When SMART Isn't Always Best: An Investigation of Emergency Medicine Resident Goal Setting Practices

Goal setting is a foundational component of self-regulated learning and a key expectation in competency-based medical education. While widely promoted as a strategy to enhance learning and guide skill development, learners often struggle with or resist goal setting in the clinical learning environment. This study aims to elucidate resident trainee relationships to, and perceptions of, clinical goal setting.

We completed an inductive qualitative study at a single 4-year format emergency medicine residency program in the United States. We conducted semi-structured interviews with residents in all four post-graduate years. Purposive sampling was used to ensure diversity in level of training and opinions on goal setting. Interviews explored experiences with shift-based goal setting, perceived barriers, and desired improvements. We analyzed transcripts using constant comparative methods within a constructivist grounded theory framework.

Twelve interviews yielded three major themes: (1) Meaningful goals are hard to operationalize-residents struggled to generate clinical learning goals amidst high cognitive load, limited intrinsic goal setting skill, unpredictable clinical content, and limited supervisor continuity; (2) Relationships with supervisors matter-prompted goal setting was perceived as effective only through genuine, bidirectional educational relationships; and (3) SMART goals may not always be the smartest choice-learners often found rigid, rubric-based goal structures misaligned with the clinical realities of shift-based training. Instead, participants adopted their own flexible, longitudinal, and learner-centered goal strategies.

Despite theoretical and institutional endorsement of goal setting, trainees struggle to apply traditional goal setting practices to clinical education. This tension may be due to a thus far undescribed component of goal setting theory-namely, the "wickedness" or "kindness" of the specific clinical learning environment. We recommend encouraging adaptive goal setting practices that are relationally supported, longitudinally oriented, and tailored to the realities of the kindness or wickedness of the clinical learning environment.