Optimizing Motivation Theory for Medical Training: Teaching on the Wards

Doctor teaching residents on medical rounds.

By Eric Gantwerker MD, MMSc (MedEd), FACS
November 15, 2018

As we take theory to practice we discuss what motivates our trainees to learn and how can we use motivational learning theory to promote deep and meaningful learning among our trainees.

Self-determination theory (SDT) purports that humans are by nature curious and have the desire to learn.1,2 SDT underlies the concept of motivation; described as a continuum from amotivation (lack of motivation) to extrinsic motivation (external rewards) to intrinsic motivation (inherent interest).3 A closely related concept is self-regulated learning (SRL), described by Zimmerman et al., that delineates the complex interplay between motivations, learning, assessment, and metacognition that impacts effective learning processes.4,5

Intrinsic motivation and SRL have been associated with deeper forms of learning, improved performance, increased interest, commitment, and satisfaction.2,3 As we take theory to practice we discuss what motivates our trainees to learn and how can we use motivational learning theory to promote deep and meaningful learning among our trainees. Strategies to foster intrinsic motivation and SRL have been tied to three basic psychological needs: autonomy, competence, and relatedness.1,2 In addition, some common practices are discussed regarding their impact on motivation and SRL.

Teaching to Curiosity

Curiosity is the strongest intrinsic motivator.8 We currently live in a world with immediate access to information. In every learning experience I have with a trainee, we try to spark that curiosity. I often use real world factoids and tie them back to medical experiences they may have had. For example, I talk about stridor to my trainees which is a sound created when there is a narrowing of the airway. We get to the point of discussing why the sound is created and relate it to partially blocking the end of a hose. They get extremely curious and connect disparate concepts together. This also goes to teaching ‘the why’ and encouraging trainees to ask why things are the way they are. As an instructor, I never answer ‘because that was how I learned.’ It does not lead to any deeper understanding of the facts.

Autonomy

Autonomy is derived from the Greek for ‘auto’ meaning self and ‘nomos’ meaning laws. It is free will and self-governance, free from external factors.6 In education, this is the desire to self-author your learning. The key is to involve the trainee in their own learning and to give them choices. One can do this by allowing the trainee to select how and when they want to learn and when they want to be assessed. I employ this in the operating room by asking the trainee what part of the procedure they would like to focus on today. In the clinic, this is asking them to bring a topic that they would like to discuss for the day.

I also try to respect autonomy of assessment by never using cold calling in learning environments. Cold calling (or pimping) is the common practice of putting trainees on the spot to answer knowledge-based questions in front of their peers or co-workers.7 Trainees often have not been given ample time to formulate their knowledge into a cogent thought by the time they are expected to answer. This can lead to negative emotions of shame, anxiety, and depression. Instead, I pose the question to all the trainees at once and allow the trainees to answer who feel comfortable speaking up. I also employ free-text audience response systems in my learning sessions, so trainees can answer anonymously and start the conversation. It is also important to note that cold calling is very different from the Socratic Method (see Socrates was not a pimp: changing the paradigm of questioning in medical education).

Competence

Competence is best achieved by “introducing learning activities that are optimally challenging.”1 This involves giving graded responsibilities as trainees demonstrate competence so they have a sense of achievement as they master the discipline and are rewarded with more complex tasks. It is not uncommon to hear “’Third-year residents are never allowed to do ‘X’” in the operating room in otolaryngology training. Judging someone based on their year in training does not promote competence and, in fact, can stifle the trainee’s growth. In my practice, this means regardless of their year in training, I base their responsibilities on their demonstrated competence.

For clinical teaching, I teach sleep studies by first asking trainees to interpret a sleep study without the report. Once they struggle through, I take them through one data point at a time. I then give them a new study to interpret. They almost always match the expert interpretation. This gives them a huge sense of accomplishment and competence and invariably they seek out new studies on their own to go and interpret.

Relatedness

This involves making the trainee feel welcome to “the club.” It is teaching them the language of the domain and making them feel that the faculty has been there before and understand what they are going through. It also requires the faculty to remember what it was like to be in their shoes and be respectful of their knowledge and growth.

It is important to foster intrinsic motivation in our trainees as it leads to improved learning experiences, satisfaction with learning, and better performance. Faculty can start by satisfying the basic psychological needs of autonomy, competence, relatedness, and teaching to curiosity. Respect your learners and their prior knowledge while presenting them with sufficiently challenging tasks. It will be worth it!


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References:

  1. Niemiec CP, Ryan RM. Autonomy, competence, and relatedness in the classroom: Applying self-determination theory to educational practice. Theory Res Educ. 2009;7(2):133-144. doi:10.1177/1477878509104318.
  2. Orsini C, Evans P, Jerez O. How to encourage intrinsic motivation in the clinical teaching environment?: a systematic review from the self-determination theory. J Educ Eval Health Prof. 2015;12:8. doi:10.3352/jeehp.2015.12.8.
  3. Ryan RM, Deci EL. Intrinsic and Extrinsic Motivations : Classic Definitions and New Directions. 2000;67:54-67. doi:10.1006/ceps.1999.1020.
  4. Zimmerman BJ. Self-regulated learning. Int Encycl Soc Behav Sci. 2001:13855-13859.
  5. White CB, Gruppen LD, Fantone JC. Self-Regulated Learning in Medical Education. In: Swanwick T, ed. John Wiley & Sons, Ltd; 2013:201-211. http://onlinelibrary.wiley.com.ezp-prod1.hul.harvard.edu/doi/10.1002/9781118472361.ch15/summary. Accessed October 1, 2014.
  6. Autonomy. Merriam-Webster. https://www.merriam-webster.com/dictionary/autonomy. Accessed October 14, 2018.
  7. Kost A, Chen FM. Socrates Was Not a Pimp: Changing the Paradigm of Questioning in Medical Education. Acad Med. 2014;XXX(Xxx):1-5. doi:10.1097/ACM.0000000000000446.
  8. Dyche L, Epstein RM. Curiosity and medical education. Med Educ. 2011;45(7):663-668. doi:10.1111/j.1365-2923.2011.03944.x.
  9. Knowles MS, Holton EF, Swanson RA. The Adult Learner. Vol 24.; 2011.

Dr. Eric Gantwerker profile pic.

 

Eric Gantwerker MD, MMSc (MedEd), FACS is a pediatric otolaryngologist and assistant professor of otolaryngology at Loyola University Medical Center who hold degrees in physiology, biophysics, and medical education with a focus on ed tech.

He is also the vice president, medical director of Level Ex where he provides clinical oversight for all its video games developed for physicians and works closely with partners from medical societies and industry to develop innovative programs using the company’s mobile, AR, and VR experiences.

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