Motivation in Education
Imagine this hypothetical: You are a resident physician. You receive eight critically ill patients during sign-out - all require attention, all new. Labs and imaging need to be rechecked, interventions evaluated, histories are incomplete, two central lines are needed, one patient needs intubation. Your phone rings. A tech comes up to you with two EKGs that need to be read (and you’d better not miss any critical elements), overhead you hear “CODE BLUE Room 6”. You race down the hall while your phone rings for a second, then a third time. The off-going physician is nowhere to be found. Nor is your attending.
You enter the room of the patient in arrest; the RN from Room 5 is at the door, blocking your way, to let you know that her otherwise healthy patient is vomiting. She’s wondering if she can give ondansetron…she needs an answer now…not concerned about the pulseless patient. As you start compressions, you hear overhead that a stroke is in the hallway, and someone needs you to place a CT scan order. Meanwhile, another tech hands you an EKG. Your patient regains a pulse. You instruct the tech to run to ask another doctor to come help. Two arrive. You ask one of them to take care of the stroke. You ask the other to go to Room 4 to intubate the patient who needed it before the code.
This situation is real…and stressful…for many reasons. Cognitive overload. Perceived risk to patients, risk of poor outcomes. Risk of litigation for those poor outcomes. Adversarial interaction with a colleague. Expectation that you can be all things to all people all the time.
Did anyone provide affirmation of your effort? Did you leave with feelings of competence, of relatability to the patient and team…that you were glad you chose this for yourself? Were you motivated? Defeated?
So, why do we do it? And how, as an educator, do you motivate a learner to accept this burden? The learner could have chosen a career in finance. It would have paid more. But someone must do it…we need doctors…so how do you encourage a student or resident to remain motivated, to learn, and to persevere, especially when faced with difficulty?
This post asks us to reflect on what motivates learners, how to sustain motivation, and what kind of students and future doctors we would like. It ends with examples of how to teach in a manner that promotes motivation, rather than destroy it as is often the case with corrective instruction based on superficial and extrinsic incentives.
Do we want learners who are intrigued and interested in medicine (and in lifelong learning) or those who bring superficial understanding, and require incentives, explicit structure, and regulations to keep up with advances in the science and practice of medicine? What society, educators, and patients deserve are physicians interested in the study and practice of medicine purely for the sake of it. The antithesis is a physician whose main motivation is to achieve external reward and recognition which may result in shallow learning, inappropriate practice, and misaligned patient-provider goals.
Motivation determines thought and action - it influences why behavior is initiated, persists, and stops, as well as what choices are made. Motivation and learning are entwined. For learning to take place, motivation must be present. [1-6] The level and type of motivation of a student has been shown to be a larger determinant of educational outcome than any method of teaching.[1, 2] Motivation can be created. The type, quantity, and character of motivation can be influenced by instructors. A philosophy of teaching which stimulates intrinsic motivation can generate learners who engage in autonomous, not forced, lifelong learning.
The most significantly studied motivational theory, and most applicable to education and accomplishment is Self-Determination Theory (SDT) from Deci and Ryan.[3-6] Earlier theories emphasized the quantity of motivation – its presence, absence, or amount. SDT emphasizes the quality. This has a more significant and directly applicable role in medical education than previous theories. SDT argues that even if the quantity of motivation is high, the quality will yield different outcomes. SDT posits both level and quality of motivation determine behavior.
Two types of motivation are described in SDT: intrinsic motivation, defined as pursuit of an activity out of personal interest because of an internal or inherent desire, and extrinsic motivation, defined as pursuit of an activity to obtain reward or avoid loss or punishment. SDT posits that intrinsic motivation is the desired quality, as it leads to deep learning and better outcomes. Yet in medicine, curricula and interactions are more frequently designed around extrinsic motivators like evaluations, grades, performance metrics, salary, prestige, and awards. [1-6]
Intrinsic motivation is built on the inherent human needs of autonomy, competence, and relatedness. SDT has demonstrated that motivation can change along a continuum of amotivation to pure intrinsic motivation and vice versa depending on a person’s feelings of autonomy, competence, and relatedness around the task at hand. [3-6] The need for autonomy describes the need to feel that "I am doing this because I want to and my decisions and opinions matter.” The need for competence is about feeling that one has the capability to achieve a desired goal. “I can hit the target.” The need for relatedness describes being able to relate or matter to significant persons, i.e., parents, teachers, peer groups, through work, actions, and achievement. In medical education, patients are also significant persons. Fulfilment of these three basic needs (autonomy, competence, relatedness) stimulates intrinsic motivation for a particular activity. SDT puts forth that intrinsic motivation leads to deep learning and information processing, higher achievement, decreased drop-out behavior, greater creativity, and enhanced well-being.
To promote intrinsic motivation in your clinical teaching, consider these examples:
Example 1: Two residents receive a patient from EMS, who is quickly recognized to be in cardiac arrest. They rapidly initiate CPR, intubate through vomit using a bougie (for the first time) and succeed in resuscitation without criticizing the medics. The attending is available but not directive, she observes, then states, heartfelt, “Great job.”
This scenario respects the autonomy and competence of the residents to do the work (the attending did not jump in). Their success, recognized by a supervisor, allows them to relate in a positive way through recognition of significant people (their attending and their patient) through a life saved. The lack of criticism for the unrecognized arrest (while it should be addressed productively) promotes relatedness with the medics as well. Experiences such as this reinforce the reasons why the residents entered medicine – helping and caring above all. Lesson: Recognition of effort and being supportive without being overly directive promotes feelings of autonomy and competence among learners.
Example 2: On rounds, an attending wearing an Alpha Omega Alpha pin states to a resident who provided an incorrect answer to a question about a medication: “You see this pin…you see it? This is AOA. And it’s something you’ll never be.”
This (hopefully hypothetical) scenario takes an opportunity to teach and explain, an opportunity to build someone up and add to knowledge, and not only overlooks any chance to teach but directly attacks competence. This would surely move the recipient along the motivational continuum in the wrong direction. Why would this learner want to continue to work on behalf of someone so hurtful and mean? Lesson: The model of the demeaning superior seldom if ever benefits the learner.
Example 3: An intern has never managed a patient on a ventilator before. Overnight, without any senior residents or attendings around, the scared intern hears the vent alarming: increased airway pressure and low oxygen saturation. They are sweating - he has no idea what he is doing. He thinks logically through checking equipment, examining the patient, obtaining labs and an x-ray, suctioning the tube, and adjusting pressure, volume, and rate. The patient improves. The next morning, the team is generally indifferent to the effort required.
This scenario promotes autonomy and competence, though it must be self-recognized. Relatedness is limited as the team, likely composed of several senior members, likely believes the effort overnight to be standard and rote, though it was new and challenging for the intern. Lesson: Taking a moment to admit to and discuss a similar challenge in training could promote relatedness for this learner and highlight their importance not just to the team but emphasize their shared experience as they enter the community of practice.
Example 4: An award is given to the resident with the highest score on an examination.
This scenario, however well intentioned, may have unintended consequences. Many persons are not motivated by external rewards. Many may view themselves as ‘average’ which may result in failure of attempts to study harder when “they’re sure they won’t win”. This external motivation structure has been shown to sub-optimally motivate all learners except the one who wins the award. Lesson: Incentive structures should focus on increasing autonomy, competence, and relatedness to drive intrinsic motivation.
Teaching in medicine, if targeted to enhance student autonomy, competence, and relatedness, can drive intrinsic motivation and promote lifelong learning. Focusing one’s interpersonal efforts and teaching actions to highlight and augment these aspects can move learners along the continuum, harnessing these intrinsic motivators to greater educational effect, arming learners with the intrinsic drive to confront even the most challenging clinical scenarios.
Author: Andrew Beck, MD, PGY-4
Faculty Reviewer: Chris Merritt, MD.
References
1: Kusurkar RA, Croiset G, Ten Cate TJ. Twelve tips to stimulate intrinsic motivation in students through autonomy-supportive classroom teaching derived from self-determination theory. Med Teach. 2011;33(12):978-82. doi: 10.3109/0142159X.2011.599896. PMID: 22225435.
2: Ten Cate TJ, Kusurkar RA, Williams GC. How self-determination theory can assist our understanding of the teaching and learning processes in medical education. AMEE guide No. 59. Med Teach. 2011;33(12):961-73. doi: 10.3109/0142159X.2011.595435. PMID: 22225433.
3: Deci EL, Ryan RM. Intrinsic Motivation and Self-Determination in Human Behavior. New York: Plenum; 1985.
4: Ryan RM, Deci EL. Intrinsic and extrinsic motivations: Classic definitions and new directions. Contemporary Educational Psychology. 2000; 25:54-67.
5: Ryan RM, Deci EL. Self-determination theory and facilitation of intrinsic motivation, social development and well-being. American Psychologist. 2000; 55:68-78.
6: Marley L Carman I. Selecting medical students: A case report of the need for change. Medical Education. 1999;33,455-459