Moving Us Closer To Osler
A Miller Coulson Academy of Clinical Excellence Initiative

Personalized Clinical Quality Improvement


Use evidence-informed practices in your self-directed learning—build a case tracking system, work simulated cases, use quizzing, and seek new evidence efficiently. 

I graduated internal medicine residency and passed my boards. I settled into my new role as chief resident and started my career in hospital medicine. I embraced the generalist mentality: I could care for and learn about patients with any condition. I felt ready to practice independently, but why did I have an unsettling feeling that I was not prepared to learn independently? Medical training provided a structure for learning and a steady sequence of validation that I was progressing satisfactorily. After residency, I feared my learning would slow down—or worse, that my clinical skills and knowledge would deteriorate. 


I collected advice from clinical mentors and realized that there was no “how to” guide for learning effectively in the context of a fast-paced job and my personal life emerging from hibernation. I turned to insights from other disciplines, like the learning sciences, that helped me slowly shape a practical and evidence-informed self-directed learning plan. This plan relies on four key strategies: 


1. Track cases. 

Track cases systematically by recording a specific clinical question, like, “Is this weight loss from cancer or infection?” and an initial impression. Set an appropriate date for follow up and record the outcome and a learning point. 


2. Work simulated cases. 

Simulated cases can be found in medical journals, apps, and podcasts. Engage with these in a systematic way that best approximates the challenges faced by the case authors. For example, pause and commit to a differential diagnosis and management plan before reviewing the case outcome or the authors’ clinical reasoning.  


3. Use quizzing. 

This is a simple and robust learning method that capitalizes on several learning sciences concepts. Try tests available on journals, apps, and question banks, or make quizzes based on self-identified knowledge gaps. For the latter, consider using a digital notecard program. 


4. Seek new evidence efficiently. 

After an initial attempt to keep up with a multitude of journals after graduating residency, I felt overwhelmed, inefficient, and guilty. This angst was foreseeable, as I later encountered evidence that generalist clinicians can’t efficiently update their mental models and make practice changes via an exclusive reading of primary literature. Although there’s no established best practice, I encourage self-directed learners to lean most heavily on secondary literature—such as using Twitter, medical podcasts, and journal summary resources—to maintain awareness of impactful developments. 


A confession 

I’m still struggling with my self-directed learning. It’s a challenge to be consistent, and I often feel inadequate. I try to be kind to myself through the ups and downs. I know that learning after my training is over is both critically important for my patients and one of the central joys of medicine. 








This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.