VIEW FROM THE ASSOCIATION OF PEDIATRIC PROGRAM DIRECTORS

Individualized Learning Plans: Basics and BeyondSu-Ting T. Li, MD, MPH; Ann E. Burke, MD

From the Department of Pediatrics, University of California, Davis, Sacramento, Calif (Dr Li); and Department of Pediatrics,Wright State University Boonshoft School of Medicine, Dayton, Ohio (Dr Burke)Dr Burke is the president of the Association of Pediatric Program Directors.Address correspondence to Su-Ting T. Li, MD, MPH, 2516 Stockton Blvd, Sacramento, California 95817. (e-mail: su-ting.li@ucdmc.ucdavis.

edu).

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SELF-DIRECTED, LIFELONG LEARNING is an impor-tant tenet of medical professionalism because it is inte-gral to maintaining professional competency.1–3

Although patients may assume that physicians withmore clinical experience provide better patient care,the relationship between clinical experience and qualityof care is not as straightforward as it may seem.Recent graduates may continue to improve their patientcare in the first few years of practice as they garneradditional clinical experience. However, compared withphysicians in practice fewer than 10 years, physicianswho have been in practice longer (more than 20 years)have declining knowledge of current medical evidenceand practice guidelines and provide lower quality ofcare to their patients.4 Continued lifelong learning couldprevent the deterioration of current medical knowledgeand the decline in quality of care seen over time. Inrecognition of this concern, the Liaison Committee onMedical Education,5 the Accreditation Council on Grad-uate Medical Education (ACGME),6 and the AmericanBoard of Medical Specialties Maintenance of Certifica-tion7 all identify lifelong learning as essential to thecontinuum of medical education.

An individualized learning plan (ILP) is a tool de-signed to help develop self-directed, lifelong learningskills in learners that is now required by the ACGME’sPediatric Review Committee.8 It is possible that ILPscould also benefit practicing physicians by helpingsupport their lifelong learning. The American Board ofPediatrics explicitly requires pediatricians to “assess andenhance knowledge in areas important to their practice,”essential components of an ILP, in part 2 of maintenanceof certification (MOC) requirements. The Royal Collegeof Physicians and Surgeons requires a variation of ILPs(personal learning projects) for MOC of Canadian physi-cians.9,10 As ILPs are a recent requirement for pediatricresidents and fellows, most practicing physicians areunfamiliar with ILPs. The purpose of this paper is tofamiliarize readers with ILPs by describing thefollowing: 1) the basic components of an ILP, 2) howILPs could improve lifelong learning in both traineesand practicing physicians, 3) current literature on ILPs,and 4) key research questions on ILPs.

ACADEMIC PEDIATRICSCopyright � 2010 by Academic Pediatric Association 289

ILP COMPONENTS

The basic elements of an ILP are 1) reflection on long-term career goals and self-assessment of areas of strengthand weakness, 2) goal generation, 3) development ofplans/strategies to achieve the goal, 4) assessment of prog-ress on goal, and 5) based on assessment, revising goal/plan or generating a new goal.11 ILPs should be an iterativeprocess, where physicians continuously revise goals orplans considering current learning needs and progress ongoals and should be flexible enough to be adapted for usefor learners at different levels, as well as to various learningneeds and styles. Goals could be long-term or near-termand could focus on improving process (eg, “I will improvemy use of evidence-based medicine by forming a clinicalquestion based on a patient encounter every week andread about it in the medical literature”) or content (eg, “Iwill improve my EKG interpretation by taking a courseon EKG interpretation and reading 1 EKG per week andcomparing my EKG read to that of the cardiologist”).ILPs can be written on paper or recorded electronically.

The advantages of an electronic ILP include the potentialease of modifying goals or plans and having a centralizedrecord of previous ILPs. The advantage of a paper ILP isits portabilitydit can be completed and carried anywhere;one does not need to be near a computer to complete it ormodify it. The American Academy of Pediatrics’ Pedia-Link12 offers an electronic ILP that many pediatric resi-dency programs use; it is also developing the capabilityto carry forward an electronic ILP created during residencyinto fellowship and MOC. Although there are benefits toportable handwritten ILPs, there is some evidence thatpediatric residents may prefer an electronic ILP.13

WHY ILPS?Adult learning theory postulates that adults learn best

when they are actively engaged in the learning processand self-direct their own learning goals and activities.14

ILPs help improve development of self-directed, lifelonglearning skills by actively engaging learners to take owner-ship of their own learning. Self-directed, lifelong learningincludes learner identification of learning needs and deter-mination of how to meet those needs.15–17 ILPs allow

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290 LI AND BURKE ACADEMIC PEDIATRICS

learners to practice the process of lifelong learning ina thoughtful and systematic fashion.11

A critical element of ILPs is committing to a goal anddeveloping an organized plan by writing it down. Thereis limited evidence that contracts between patients andhealth care providers improve adherence to treatment andlifestyle changes.18 Similarly, there is some evidence thatformally writing down learning goals/plans is importantto goal attainment. In a study of respiratory therapists,those with written learning contracts were more likely tohave participated in continuing medical education coursesand read instructional materials in the last 6 monthscompared with those without written learning contracts.19

Writing down their learning goals, plans/strategies toachieve goals, and outcomes by which to measure goalachievement actively engages learners in the learningprocess and helps them commit to achieving the goalsthey set for themselves.11,14

ILPs emphasize self-reflection on career goals byoffering learners time to examine their goals, practice theskill of repetitive examination of these goals, and considerprocesses by which they might successfully achievea goal or restructure it so that it might be achieved. Byallowing learners to practice the process of reflection,goal generation, plan development, and follow-through,ILPs represent teachable strategies for developing whathas been variously described as “reflective practice,”9

“mindful practice,”20,21 or “self-monitoring.”21,22 Reflectivepractice promotes continual learning from clinicalexperience through understanding current limitations(“I don’t know how to treat this patient’s disease”) anddeveloping a plan to address the limitation (“I will readabout how to treat this patient’s disease”).9,20,21,23

Although physicians have previously been shown tohave poor self-assessment skills,24 self-assessment skillscan be developed and have been shown to improve withexternal feedback.25,26 ILPs in residency allow residentsto develop their self-assessment skills with external feed-back from evaluations and guidance from mentors. Asa learners’ ability to reflect improves, external mentorshipcan be replaced by external evaluation (eg, patient evalua-tions as required by MOC), peer feedback, and mindfulpractice (self-reflection on patient interactions and othercontexts of work).11

Goal generation and plan development and follow-through can be initially difficult for learners. A studyof ILPs in third-year medical students found thatstudents were more comfortable picking learning goalsfrom a preselected list of learning goals than generatingtheir own list.27 Although most residents felt comfort-able assessing their areas of strength and weaknessand generating a goal, they had more difficulty devel-oping/following through with a plan to accomplish theirgoal.28–30 ILPs during residency allow practice of goalgeneration and plan development, and follow-throughwith guidance from a mentor. ILPs during MOC wouldallow practicing physicians to continue refining theselifelong learning skills in a thoughtful, organized, andsystematic manner.

For faculty mentors, discussing an ILP with a learner canlead to a richer understanding of the learner, their goals,and strategies for accomplishing these goals. However,faculty members, including program directors, who arenewly responsible for facilitating the development of resi-dent learner ILPs may feel unprepared for the task. Mostare just starting to get familiar with the concepts of ILPsand most have not created an ILP of their own. As ILPsare generally novel for faculty as well as residents, facultydevelopment will be needed to optimize support fortraining of faculty to be ILP mentors. Sources for ILPfaculty development exist on MedEdPORTAL, the Associ-ation of Pediatric Program Directors’ Share Warehouse,and other venues.31

WHAT IS KNOWN ABOUT ILPS?There is wide variation in the way ILPs are currently

used in residency training programs.30 Because they area new program requirement, pediatric residency programsare experimenting and refining their tools and processesfor their accomplishment. An understanding of currentliterature on these plans can help direct their most effectiveuse.A study of resident-reported barriers to and strategies for

achieving learning goals suggested that successful ILPgoals and plans include certain I-SMART11 strategies forgoal generation and plan development. Strategies includedchoosing goals important to the learner and having thelearner prioritize achievement of their goal, deconstructingbroader goals into incremental specific steps and planson how to accomplish each step, setting a measurableoutcome to assess progress on accomplishing goals, estab-lishing internal accountability by using a reminder andtracking system to track progress on goals and externalaccountability by sharing goals with others, creating andcontinually modifying goals and plans so that they arerealistic and based on current context and availableresources, and developing a timeline for achieving goalsor a way to incorporate goals into daily routines.11 Incorpo-rating these strategies for goal generation and plan devel-opment into ILPs may result in more effective goalachievement.Residents reported least confidence in their ability to

develop or follow-through with a plan for achieving theirlearning goal.28–30 Factors associated with achievingprogress on learning goals created in ILPs includetracking progress on achieving learning goals, greaterconfidence in self-directed learning abilities, greaterpropensity toward lifelong learning, higher level oftraining, writing an ILP longer ago, reporting that ILPshelp align learning goalswith learning needs, being decidedon a career path, andmale gender.30 This suggests that addi-tional resident and faculty development are needed in theareas of plan development and follow-through. Dissemina-tion of strategies for ILP plan development (incorporatingI-SMART strategies11) and plan follow-through (sugges-tions for tracking progress on goal achievement)could help learners produce more effective ILPs and

ACADEMIC PEDIATRICS INDIVIDUALIZED LEARNING PLANS: BASICS AND BEYOND 291

make greater progress on addressing their self-identifiedlearning needs.

FUTURE DIRECTIONS

The development and use of ILPs is an area ripe for futureresearch. Although some characteristics of successful ILPs(eg, tracking progress on goal achievement)30 are known,further delineation of characteristics of successful ILPs isneeded. Some characteristics contributing to their successmay bemore easily modified and taught than others. Learnercharacteristics (eg, propensity for lifelong learning,30 person-ality of learner) may bemore difficult to modify than charac-teristics specific to the ILP itself (eg, type of learning goal,frequency of revisions to ILPs, tracking progress on goalattainment30) or external contributions to success (eg, degreeor type of mentorship). Once characteristics of successfulILPs are identified, programs can create curricula to supporteffective ILP development in their learners.

Additionally, once modifiable characteristics of success-ful ILPs are identified, valid and reliable tools to assess thequality of ILPs should be developed. These tools would beimportant for both residency training and MOC. Duringresidency training, an ILP evaluation tool would allowprograms to assess trainee development of self-directed,lifelong learning skills. Programs could then set milestonesfor development of lifelong learning skills based on level oftraining and monitor attainment of these milestones.During MOC, an ILP evaluation tool would allow betterassessment of lifelong learning of practicing physicians.Currently, assessment of lifelong learning is primarilybased on a portion of the process of lifelong learning(self-assessment32). Inclusion of ILPs and ILP evaluationsin MOC would allow assessment of lifelong learningbeyond self-assessment to include goal generation, plandevelopment, and documentation of measurable progressin goal attainment.

Ultimately, the question remains whether optimal imple-mentation of ILPs leads to better patient care outcomes.Theoretically, ILPs develop lifelong learning skills by al-lowing learners to systematically and actively engage inthe process of lifelong learning.11 In turn, active engage-ment in lifelong learning allows physicians to continuallyimprove their patient care skills and remain up to dateon current medical evidence and practice guidelines.However, it has yet to be studied whether ILPs in residencyandMOC result in meaningful prolonged behavior changesand maintenance of professional competence. We havedelineated a few key questions that remain regardingILPs. However, there are many questions yet to be exploredas to the best use of ILPs and their role in improving andmaintaining professional competence in training andMOC. Addressing these questions may improve the devel-opment of self-directed, lifelong learning skills needed toremain competent physicians.

ACKNOWLEDGMENTS

We thank Daniel C. West, MD, and Debora A. Paterniti, PhD, for

thoughtful comments on an earlier draft of this manuscript.

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