAustralia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePublication Type\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of Studies\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOriginal research report\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20 (87%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eReview\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (13%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eResearch Design\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of Studies\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eQualitative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11 (48%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCausal / Experimental\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (17%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDescriptive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (13%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMixed Methods\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eProgram Evaluation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSpecialty\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of Studies\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGeneral Surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16 (80%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOrthopedic Surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (15%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOtolaryngology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (15%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eObstetrics Gynecology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUrology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCardiothoracic Surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePlastic Surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNeurosurgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOphthalmology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOral Maxillofacial Surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eForethought Phase\u003c/p\u003e\n\u003cp\u003eAmong the included studies, 16 articles addressed the forethought phase with heavy emphasis on preoperative preparation and goal setting [\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e]. Strategic planning\u0026mdash;identifying what to study, when, and how\u0026mdash;were explored in seven studies [\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e]. Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e summarizes the common topics residents reviewed preoperatively and the corresponding resources they used to prepare. While there is a plethora of resources, one study surveyed 108 otolaryngology residents nationwide in the U.S. and found that textbooks, surgical education websites, and atlases were the three most used items among all respondents, and journal articles and personal notes were more often utilized by residents who rated the effectiveness of their preparation highly [\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e]. Residents also considered multiple factors such as case complexity, familiarity, expected level of autonomy, and attending surgeon when deciding how much time to devote to preparation [\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e]. One study described that some residents addressed time constraints by creating a personalized surgical guide that consolidated frequently referenced information [\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e]. Several studies noted that residents associated preoperative preparation with greater engagement in the OR and, at times, increased intraoperative autonomy [\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e]. Strategic planning also took place in simulations, where residents found it helpful to break down their tasks into manageable steps easier to train for and master [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\n\u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003ePreoperative Preparation Topics and Resources Identified in Included Studies\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTopics\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eResources Used\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eStudies\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTechnical Skills\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSimulations\u003c/p\u003e\n \u003cp\u003eReview prior notes on errors made\u003c/p\u003e\n \u003cp\u003eReview recordings\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15, 18, 19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eProcedural Steps, Anatomy, Complications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTextbooks\u003c/p\u003e\n \u003cp\u003eSurgical atlas\u003c/p\u003e\n \u003cp\u003eWebsites (UpToDate, Medscape, E-medicine, Google)\u003c/p\u003e\n \u003cp\u003eVideos (The Society of American Gastrointestinal and Endoscopic Surgeons, YouTube)\u003c/p\u003e\n \u003cp\u003eJournal articles\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15, 16, 18, 19, 20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePatient-Specific Factors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePatient chart, including labs and imaging\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15, 16, 17, 19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSurgeon Preferences\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAsk the attending surgeon\u003c/p\u003e\n \u003cp\u003eReview old operative notes\u003c/p\u003e\n \u003cp\u003eAsk peers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15, 17, 20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eFour studies highlighted a preparation strategy that extends beyond physical resources\u0026mdash;mental rehearsal [\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e]. This technique involves visualizing procedural steps without physically performing them. Skervin and Scott found that most of their survey respondents (91.9% of surgical trainees) engaged in mental rehearsal independently to prepare for complex cases [\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e]. Through this strategy, residents identified potentially challenging steps and addressed these gaps using supplemental resources such as videos [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eGoal setting was another commonly reported forethought strategy across eight articles [\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e]. While many emphasized the importance of establishing goals preoperatively, Ranney et al. also underscored the value of explicitly sharing these goals with attending surgeons [\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e]. Three studies tested interventions that structured this dual process. Fieber et al. introduced resident-initiated, inquiry-based preoperative briefing (R-PROB), in which residents sent two to four learning goals to their attendings at least 24 hours before the procedure and discussed them face-to-face [\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e]. Lillemoe et al. implemented educational timeouts (ETOs), during which residents and attendings met preoperatively to review: 1) learning goals tied to a specific operative step, 2) the resident\u0026rsquo;s current autonomy level in that step, and 3) strategies to advance toward the resident\u0026rsquo;s goals [\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e]. Goal setting was not limited to the OR. One study described how surgical residents identified their strengths and weaknesses to develop a six-month individualized learning plan using the SMART (specific, measurable, achievable, relevant, and time-bound goal) framework [\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e]. These goal setting practices highlight the proactive engagement residents employ to shape their learning trajectories within surgical training.\u003c/p\u003e\n\u003ch3\u003ePerformance Phase\u003c/h3\u003e\n\u003cp\u003eTen articles described strategies used by residents during a learning activity, most commonly while operating [\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e]. The strategies largely fell into two categories: verbalization and help-seeking behaviors.\u003c/p\u003e\n\u003cp\u003eFive studies named verbalization as a common strategy used in the OR [\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e]. Residents verbalized their thought processes and observations as they progressed through the procedure\u0026mdash;for example, identifying anatomic structures as they appeared, proposing plans, and requesting instruments for the next step [\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e]. Communicating uncertainties was also critical. When facing a challenging step, residents often articulated what they were attempting, what they perceived to be going wrong, and how they planned to address it [\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e]. Nieboer et al. conducted a conversation analysis of verbal exchanges between trainees and supervisors during a total hip replacement and identified four ways residents sought guidance from supervisors: residents (1) explicitly asked for input, (2) evaluated the task before soliciting an opinion (\u0026ldquo;This is what I think. What do you think?\u0026rdquo;), (3) requested confirmation of their assessment (\u0026ldquo;This is what I think. Do you agree?\u0026rdquo;), and (4) offered an evaluation of the ongoing activity without seeking feedback [\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eWhile attending surgeons were the primary source of support during operations, Woelfel and Kunze recognized that residents also seek help from other personnel [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e]. For instance, residents consulted seasoned scrub technicians, gaining insight into the preferences and workflow of attending surgeons on a new rotation [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e]. Senior residents also served as near-peer mentors, helping junior residents navigate patient care and systems-based practices such as the electronic medical record, OR logistics, and procedural techniques. In shared cases, seniors could identify operative learning opportunities for their juniors [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003eSelf-Reflection Phase\u003c/h2\u003e\n \u003cp\u003eTen articles described topics and practices used by residents to reflect on a learning activity [\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e]. Common themes of reflection included clinical decision making in evaluation and management of the patient, technical skills, complications and mistakes, and interpersonal dynamics within the surgical team [\u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e]. Reflection methods varied. For example, Morrill et al. reported that many residents engaged in daily reflection, most often mentally and shortly after cases [\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e]. A summary of additional reflection methods is presented in Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\n \u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eMethods of Reflection Identified in Included Studies\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eReflection Method\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eDescription\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMental\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRe-living experience with step-by-step mental review, internal narration [\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWritten\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNote-taking, reading literature, re-reading patient charts, journaling, artistic endeavors [\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e]\u003c/p\u003e\n \u003cp\u003eMonthly written reflections with guiding questions [\u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVerbal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePostoperative discussion with attending about struggles, dictating operative notes [\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/p\u003e\n \u003cp\u003eConversations with peers/family [\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eChart stalking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFollowing patient chart over time to observe changes in management plans, orders, and outcomes [\u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003eMultiple studies emphasized identifying personal strengths and weaknesses as a core objective of reflection [\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e]. For instance, DeVries et al. noted that complications often served as memorable primers for reflection, prompting adaptive behaviors in future scenarios [\u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e]. Other times, residents felt driven to evaluate their own performance out of the spirit of competing against themselves, especially in settings such as simulations where they could gamify their learning tasks [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e]. Reflective questions\u0026mdash;such as how a learning point aligns with existing knowledge, its broader applicability, contributing factors, or how the situation could have been better managed\u0026mdash;can help structure this process [\u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e]. Reflections can guide goal formation, as demonstrated by O\u0026rsquo;Connor et al., whose intervention began with residents\u0026rsquo; self-assessments of strengths and weaknesses that led to the creation and monitoring of individualized learning plans [\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003eExternal Scaffolding of SRL\u003c/h2\u003e\n \u003cp\u003eWhile the learner is the primary agent of SRL, many strategies identified in the literature involved external influences, including attending surgeons and peers. For example, both resident-initiated, inquiry-based preoperative briefing and educational timeouts in the forethought phase required attending participation [\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e], and senior residents were frequently cited as resources for preoperative preparation and clinical learning [\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e\n \u003cp\u003eThree studies discussed how all three phases of SRL\u0026mdash;forethought, performance, and self-reflection\u0026mdash;could be socially mediated through interactions with mentors and peers [\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e]. Carlson and Tannyhill explained that residents regularly extend their SRL efforts by involving faculty, peers, patients, and other healthcare professionals in co-regulated learning environments [\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e]. Similarly, Aho et al. implemented a curricular model in which residents met with a faculty mentor at the beginning, middle, and end of a six-week simulation lab rotation to set goals, receive technical advice and feedback, and review learning curves. All participants (n\u0026thinsp;=\u0026thinsp;6) demonstrated improvement in laparoscopic tasks and reported increased practice when supported by faculty mentors in contrast to doing it alone [\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e]. The impact of learning with peers was exhibited in the study conducted by Sonnadara et al., which found that residents in student-led groups outperformed their instructor-led counterparts after practicing technical skills with their peers by collaboratively exploring concepts and knowledge, identifying learning strategies, and exchanging feedback with minimal involvement from instructors [\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n \u003ch2\u003eBarriers and Challenges to SRL Implementation\u003c/h2\u003e\n \u003cp\u003eThe included studies identified several challenges to implementing SRL strategies. Authors in multiple studies commonly cited time constraints as a barrier to preoperative preparation, goal discussion, and postoperative case reflection [\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e]. Furthermore, studies noted a lack of structural support for residents to adopt these behaviors; some residents reportedly developed preoperative preparation systems through trial and error and struggled to locate adequate resources [\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e]. Jabbour et al. illustrated this challenge when they reported residents\u0026rsquo; average self-rated preparation effectiveness at 3.53 and efficiency at 3.19 on a 5-point Likert scale [\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e]. Additionally, the literature revealed instances where residents demonstrated limited understanding of certain SRL strategies, such as being unaware of mental rehearsal\u0026rsquo;s potential for skill acquisition beyond case preparation [\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e]. Another study, by Nieboer et al., questioned whether residents\u0026rsquo; intraoperative verbal cues for input were deliberate, pre-planned learning strategies, suggesting instead that these behaviors might represent spontaneous requests or \u0026ldquo;reflection in action\u0026rdquo; [\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e\n\u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003e Our scoping review illuminates the landscape of SRL strategies adopted by surgical trainees, demonstrating a clear emphasis in the literature on the forethought phase. Residents engage in diverse preoperative preparations, including mental rehearsal and goal setting, which are perceived to enhance confidence, reduce stress, and improve preparedness for cases. This review also identified crucial strategies within the performance phase, such as verbalizing intraoperative thoughts, as well as varying methods of self-reflection. Furthermore, our findings highlight that help-seeking is a pervasive and continuous strategy across all SRL phases, involving a wide array of colleagues and supervisors. This review therefore provides a foundational understanding of how surgical residents actively regulate their learning, predominantly through anticipatory actions but also through ongoing self-monitoring and reflection.\u003c/p\u003e\u003cp\u003eSRL is a highly valued construct in education and an essential component of modern medical training. A recent systematic review aimed at identifying core competencies for lifelong learning across educational disciplines found that self-regulation and self-direction were the most frequently represented attributes, appearing in 65% of included studies [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. This emphasis on self-regulation is echoed in the ACGME\u0026rsquo;s Surgery Milestones, where the practice-based learning and improvement (PBLI) competency explicitly requires residents to identify learning needs, seek performance data, apply feedback, and update learning plans [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. While the Delphi study by Johnson et al. established \u003cem\u003ewhat\u003c/em\u003e factors constitute SRL in surgical education, our review complements their framework by illustrating concrete examples of \u003cem\u003ehow\u003c/em\u003e surgical residents operationalize these behaviors in practice and by providing insight into the lived application of SRL across its phases [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWhile our review extensively captured the cognitive and behavioral facets of self-regulation, a notable absence emerged concerning its motivational and emotional components. Within the forethought phase, Zimmerman distinguishes between task analysis (goal setting and strategic planning) and self-motivation beliefs. He underscores that the value of SRL skills inherently diminishes without a learner\u0026rsquo;s motivation to engage, as factors like perceived self-efficacy, outcome expectations, and intrinsic or extrinsic value driving behaviors are deeply intertwined with goal setting and learning initiation [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Similarly, our review revealed a distinct lack of papers discussing self-satisfaction or residents\u0026rsquo; emotional reactions to their performance, which contribute to a critical feedback loop influencing future behavior and goal adjustment within the self-reflection phase. The limited attention to these emotional and motivational dimensions in our review signals a need for future research to explore these potentially under-examined areas for a more holistic understanding of SRL within surgical residents.\u003c/p\u003e\u003cp\u003e While identifying effective SRL strategies is a critical first step, our review highlights that implementing them meaningfully presents significant challenges for surgical residents. As evidenced by multiple studies, barriers such as pervasive time constraints hinder residents from consistently incorporating strategies into their daily workflow. Crucially, gaps remain in understanding how much time these strategies cost residents, precisely when residents engage in such activities, and how residents manage to find time for them amidst their demanding schedules. These observed difficulties in translating knowledge into deliberate action, coupled with concerns raised in the literature regarding residents' awareness and optimization of SRL behaviors, pose important questions about the true extent of residents\u0026rsquo; engagement in these habits. Recognizing that the development of sophisticated metacognitive processes, like real-time self-evaluation, requires time and experience, it becomes evident that supporting residents to overcome these barriers is paramount.\u003c/p\u003e\u003cp\u003eThese challenges to implementation underscore the need to formally incorporate SRL into surgical education curricula. To begin, further research is essential to bridge the knowledge gaps identified in our review. This includes exploring surgical residents\u0026rsquo; self-motivational beliefs, emotional regulation, and practicalities of time management. Beyond this, introducing the SRL framework to both residents and faculty in diverse instructional settings (e.g., grand rounds, simulation, faculty development meetings) can foster a mutual understanding of its principles to guide teaching and learning. This awareness may benefit residents by encouraging intentional practice, while clarifying faculty\u0026rsquo;s pivotal role in scaffolding these habits [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Educators can also create structured opportunities for SRL across all phases of learning. For example, providing program-approved resource databases for case preparation, establishing routine preoperative goal-setting discussions, and facilitating robust postoperative and post-simulation debriefs with guiding questions may promote efficient integration of SRL into trainees\u0026rsquo; daily workflow. Furthermore, other SRL domains, particularly mental rehearsal, may benefit from didactics, providing the impetus for residents to learn how to meaningfully engage with and effectively hone these skills over time [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e This scoping review has several limitations. First, while efforts were made to conduct a comprehensive search, some relevant articles may have been missed due to variability in how SRL-related concepts are described in literature and exclusion of studies that included other participant groups (e.g., medical students, non-surgical residents) alongside surgical residents but did not stratify results by learner level or specialty. Second, many of the included studies were qualitative or descriptive in nature, with limited data on the outcomes or effectiveness of the SRL strategies reported. Third, while some strategies may be generalizable, others may not apply across all training environments, and there may be variations in learning styles and resources suited for that particular surgical specialty. Lastly, as many behaviors were self-reported, there remains uncertainty regarding the depth, consistency, or intentionality of their use, which limits the ability to assess how well SRL is operationalized in practice.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003e This scoping review highlights the diverse ways in which surgical residents engage in SRL across the forethought, performance, and self-reflection phases, supported by external scaffolding. In collating specific SRL strategies into a single resource, it also aims to provide guidance for both residents and mentors working on integrating SRL into daily practice. Despite growing recognition of SRL as a vital competency for surgical training, gaps remain in ensuring these behaviors are applied intentionally, effectively, and consistently. Future work should focus on developing targeted, longitudinal interventions to explicitly teach and reinforce SRL strategies within the surgical curriculum. Empowering residents with the tools and structure to regulate their learning has the potential to not only enhance skill acquisition but also foster reflective and adaptive surgeons equipped for and committed to lifelong learning.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflict of Interest:\u0026nbsp;\u003c/strong\u003eOn behalf of all authors, the corresponding author states that there is no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement:\u0026nbsp;\u003c/strong\u003eThe data extracted and analyzed during this review include information from published studies, a subset of which is presented in the manuscript and its appendix. Additional extracted data (e.g., reflexivity statements, methodological framework, primary conclusions, etc.) are not included in the manuscript to prioritize relevance and clarity but may be obtained from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMammadov S, Schroeder K. A meta‑analytic review of the relationships between autonomy support and positive learning outcomes. \u003cem\u003eContemp Educ Psychol\u003c/em\u003e. 2023;75:1‑22. https://doi.org/10.1016/j.cedpsych.2023.102235\u003c/li\u003e\n\u003cli\u003evan Houten‑Schat MA, Berkhout JJ, van Dijk N, Endedijk MD, Jaarsma ADC, Diemers AD. Self‑regulated learning in the clinical context: a systematic review. \u003cem\u003eMed Educ\u003c/em\u003e. 2018;52(10):1008‑1015. https://doi.org/10.1111/medu.13615\u003c/li\u003e\n\u003cli\u003ePanadero E. 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Unveiling the competencies at the core of lifelong learning: a systematic literature review. \u003cem\u003eEduc Res Rev\u003c/em\u003e. 2024;45:100646. https://doi.org/10.1016/j.edurev.2024.100646\u003c/li\u003e\n\u003cli\u003eAccreditation Council for Graduate Medical Education. ACGME program requirements for graduate medical education in general surgery. Chicago, IL: ACGME; 2019.\u003c/li\u003e\n\u003cli\u003eZimmerman BJ. Attaining self‑regulation: a social cognitive perspective. In: Boekaerts M, Pintrich PR, Zeidner M, eds. \u003cem\u003eHandbook of Self‑Regulation\u003c/em\u003e. San Diego, CA: Academic Press; 2000:13‑39.\u003c/li\u003e\n\u003cli\u003ePapanagnou D, Corliss S, Richards JB, Artino ARJ, Schwartzstein R. Progression of self‑directed learning in health professions education: clarifying terms and processes. \u003cem\u003eAcad Med\u003c/em\u003e. 2024;99(2):236‑? https://doi.org/10.1097/ACM.0000000000005191\u003c/li\u003e\n\u003cli\u003eWallace L, Raison N, Ghumman F, Moran A, Dasgupta P, Ahmed K. Cognitive training: How can it be adapted for surgical education? \u003cem\u003eThe Surgeon\u003c/em\u003e. 2017;15(4):231‑239. https://doi.org/10.1016/j.surge.2016.08.003\u003c/li\u003e\n\u003cli\u003eSouiki T, Benzagmout M, Alami B, et al. Impact of mental imagery on enhancing surgical skills learning in novice\u0026rsquo;s surgeons: a pilot study. \u003cem\u003eBMC Med Educ\u003c/em\u003e. 2021;21(1):545. https://doi.org/10.1186/s12909-021-02987-z\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"global-surgical-education-journal-of-the-association-for-surgical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"GSED","sideBox":"Learn more about [Global Surgical Education - Journal of the Association for Surgical Education](https://link.springer.com/journal/44186)","snPcode":"44186","submissionUrl":"https://www.editorialmanager.com/gsed/default1.aspx","title":"Global Surgical Education - Journal of the Association for Surgical Education","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6960218/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6960218/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e\u003cp\u003eSelf-regulated learning (SRL) is a proactive approach that can help surgical residents maximize learning among their many competing demands. While the literature reports frameworks for SRL in surgical education, a comprehensive list of strategies is needed for practical use. We conducted a scoping review to map SRL strategies used by surgical residents into a single collated resource.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eWe searched five electronic databases (PubMed, Embase, Web of Science, Cochrane, CINAHL) on July 16, 2024. Two team members independently reviewed abstracts, and six team members reviewed full texts in pairs with an initial calibration process and iterative conflict resolution. We characterized resident behavior by the three phases of Zimmerman\u0026rsquo;s model of SRL\u0026ndash;forethought, performance, and self-reflection.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eTwenty-three articles were included from 4493 screened abstracts. For forethought: (1) Preoperatively identify and communicate learning goals to faculty via email or educational timeouts; (2) Review procedural steps and relevant anatomy in preparation for cases. For performance: (3) Verbalize observations, next steps, and challenges intraoperatively; (4) Seek help, including the expertise of supervisors, other healthcare professionals, and near peers. For self-reflection: (5) Make written, oral, or mental reflections of one\u0026rsquo;s performance and experiences to identify key learning points, areas of improvement, and reactions to clinical events.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003e Our scoping review identified specific strategies that surgical residents use to maximize SRL inside and outside of the operating room. The outlined SRL behaviors can help residents engage in practice-based learning and improvement by evaluating their current practices and considering new positive habits.\u003c/p\u003e","manuscriptTitle":"Unveiling Self-Regulated Learning Practices in Surgical Residents: A Scoping Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-10 12:47:37","doi":"10.21203/rs.3.rs-6960218/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"","date":"2025-07-21T03:50:05+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-07T13:24:32+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"Global Surgical Education - Journal of the Association for Surgical Education","date":"2025-07-04T23:25:47+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-01T05:51:35+00:00","index":"","fulltext":""},{"type":"submitted","content":"Global Surgical Education - Journal of the Association for Surgical Education","date":"2025-06-25T18:12:10+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"global-surgical-education-journal-of-the-association-for-surgical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"GSED","sideBox":"Learn more about [Global Surgical Education - Journal of the Association for Surgical Education](https://link.springer.com/journal/44186)","snPcode":"44186","submissionUrl":"https://www.editorialmanager.com/gsed/default1.aspx","title":"Global Surgical Education - Journal of the Association for Surgical Education","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"ce50bba6-ccf1-4628-aab8-fecb7705268d","owner":[],"postedDate":"July 10th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-11-19T13:39:34+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-10 12:47:37","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6960218","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6960218","identity":"rs-6960218","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}