2013 APDS SPRING MEETING
How Residents Learn Predicts Success
in Surgical Residency
Ralph C. Quillin III, MD, Timothy A. Pritts, PhD, Dennis J. Hanseman, PhD, Michael J. Edwards, MD,
and Bradley R. Davis, MD
Department of Surgery, University of Cincinnati, Cincinnati, Ohio
BACKGROUND: Predictors of success in surgical residency
have been poorly understood. Previous studies have related
prior performance to future success without consideration of
personal attributes that help an individual succeed. Surgical
educators should consider how residents learn to gain
insight into early identification of residents at risk of failing
to complete their surgical training.
METHODS: We examined our 14-year database of surgical
resident learning-style assessments, Accreditation Council
for Graduate Medical Education operative log data of
graduating residents from 1999 to 2012, first time pass
rates on the American Board of Surgery Qualifying and
Certifying examinations, and departmental records to iden-
tify those residents who did not complete their surgery
training at our institution. Statistical analysis was performed
using the chi-square test, Wilcoxon rank-sum, and regres-
sion analysis with significance set at p o 0.05.
RESULTS: We analyzed 441 learning-style assessments from
130 residents. Surgical residents are predominantly action-
based learners, with converging (219, 49.7%) and accom-
modating (112, 25.4%) being the principal learning styles.
Assimilating (66, 15%) and diverging (44, 10%) learning
styles, where an individual learns by observation, were less
common. Regression analysis comparing learning style with
case volume revealed that residents who are action-based
learners completed more cases at graduation (p o 0.05 for
each). Additionally, surgical residents who transferred to a
nonsurgical residency or nonphysician field were more likely
to learn by observation (p ¼ 0.0467).
CONCLUSIONS: Surgical residents are predominantly
action-based learners. However, a subset of surgical resi-
dents learn primarily by observation. These residents are at
risk for a less robust operative experience and not complet-
ing surgical training. Learning-style analysis may be utilized
by surgical educators to identify the potential at-risk
Correspondence: Inquiries to Ralph C. Quillin III, MD, Department of Surgery,
University of Cincinnati, 231 Albert Sabin Way, ML 0558, Cincinnati, OH 45267-
0558; fax: þ1-513-558-8677; e-mail: quillirc@email.uc.edu
Journal of Surgical Education  & 2013 Association of Program Directors in Surgery. Published by
Elsevier Inc. All rights reserved.
residents in general surgery. ( J Surg 70:725-730. J
C 2013
Association of Program Directors in Surgery. Published by
Elsevier Inc. All rights reserved.)
KEY WORDS: learning style, general surgery, attrition,
success, operative volume
COMPETENCIES: Patient Care, Medical Knowledge,
Practice-Based Learning and Improvement, Interpersonal
and Communication Skills
BACKGROUND
Predictors of success in surgery residency are poorly under-
stood. Studies that have examined the topic largely relate
prior academic performance in medical school and scores on
standardized tests with success in surgical residency.1-3
However, these studies fail to consider the personal attrib-
utes that help an individual succeed. Surgical educators
should consider how residents learn, because the highest
level of learning and subsequent success is achieved in an
environment congruent with an individual’s style of learn-
ing.4-6
The Kolb learning style inventory (LSI) is a reliable and
validated tool for the self-assessment of an individual’s
learning style.7 This inventory is based on David Kolb’s
theory of experiential learning, where learning occurs when
an individual perceives and then processes information,
creating knowledge.8,9 Results from the inventory are
reported on a 2-dimensional graph (Fig. 1A) based on
how an individual perceives (vertical axis) and processes
information (horizontal axis). Perception of information
may vary from experiencing physical events or interactions
(concrete experience, “CE”) to developing intellectual con-
structs, such as ideas and theories (abstract conceptualiza-
tion, “AC”). This information is then processed through
either reflection (reflective observation, “RO”) or action
(active experimentation, “AE”).8
Ideal learning incorporates each of these different com-
ponents. However, learners develop preferences for different
methods and subsequently develop unique learning
1931-7204/$30.00 725
http://dx.doi.org/10.1016/j.jsurg.2013.09.016

FIGURE 1. Classification of learning styles based on the Kolb LSI.
(A) The LSI reports how an individual perceives information (experien-
cing “CE” to thinking “AC”—vertical axis) and how they process
information (reflecting “RO” to acting “AE”—horizontal axis) when they
learn. (B) The 4 different learning styles are identified to a specific
quadrant through the subtraction of the perception continuum compo-
nents (AC-CE) and processing continuum components (AE-RO) of
the LSI.
8,10
styles. Individuals are categorized into 4 different learn-
ing styles (Fig. 1B). Diverging learners learn by observation,
viewing concrete situations from many different points of
view, and like to gather information from many different
sources. Assimilators prefer to observe rather than take
action when they learn and are less focused on people and
more interested in ideas and abstract concepts. Conversely,
accommodators prefer to learn by doing and rely on their
gut feeling and others, rather than their own analysis, to
solve problems. Finally, convergers are action-based learners
who make decisions based on their own ability to solve
problems and prefer not to deal with social or interpersonal
issues.11
Learning-style analysis has been applied to a variety of
fields and learning styles are generalized within occupational
groups.12 Studies of medical students have shown that
students with a given learning style are more likely to enter
726 Journal of Surgical Education  Volume 70/Number 6  November/December 2013
a particular medical specialty.13 Learning-style analysis has
been applied to evaluate trainees and physicians in a variety
of medical fields including internal medicine,14 pedia-
trics,15,16 anesthesia,17 family medicine,18 and surgery,6,19,20
with each specialty having a characteristic learning style.
However, no study has examined the association of surgical
resident learning style with success in surgical training. In
this study, we hypothesized that resident learning styles were
associated with operative volume, success on surgical boards
and attrition from surgical residency.
METHODS
The Kolb LSI (HayGroup, Boston, MA) was administered
yearly to categorical general surgery residents at the Uni-
versity of Cincinnati’s Department of Surgery from 1999 to
2012. Accreditation Council for Graduate Medical Educa-
tion operative log data of graduating general surgery
residents were examined. First time pass rates on the
American Board of Surgery Qualifying Examination
(ABSQE) and American Board of Surgery Certifying
Examination (ABSCE) were examined. Finally, records
from the Department of Surgery’s Division of Education
were queried for those residents who began but did not
complete their surgical training at our institution. Statistical
analysis was performed using linear regression analysis, the
chi-square test for categorical variables and the Wilcoxon
rank-sum test for ordinal variables. All statistical analyses
were performed using SAS Version 9.2 (SAS Institute, Cary,
NC). Significance was defined as p o 0.05. This study was
approved by the University of Cincinnati’s institutional
review board.
RESULTS
Surgery Resident Cohort
From 1999 to 2012, 130 residents trained in general
surgery at the University of Cincinnati’s Department of
Surgery (Table 1). Of these residents, 115 completed
residency or were currently training at the time of our
analysis. Over the 14-year period, 126 residents (96.9%)
completed 441 learning-style inventories. Surgical residents
were predominantly action-based learners, with converging
and accommodating being the principal learning styles,
whereas the observation-based learners, assimilating and
diverging, comprised the minority of learning styles.
Learning Styles and Operative Volume
Our previous work suggested that general surgery resident
learning styles do not change over the course of their
training.6 We examined each resident’s first documented
learning style. Using multiple linear regression analysis, a
TABLE 1. Characteristics of Surgery Resident Cohort
Surgical Resident Information n (%)
Residents 130 (100)
Gender (Male) 104 (80.0)
Completed or currently training at UC 115 (88.5)
Resident learning style
Diverging 44 (10.0)
Assimilating 66 (15.0)
Converging 219 (49.6)
Accommodating 112 (25.4)
UC, University of Cincinnati.
correlation between resident learning style and case volume
was revealed (Fig. 2). The surgical residents with converging
and accommodating learning styles performed more cases
(967.4 ⫾ 38.7, p ¼ 0.0146 and 1001.3 ⫾ 45.8, p ¼
0.004, respectively), when compared with residents with
assimilating (907.6 ⫾ 53.7, p ¼ 0.6920) and diverging
(886.2 ⫾ 34.5, reference group) learning styles. Addition-
ally, linear regression analysis revealed that for each unit
increase in AE-RO score (a measure of action-based learn-
ing), the number of major cases increased on average by 3.3
(p ¼ 0.0327), further suggesting a relationship between
action-based learning and operative volume. There was no
relation between AC-CE score and operative volume (p ¼
0.6783). Having established a relationship between resident
learning style and operative volume during surgical resi-
dency, we then examined if learning styles were associated
with attrition from surgical residency.
Learning Styles and Resident Attrition
Characteristics of the 15 residents who left our training
program over the 14-year period are depicted in Table 2.
FIGURE 2. Surgical resident learning styles are associated with
operative volume at graduation. Surgical residents completed more
cases if they were accommodating (p ¼ 0.004) and converging (p ¼
0.0146) learners, whereas no association with operative volume was
seen for assimilating (p ¼ 0.6920) and diverging (reference group)
learners.
Journal of Surgical Education  Volume 70/Number 6  November/December 2013
Four (26.7%) transferred to a different surgical residency
program, 6 (40.0%) transferred to a nonsurgical residency,
and 5 (33.3%) transferred to a nonmedical field. The
learning styles of our surgical residents were primarily
converging (57.0%) and accommodating (22.8%) and were
similar to those of the residents who transferred to a
different surgical residency (converging 50% and accom-
modating 50%, p ¼ 0.5676). However, residents who
transferred to a nonsurgical or nonmedical field were more
likely to be assimilating and diverging than those residents
who completed their surgery training or are currently
training at our institution (Fig. 3A, p ¼ 0.0467). Addi-
tionally, the median AE-RO score was lower for those
residents who transferred to a nonsurgical or nonmedical
field (3; range 48 to 22) than that of surgical residents
(15; range 15 to 26), reflecting their tendency for
observation-based learning (Fig. 3B, p o 0.001). However,
there was no difference in the median AC-CE score between
the residents who transferred to a nonsurgical or non-
medical field (10; range 32 to 36) and that of the surgical
residents (10; range 15 to 26, p ¼ 0.818).
Learning Styles and Board Exams
Learning-style assessments were collected from 71 of the 69
general surgery residents that graduated over the 14-year
study period. At the time of data analysis, all 69 residents
had completed the ABSQE with a first time pass rate of
92.8%, whereas 66 residents had completed the ABSCE
with a first time pass rate of 87.9%. There was no
association between resident learning style and first time
pass rate on ABSQE (p ¼ 0.615) and first time pass rate on
ABSCE (p ¼ 0.510, Fig. 4A). For a more robust analysis,
we examined the first time pass rate on both the ABSQE
and ABSCE. The combined first time pass rate for our
study period was 81.8%. Again, there was no correlation
evident between resident learning style and the combined
TABLE 2. General Surgery Resident Attrition
Surgical Resident Attrition Information n (%)
Residents not completing training 15 (100)
Completed learning-style assessment 13 (86.7)
Gender (Male) 9 (60.0)
Year of training when left program
R1 1 (6.7)
R2 7 (46.7)
R3 5 (33.3)
R4 2 (13.3)
Reason for leaving program
Transfer 11 (73.3)
Resignation 1 (6.7)
Termination 3 (20.0)
Training after leaving program
Transfer to different surgical residency 4 (26.7)
Transfer to nonsurgical residency 6 (40.0)
Transfer to nonmedical field 5 (33.3)
727

FIGURE 3. Residents who leave surgery residency for a nonsurgical
field are more likely to learn by observation. (A) Surgical residents are
primarily converging (57%) and accommodating (22.8%) learners,
whereas residents who leave surgical training for a nonsurgical field
are converging (33.3%), assimilating (33.3%), and diverging (22.2%)
learners (p ¼ 0.0467). (B) Residents who transferred to a nonsurgical
field had a lower AE-RO scores than surgical residents (p o 0.001),
reflecting their tendency for observation-based learning, but had similar
AC-CE scores to surgical residents (p ¼ 0.818). Boxes plot the median,
25th, and 75th percentiles. Vertical error bars represent the 10th and
90th percentiles.
first time pass rate on both the ABSQE and ABSCE (p ¼
0.643, Fig. 4B).
DISCUSSION
In this study, we reviewed our 14-year experience with the
Kolb LSI. We found general surgery residents are primarily
action-based learners, with 57.0% being convergers and
22.8% being accommodators. These residents, who learn by
doing, performed more major cases than residents who learn
by observation. Additionally, we found resident learning
styles were associated with attrition from surgical residency.
728 Journal of Surgical Education  Volume 70/Number 6  November/December 2013
Residents who learn by observation are more likely to leave
surgical residency for a nonsurgical field.
Some aspects of our data expand on previously reported
studies, whereas others are unique and provide additional
and important insight into surgical resident education.
Several studies examining both medical students and
residents demonstrated an influence of learning style on
objective measures of academic achievement.5,10,21 In a 10-
year study of anesthesiology residents, Baker et al.17 found
residents with accommodating learning styles were more
likely to receive favorable evaluations by faculty. In our
study, we also found a correlation between resident learning
styles and success in residency training.
Action-based learners had a more robust operative
experience at graduation than observation-based learners.
FIGURE 4. Resident learning styles are not associated with success on
surgical board examinations. Of the 69 graduating general surgery
residents with learning-style assessments, 4 were diverging, 13 were
assimilating, 43 were converging, and 9 were accommodating
learners. (A) There was no relationship between resident learning style
and first time pass rate on the American Board of Surgery Qualifying
Examination (ABSQE, p ¼ 0.615) and first time pass rate on the
American Board of Surgery Certifying Examination (ABSCE, p ¼
0.510). (B) There was no relationship between resident learning style
and the combined first time pass rate on both the ABSQE and ABSCE (p
¼ 0.643).
These findings may be explained by action-based learners
being more adept at learning technical skills than their
observation-based counterparts, whose style of learning is
discordant with current methods of teaching technical
procedures. This assertion is in part supported by the
literature where resident learning styles have been associated
with operative skill. In a study utilizing an alternate metric
of learning-style assessment, residents with action-based
“bodily kinesthetic” learning styles displayed superior per-
formance on basic and complex laparoscopic surgical
tasks.22 This association between observation-based learning
and operative volume in surgical residency may have more
implications beyond clinical competency and may affect
surgical resident satisfaction with their choice of career.
In 1975, Polvnick first established an association between
the learning styles of medical students and their career
choice, with accommodating learners having a propensity to
pursue primary care specialties.13 Although students appear
to make career decisions on the basis of learning style,
residency programs may also select trainees who display
characteristics of a particular learning style.12,17,20 However,
when trainees select a field where their style of learning is
discordant with the majority of their peers, their experience
in the training program may result in negative perceptions
of their learning environment and subsequent dissatisfaction
with their career path.23 This was possibly a factor in our
study, as the observation-based learners were more likely to
leave our program for a nonsurgical residency or a non-
medical field. Moreover, attrition from surgical residency
was recently associated with residents’ lack of satisfaction
with their operative experience and concerns that their
operative experience did not help develop their operative
skills.24 Although attrition from surgical training has been
difficult to predict, with 2 large series correlating it only
with postgraduate training year,25,26 our data provide
evidence of a novel factor associated with residents at risk
for attrition from surgical training.
Several studies have examined factors related to success
on general surgery board examinations. Surgical residents
who performed poorly on the United States Medical
Licensing Examinations steps 1 and 2 and American Board
of Surgery In-Training Examination were less likely to pass
both the ABSQE and ABSCE.1-3 Additionally, surgery
residents who were Alpha Omega Alpha members, ranked
in the top third of their medical school class and those with
dedicated research during their surgical training were more
likely to pass their surgical boards.1,3 Learning styles have
previously been correlated with academic achievement in a
study of more than 700 first-year college students and with
success on United States Medical Licensing Examinations
step 1 in a study of more than 200 medical students.21,27
In our study, however, we were unable to find a correlation
between resident learning styles and passing the ABSQE or
ABSCE on the first attempt. Additionally, we previously
demonstrated no association between resident learning style
Journal of Surgical Education  Volume 70/Number 6  November/December 2013
and performance on the American Board of Surgery In-
Training Examination.6
Based on our findings, we believe that learning analysis may
play a role in the resident selection process. Using the TriMetrix
Personal Talent Report, a measure of an individual’s behavior
style, intrinsic motivators, and personal skill inventory, Bell
et al.28,29 was able to identify applicants who matched the
structure, culture, and job benchmarks of their training
program. And although we agree that an applicant should
not be selected on the basis of learning style alone, having this
additional piece of data may guide program directors when they
attempt to rank 2 similarly matched candidates.
There are several limitations of our study. Firstly, it was
carried out at a single institution. Secondly, although data for
the study were collected over a 14-year period, this time frame
spanned the tenure of 3 chairmen and 3 program directors at
our institution. Therefore, resident selection practices likely
varied over the course of the study, potentially confounding
our results. Our analysis of success on surgical boards may be
limited given the low number of residents who failed either
examination on their first attempt. And lastly, our analysis of
attrition may be limited by the small number of residents who
left our training program. However, given the strong relation-
ship observed between attrition and observation-based learning
styles, we believe this effect to be real.
CONCLUSIONS
Based on our experience with the Kolb LSI, we found general
surgery residents are predominantly action-based learners.
However, a subset of surgical residents learn primarily by
observation. These residents are at risk for both a less robust
operative experience and not completing their surgical training.
Further study is necessary to assess if this correlates with
operative competency and career satisfaction upon graduation.
Finally, learning style analysis may be utilized to identify
potential of at-risk residents in general surgery.
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