By Krystal Ya-Fong Lai, MD
In her article, “Motivation: An Integral Component of Resident Well-Being”, Dr. Amber Deptola summarizes a few dominant theories regarding student motivation. Much of the medical education literature on this subject is, unsurprisingly, written and framed through the lens of the educator. Research concerning student motivation is often aimed at devising new instructional techniques and assessment tools, improving the students’ learning environment and experiences, and understanding what makes students tick.
As a medical student, now rising intern, I eagerly dove into this body of work on motivation for selfish reasons, hoping that the science might foster self-reflection on my own motivations and offer ways I might improve upon them and my work.
Deptola compared several frameworks for learner motivation:
- Self-theories of Ability: growth vs fixed mindset
- Achievement Goal Theory: a model in which learners are motivated by achievements and attainable goals
- Self-determination Theory: motivation at its best when three specific learner needs are met — competence, relatedness, and autonomy.
Sounds promising! Let’s explore, Self-determination Theory
The three requisite learner needs of Self-determination Theory are:
- Competence, “the desire to feel effective in challenges that match a person’s capacities”
- Relatedness, “a desire to feel valued and to have a sense of belonging”
- Autonomy, “the desire to make one’s own choices”
Research shows that when these three needs are cultivated, “individuals are more oriented to mastery and learning, view challenges as opportunities for individual growth, and are less likely to experience psychological distress or engage in maladaptive behaviors.”
Included in the article are examples of ways that an educator can foster this sort of positivity, explained through the author’s own experience in graduate medical education. These include recognizing small successes, being inclusive during both patient and non-patient centered activities, and explicitly setting expectations by giving learners choices when there are multiple valid approaches or solutions.
Wait… I Have Questions
Deptola’s article raises a significant dilemma for me:
- Where does the locus of control exist within self-determination theory, in the context of graduate medical education?
Competence. Relatedness. Autonomy.
- How much control does a learner have over the degree to which these needs are addressed, as they navigate through the environments of medical school, residency, and fellowship?
We can imagine the domain of competence as being the most individualistic. One can argue that competence is correlated to effort invested in reviewing material, studying, being engaged with the day to day clinical work, etc. And while I would agree that this might be the most accessible domain, it is predicated on the assumption that we as students are aware of how to achieve competency through effective learning strategies.
We might shoulder the responsibility of mastering our known unknowns.
- But to what extent are we independently able to address, let alone identify, unknown unknowns, especially within a field as vast and complex as medicine?
- Can the summit of competency — a fallacy already, in comparing it to a single achievable feat –be scaled by the learner alone?
The environment and support system surrounding the learner clearly play an integral role.
And if competence already involves an interplay between internal and external forces, then relatedness and autonomy seem to pose even greater barriers to a learner seeking self-improvement.
Relatedness by definition requires a receptive, supportive environment by virtue of the definition of “belonging”. While we can exercise self-appreciation and choose to value ourselves, no matter our level of training, I think the need here is one at a broader level, of feeling valued by community members, by “others”. We can do our best as individuals, maximize competency, perform our roles within an environment, reach out to those around us, but without a reciprocal action, this need is easily stymied.
The number of horror stories I’ve heard from my fellow medical students regarding cold team members, outright emotionally hurtful encounters, or teams that swallow medical students whole and leave us feeling as if we are not seen or heard, is frankly alarming.
- What power do we have in a system that is inherently hierarchical, to safely advocate for our well-being in this paradigm?
And autonomy, too, raises similar questions. As trainees, our autonomy is largely defined by our supervisors, our programs, and our administrators. We can be proactive and confident and choose to share our voices and opinions. We can posit treatment plans and think we know what the next best step is, and we can ask for things that we think we need.
- But can an individual create their own autonomy within a structured system, historically rigid in its predefined roles and responsibilities?
- Or is the autonomy of medical learners the most top-down need within this theory?
Models of Self-determination Theory are rich in tips and tricks and tools that the educator can use to create an improved learning environment, by allowing those at the locus of control to lower barriers and actively engage the three needs described. Paradoxically, one might view the locus of control, as described by this theory, as undermining the very autonomy the theory seeks to empower.
I am still new to the field of medical education, and I have much to learn, but I am curious to see what research will come about learner motivation. No one theory will be all-encompassing, as motivation is understandably complex and difficult to precisely define. But as I embark on a career in medical education, I plan to explore these theories of motivation.
About the author:
Krystal Ya-Fong Lai, MD is an intern in Internal Medicine at UT Southwestern. She is a recent graduate of Stanford School of Medicine and its ‘Introduction to Medical Education’ course.
Edited by: Michael A. Gisondi, MD, Associate Professor and Vice Chair of Education in the Department of Emergency Medicine at Stanford School of Medicine. He teaches the course, ‘Introduction to Medical Education.’ @MikeGisondi
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