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

The commentary responds directly to an investigation by Kabbash, Fieber, Shaw, Cochran, Sarosi, and Falcone, who asked a question that sounds almost too obvious to need answering: does more mean better? Their study, published in the same journal, evaluated faculty-to-resident feedback in general surgery by measuring not just how often attending surgeons provided workplace-based assessments, but what those assessments actually contained. The concern underlying the work is familiar to anyone who has sat on a clinical competency committee. Volume of assessment data is easy to count. Quality is not. A resident may accumulate dozens of brief encounter ratings over the course of a rotation, and still graduate with no coherent picture of whether independent performance has been demonstrated in the operating room, on the wards, or in the emergency department.

The American Board of Surgery has embraced EPAs for general surgery precisely to close that gap. Rather than treating every task as a separate competency checkbox, EPAs bundle the discrete skills, knowledge domains, and attitudes required for units of professional work that can be entrusted to a learner. The board’s framework identifies the core activities a general surgeon must be able to perform unsupervised by the end of training, from managing critically ill patients to performing defining operations of the specialty. When an assessor marks a resident as entrusted for one of these activities, the judgment is meant to carry real weight: it is a statement about readiness for unsupervised practice, the same readiness that certification ultimately vouches for.

That weight is exactly why Lipman insists on extensiveness as a first condition. A sparse set of EPA ratings, gathered on only a handful of occasions or from only a subset of a resident’s supervisors, cannot capture the variability inherent in surgical work. Performance fluctuates with case complexity, patient acuity, team dynamics, and the sheer human reality of fatigue and stress. A resident entrusted after three observations on straightforward elective cases may not be equivalent to one entrusted after thirty observations spanning emergencies, revisions, and high-acuity trauma. Extensiveness, in this framing, is not bureaucratic accumulation for its own sake. It is the statistical and practical foundation that allows committees to distinguish a resident having a good week from a resident who is genuinely, reliably ready.

The second condition, that EPAs be practiced, addresses the often-ignored reality that assessment is itself a clinical skill. Faculty surgeons are experts in operating and in patient care, but the act of observing a trainee, anchoring that observation to the specific behavioral anchors of an EPA scale, and translating it into a calibrated trust judgment is a separate craft that requires deliberate rehearsal. Assessment researchers have long documented the hazards of uncalibrated raters: leniency bias, central tendency, halo effects that let a charming resident’s minor lapses slide, and harshness toward trainees whose style differs from the rater’s own. Without regular practice, rater drift is inevitable. Two attendings asked whether the same resident can be entrusted with the same activity should, in principle, reach the same conclusion. In unpracticed systems, they frequently do not.

The commentary highlights a scoring approach developed to address exactly this quality problem. The Quality of Assessment of Learning, or Qual, score, introduced by Chan, Sebok-Syer, Sampson, and Monteiro in Teaching and Learning in Medicine, provides validity evidence for a system that rates short, workplace-based comments on trainee performance. Instead of accepting any narrative feedback as equal evidence, the Qual framework distinguishes comments that contain specific, actionable, behaviorally anchored observations from vague platitudes like good job or needs to read more. Applied to EPA-linked assessments, such scoring gives programs a way to audit not just how many assessments their faculty complete, but how informative each one actually is. It converts the sprawling noise of workplace commentary into something a competency committee can weigh.

The Kabbash study’s central finding, that higher volumes of faculty feedback did not automatically translate into higher-quality feedback, reframes a comfortable assumption in surgical education. Programs have often responded to accreditation pressure by simply demanding more assessments, building dashboards that turn red when completion rates sag, and nudging faculty to submit ratings before their logs expire. But if the additional assessments are generic, unanchored, or copied between residents, the dashboard turns green while the underlying evidence base for trust decisions remains thin. Lipman’s commentary makes the corollary explicit: extensive but inaccurate assessment may be worse than limited assessment, because it manufactures false confidence in an entrustment decision that the data cannot actually support.

Accuracy, the third pillar, is where the technical demands on programs become most serious. For EPA judgments to be accurate, they must be grounded in direct observation of the specific activity in question, made by raters who have seen enough of the resident’s work to generalize, and recorded with enough specificity that a future reader can reconstruct the basis for the decision. This has operational consequences. Assessment must be embedded into the workflow rather than bolted on afterward, ideally captured immediately after a case or shift while observations are fresh. Faculty development must treat entrustment rating as a teachable, coachable skill, with calibration exercises in which multiple raters score the same performance and reconcile their differences. Programs must also resist the seduction of automation that merely counts forms, and instead build review processes that sample and score the narrative content of assessments using validated instruments.

For residents, the stakes of getting this right are personal and immediate. Trainees respond to the feedback culture they inhabit. When they perceive that ratings are arbitrary, they learn to game the system, requesting assessments at convenient moments and from lenient raters. When they perceive that ratings are extensive, practiced, and accurate, feedback becomes a form of coaching rather than surveillance, and the EPA framework starts to do what it was designed to do: tell a resident, in concrete behavioral terms, what they can already be trusted to do alone and what they must still work on under supervision. The commentary’s synthesis suggests that programs which invest in all three pillars will not only produce better data but will change the day-to-day conversation between teachers and learners.

As competency-based medical education continues its march through surgical training, the lessons of this exchange between the Kabbash study and Lipman’s commentary extend well beyond general surgery. Every specialty adopting EPAs faces the same temptation to measure volume instead of value. The evidence now accumulating points toward a more demanding but more defensible standard: build an assessment system that is comprehensive enough to be representative, rehearsed enough to be reliable, and specific enough to be true. Only then can a statement of entrustment mean what it claims, and only then can the programs that certify surgeons honestly say that readiness for independent practice was demonstrated, not assumed.

Subject of Research: Quality and validity of faculty feedback in entrustable professional activity-based assessment of surgical residents

Article Title: The best EPAs are extensive, practiced and accurate

Article References: The best EPAs are extensive, practiced and accurate. (n.d.). https://doi.org/10.1007/s44186-026-00577-5

Image Credits: AI Generated

DOI: 10.1007/s44186-026-00577-5

Keywords: entrustable professional activities, surgical education, general surgery residency, workplace-based assessment, faculty feedback, competency-based medical education, Qual score, rater calibration, resident training, American Board of Surgery, feedback quality, surgical competency committees