Applying SelfDetermination Theory
to Medical Education
Olle ten Cate*, PhD
Thanks to Rashmi Kusurkar* MD and Geoffrey Williams**, MD PhD
*Center for Research and Development of Education
University Medical Center Utrecht, the Netherlands
**Healthy Living Research Center, University of Rochester, NY
Based on AMEE Guide 59 – to appear 2011 in Medical Teacher
Self-Determination Theory (SDT)
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A theory of human motivation
What drives people to do what they do?
How can we use insights of SDT to understand
processes in medical education?
Evidence is still limited
SDT a lens through which
to view medical
education
Overview
Founders of Self Determination Theory
 Seven principles that ground SDT
 The three psychological needs
 The spectrum of motivation types
 Selected examples to view elements of
medical education through the lens of SDT
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Founders of SDT: Edward Deci &
Richard Ryan – U of Rochester NY
Seven principles
1.
Man is growth-oriented, wants to build a ‘unified
sense of the self’ and integrate in social structures.
This tendency can be stimulated or hampered.
2.
Three innate psychological needs determine this
ongoing growth: need for competence, need for
autonomy and need for relatedness
3.
Behavior is regulated differently for different modes
of motivation (Amotivation, Extrinsic motivation,
Intrinsic motivation) with different loci of causality
Spectrum of motivation according to SDT
Seven principles
4.
Externally regulated behavior can become internally
regulated
5.
Stable intrinsic motivation requires the ongoing
satisfaction of the three psychological needs
6.
High intrinsic motivation and autonomous selfregulation is associated with high levels of learning,
understanding, performance, well-being
7.
Extrinsic behavior regulation has shades: external,
introjected, identified and integrated; combined in a
dichtomy: controlled self-regulation and
autonomous self-regulation
Spectrum of motivation according to SDT
Three needs associated with
intrinsic motivation when satisfied
1. COMPETENCE
People like doing what
they are good at; this
motivates to get going
Three needs associated with
intrinsic motivation when satisfied
2. AUTONOMY
People better like doing
things if they can
determine it on their
own from a position of
free choice
Three needs associated with
intrinsic motivation when satisfied
3. RELATEDNESS
People like to belong to
a group that matters
and to feel accepted by
its members
Internalizing extrinsic motivation
1.
Abiding by a law or rule, only to avoid
punishment (external regulation)
2.
Accepting rules and regulations of others, even
when rationally disagreeing (introjection)
3.
Sincere understanding, agreeing with and fully
accepting rules of others (identification)
4.
Fully integrating rules and regulations of others
with own norms and values, because of
conviction (integration)
Some general findings
Use of extrinsic
rewards (e.g.
money,
punishment)
deminishes
intrinsic
motivation.
Reasons for
action shift.
Some general findings
Autonomously motivated learners thrive and
students benefit academically when teachers
support autonomy
Some general findings
SDT based approaches in patient care
have been effective with
 alcohol treatment programmes
 weight loss programmes
 adherence to medication programmes
 smoking cessation programmes
Selected applications of SDT to
medical education
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Curriculum effects in highly motivated students
Selection effects for medical school
Assessment and examinations
Effects of clinical responsibilities
Subtleties in feedback wording
Offering electives in the curriculum
Students as teachers and researchers
Teacher motivation and curriculum models
The power of being determined to
become a doctor
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Within SDT, the Organismic Integration mini Theory
(OIT) predicts that the three need satisfaction forces will
make individuals overcome hurdles to become selfdetermined. External influences (parents, teachers,
employers etc) can stimulate or hamper.
The power of being determined to
become a doctor
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Most medical students are highly motivated.
High motivation makes them want to adapt to whatever
circumstances require whatever study effort is asked
Greatly different curricula, may yield just as competent
doctors
Much of the variance of outcomes of education may be
determined by this motivational power. Speculating..
teaching methods
assessment system
talent
motivation
residual
Selection for medical school
Passing a selection hurdle may give
candidates:
- Feeling of competence (“I’m really good!”)
- Feeling of relatedness (“now I belong to
this group”)
While psychometrically selection procedures
may be weak and disputable, they may be
great at generating motivation
Examinations
Collective assessment typically does not
stimulate autonomy
 Stimulating students to take exams when
they feel ready may create feelings of
autonomy
 Computer-based testing may create such
possibilities
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Feedback wording makes a difference
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Shifting from the individual to the context, to
manipulate feeling competent: “you are failing”
versus “this case is hard to master”
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Shifting from instruction to self-regulation, to support
autonomy: “let me tell you what to do” versus “tell
me how you think you want to do this, and ask me
anything you want”
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Pulling students into the professional community, to
stimulate feeling related: “you do not understand
how we do this” versus “we all struggled to master
this, you’ll get there too”
Electives
Electives create student autonomy
 In-depth study in a selected field may
create feelings of competence in
comparison with others
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Clinical responsibilities
If students in clerkships are allowed to legitimately
participate in health care, be it even peripherally
(Lave & Wenger) …
…their feelings of competence, autonomy and
relatedness may be boosted
… supporting intrinsic motivation
Being formally acknowledged to carry out an EPA,
even a small one, may generate this
Students as teachers, researchers
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Senior students can successfully execute
teacher tasks. Being a near-peer teacher for
junior students can generate feelings of
competence and autonomy and probably
relatedness
Students publishing in scientific journals* feel
competent and become part of the community
*15% of Dutch med stds publish >1 paper before graduation – Van Eyk et al 2010
Teacher motivation
Highly integrated, centrally managed and
coordinated, problem-based curricula risk
a decrease of teacher motivation:
- Less autonomy to determine content and
method
- Less possibility to apply personal expertise
In conclusion
Self-Determination Theory offers a
different lens through which to observe
medical education
 Effects of autonomy-supportive teaching
curriculum structure have not been well
studied in higher education and medical
education but seem promising
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Selected references
1.
2.
3.
4.
5.
6.
7.
Deci EL. 1971. Effects of externally mediated rewards on intrinsic motivation.
J Pers Soc Psychol 18105-1151971
Deci EL, Ryan RM. 2000. The “What” and “Why” of goal pursuits: human
needs and the self-determination of behavior. Psychological Inquiry 11(4)
227-268.
Deci EL, Ryan RM. (Eds) 2002. Handbook of Self-Determination Research.
University of Rochester Press Rochester NY 2002
Kusurkar RA, Ten Cate ThJ, Van Asperen MA, Croiset G.Motivation as a
dependent and independent variable in medical education: a review of the
literature. Medical Teacher 33(5): e242-e262.
Reeve J. 2002. Self-determination theory applied to educational settings. In:
Deci E.L. Ryan R.M. (Eds) Handbook of Self-Determination Research.
University of Rochester Press Rochester NY, pp. 183-203.
Ryan RM, Deci EL. 2000. Self-determination Theory and the facilitations of
intrinsic motivation social development and well-being. Amer Psych 55 (1)
68-78.
Ten Cate OThJ, Kusurkar RA, Williams GC. How can Self-Determination
Theory assist our understanding of the teaching and learning processes in
medical education? AMEE guide 59. Medical Teacher (in press)
References, continued:
9.
10.
11.
12.
13.
14.
15.
Ten Cate O, Durning S. Dimensions and psychology of peer teaching in
medical education. Medical Teacher 2007;29(6):546-552
Van den Berg BAM, Ten Cate ThJ, Ritzen MMJ. Needs assessment among
teachers at UMC Utrecht. Report within the Strategic Plan of Education
2010-2015 at UMC Utrecht. April 2011. [unpublished, Dutch]
Van Eyk et al. Scientific output of Dutch medical students. Med Teach 2010;
2010; 32: 231–235
Williams GC, Wiener MW, Markis KM, Reeve J, Deci EL. 1994. Medical
students’ motivation for Internal Medicine. J. Gen Int Med 9:327-333
Williams GC, Deci EL. 1996. Internalization of biopsychosocial values by
medical students: A test of self-determination theory. J Pers Soc Psych70
767-79.
Williams G, Saizow RB, Ryan RM. 1999. The importance of SelfDetermination Theory for Medical Education Acad Med 74 992-995.
Williams GC, McGregor H, Sharp D, Kouides R, Levesque C, Ryan RM, et
al. 2006. Testing a Self-Determination Theory Intervention for Motivating
Tobacco Cessation: Supporting Autonomy and Competence in a Clinical
Trial. Health Psych 25(1) 91-101.