What Really Drives Surgeons in Training to Keep Learning

Surgical residents are famous for their endurance, but the psychology that keeps them studying after sixteen-hour days has remained surprisingly opaque. A new qualitative study published in Global Surgical Education, the journal of the Association for Surgical Education, offers one of the most detailed portraits yet of what motivates senior surgical residents to regulate their own learning—and why many of them quietly struggle to judge whether they are actually improving. Drawing on in-depth interviews with fourteen residents across six surgical specialties at a single academic medical center, researchers from the University of California, San Francisco found that the fuel for self-regulated learning comes from two distinct sources: the slow construction of a professional identity and deeply held personal values. Yet the same interviews revealed a striking vulnerability. When residents tried to evaluate their own progress, they found themselves working in isolation, without meaningful peer comparison and with faculty feedback that was often too case-specific or inconsistent to chart a long-term trajectory.

The study is grounded in a well-established framework from educational psychology. Self-regulated learning, as formalized by Barry Zimmerman, is a cyclical process with three phases: forethought, in which learners set goals and prepare; performance, in which they execute tasks and monitor themselves in real time; and self-reflection, in which they appraise outcomes and adjust future strategies. Motivation sits at the center of this cycle, driving the initiation and persistence of self-regulatory behavior, while self-evaluation feeds the loop by shaping how learners interpret success and failure. In medicine, these capacities are not optional extras. The Accreditation Council for Graduate Medical Education explicitly requires trainees to practice reflection and commit to personal growth, seeking out feedback, identifying gaps in their knowledge, and building individualized improvement plans. In surgery, the stakes are amplified because residents must regulate learning across the operating room, the clinic, and the inpatient ward simultaneously, mastering medical knowledge alongside technical skills and the nontechnical arts of communication and teamwork.

While prior research—including a Delphi consensus framework and the authors’ own scoping review—has catalogued the behaviors through which surgical residents regulate their learning, far less attention has been paid to why they invest the effort at all, and almost none to how they appraise their growth over time. A systematic review of self-regulated learning in clinical environments found no studies focused on activities or interventions that facilitated self-evaluation. To close that gap, the research team purposively sampled senior residents who had completed at least three years of clinical training, ensuring a consistent definition of seniority across programs with different lengths. The fourteen participants included eight general surgery residents, two in plastic surgery, and one each in neurosurgery, otolaryngology, obstetrics and gynecology, and vascular surgery. Ten were within one to two years of graduating; four were in dedicated research time after their third clinical year.

The interviews themselves were carefully engineered to elicit candor. All conversations were conducted virtually by a senior medical student with no role in teaching, supervising, or evaluating the participants, a deliberate design choice intended to reduce power differentials and social desirability bias. A semi-structured guide built on Zimmerman’s three phases probed how residents prepared for cases, learned during operations, and reflected afterward. The team then applied a directed qualitative content analysis, using SRL theory to establish initial coding categories before expanding the codebook inductively to capture recurring concepts the theory did not fully anticipate. Two researchers independently coded transcripts, calibrated their framework on shared material, and resolved discrepancies through iterative consensus, with a senior surgical resident providing clinical perspective and a professor of medical education anchoring the analysis in learning theory.

What emerged was a two-tiered motivational architecture. The first tier was professional identity formation, expressed through three distinct roles residents occupy simultaneously. As physicians, they described a felt responsibility to patients that pushed them to stay current with literature and with medical knowledge far beyond surgery itself. One participant described listening to internal medicine podcasts on the commute specifically to become, in their words, a more holistic physician rather than just a technician. As trainees, they were driven by the pursuit of intraoperative autonomy, closely studying attending surgeons’ preferences—even down to how they draped—and treating granted autonomy as both a signal of preparedness and a powerful form of self-confirmation. As future surgeons approaching graduation, they described a cognitive shift from acquiring technical skills to interrogating the reasoning behind operative decisions, asking the kinds of ‘why’ questions that attending surgeons rarely verbalize but that independent practice will demand.

The second tier was personal values. Some residents described an internal standard of competence so demanding that it bordered on perfectionism; one admitted going ‘overboard’ preparing for morbidity and mortality conferences simply to avoid ever being caught without an answer. Others maintained learning objectives even for cases they expected never to encounter again, citing pride and professional ego as reason enough. Intellectual curiosity surfaced as a parallel engine, often triggered by unusual anatomy, rare pathologies, or limited exposure to particular procedures. Rather than treating these as isolated clinical oddities, curious residents reframed them as learning opportunities, explicitly recognizing their own curiosity as the activation point for preparation and engagement. The authors note that these two tiers are not truly separable: personal values shape the kind of surgeon each resident aspires to become, meaning motivation arises at the intersection of who residents are as individuals and who they are becoming as professionals.

If the motivational findings were encouraging, the self-evaluation findings were sobering. Residents consistently reported that judging their own progress was inherently difficult because they rarely saw peers at the same training level in comparable clinical settings. Without that reference point, many could not tell whether they were on track or needed to change course. Faculty feedback, in principle the obvious corrective, proved a mixed blessing. Some residents treasured a well-timed observation from an attending as confirmation of change and growth. Others found that intraoperative feedback was so case-specific that it never aggregated into a sense of longitudinal development—one resident described forgetting to ‘zoom out’ on overall progress. Still others noted that attending thresholds varied widely, with each surgeon tolerating different levels of resident performance, making the same comment mean very different things depending on who delivered it. Compounding the problem, because residents rotate among many faculty, attendings often lacked the longitudinal memory needed to place a resident’s current performance in the context of their trajectory over years.

Residents responded to this evaluative vacuum with ingenuity, constructing personal benchmarks from the raw material of daily training. Some tracked operative times for similar procedures, reading shorter durations as evidence of growing efficiency. Others counted intraoperative coaching comments, interpreting a quieting of corrective remarks as a proxy for competence. Several monitored their own comfort levels with procedures, or noticed that their personal surgical guides had grown richer and more nuanced with each review—a tangible, almost archaeological record of accumulating knowledge. The depth of postoperative reflection became another yardstick. Operative autonomy itself served as perhaps the most coveted benchmark: being trusted to lead a junior resident or medical student through a case was read as direct evidence of growth. The authors interpret these strategies through self-determination theory, which holds that satisfying the needs for autonomy, competence, and relatedness internalizes motivation, and through the work of Eva and Regehr, who argue that self-assessment is not a stable generalizable ability but a context-dependent process that functions as a monitor, mentor, and motivator.

The implications for surgical education are concrete. Because individualized benchmarks may drift from performance as judged by others, the authors argue they need external calibration—from faculty development in behaviorally anchored feedback, from coaching relationships, and from assessment systems such as entrustable professional activities. With EPAs now implemented in general surgery, programs have an opportunity to make progression toward autonomy visible in aggregated longitudinal data, and emerging nested EPA frameworks may track smaller operative tasks across core activities. But scores alone will not suffice; residents need dashboards, portfolios, and structured mentor conversations that help them compare personal benchmarks against programmatic data and interpret trends over time. The study’s limitations—fourteen residents at one institution, purposive sampling of senior trainees, and reliance on self-reported interviews—temper generalizability, and the anticipation of independent practice may be uniquely salient near graduation. Still, the core message is clear and actionable: surgical residents already supply the motivation to learn from within, but programs must supply the mirrors that let them see how far they have come.

Subject of Research: Motivations and self-evaluation practices underlying self-regulated learning among senior surgical residents

Article Title: Motivations and self-evaluation behind surgical residents’ self-regulated learning: a qualitative study

Article References: Lee, Y. L., Gozali, A., Cowan, B., Syed, S., & O’Sullivan, P. (2026). Motivations and self-evaluation behind surgical residents’ self-regulated learning: a qualitative study. Global Surgical Education – Journal of the Association for Surgical Education, 5(1), Article 163. https://doi.org/10.1007/s44186-026-00566-8

Image Credits: AI Generated

DOI: 10.1007/s44186-026-00566-8

Keywords: self-regulated learning, surgical education, surgical residents, graduate medical education, self-evaluation, motivation, professional identity formation, faculty feedback, self-determination theory, entrustable professional activities, qualitative research, operative autonomy