Despite many years of ongoing research, regulations, and initiatives to improve the well-being of our physician trainees, data show we have much more work to do.1,2 A largely untapped area of study and innovation in the well-being of medical trainees is motivation. While motivation carries no consensual definition in medical education, the social cognitive approach to understanding it is widely accepted in the literature.3 In this approach, motivation is “why people think and behave as they do,” and is influenced by both the self and one's constant interactions with the environment.4 Here, I summarize the existing literature on motivation in graduate medical education (GME) and provide actionable recommendations for application of self-determination theory in the clinical setting with the goal of improving well-being.
Existing data demonstrate a correlation between motivation and well-being in medical students.5 We know that unwell residents may have worse reported patient care and patient satisfaction, and more professionalism lapses.6,7 On the other hand, individuals with more self-driven motivation (autonomous motivation) are less depressed, less burned-out and stressed, and have better engagement, adaptability, and learning outcomes.8 As resident roles, responsibilities, and work hours evolved, I have listened to residents increasingly express a lack of motivation in the patient care setting. A resident who enters internship ready to improve the lives of patients instead ends up feeling beaten down by the types of tasks they are given, often functioning on autopilot as patient care decisions are made by others, and isolating themselves as the patient care community quietly reduces their value in patient care. Encouraging and facilitating the autonomous motivation of trainees within the clinical environment is a potential way to improve resident well-being.
To foster motivation, we need to understand it and know how to facilitate it. In order to make the case for my later recommendations, I want to briefly summarize the most cited frameworks for motivation within an educational system. Maslow's hierarchy of needs provided the initial scaffold for motivational theories. Maslow's hierarchy noted that people must have their basic needs (food, water, safety, belonging) met in order to achieve one's potential.9 Hale and colleagues discussed how published studies on resident well-being may inform a modernized version of Maslow's hierarchy of needs, where the needs are no longer hierarchical but instead dependent on each other to enable wellness.10 Since the time of Maslow, motivation science has focused on 3 primary theories: (1) self-theories of ability, (2) achievement goal theory, and (3) self-determination theory. Self-theories of ability are most well-known to the GME community as growth and a fixed mindset. In other words, how does an individual's mindset about their potential ability influence their motivation?11 Second, achievement goal theory says that an individual's motivation is influenced by the goal in sight.12 Achievement goals can be significantly influenced by how and when we assess a learner.
While self-theories of ability and achievement goal theory can greatly inform how self-factors and curricular factors influence motivation, self-determination theory (SDT) is the most readily applicable to a teacher and learner within the clinical setting and is the best studied in relation to well-being. Therefore, I want to more deeply explore the components of this theory and the potential ways that we, as educators in GME, may apply this theory in our clinical work alongside our trainees. According to SDT, autonomous motivation occurs when 3 central needs are met: autonomy, competence, and relatedness. Studies have shown that when these 3 central needs are met, 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.8 Prior publications have outlined potential methods of fostering the 3 central needs of SDT in our learners.13–15 These methods can readily be translated to the clinical setting when working with trainees.
In the Table, I define the 3 central needs of SDT and reconcile prior published recommendations for applying SDT with my own experience teaching in GME. Having spent 20 to 25 hours per week in a supervisory role to residents in a multitude of patient care settings for the past 5 years, I have found that SDT is relevant, makes my teaching more efficient, and results in an observably motivated and happier resident. These strategies work best when started during expectation setting on day one of a clinical rotation. First, setting expectations with your team early allows you to get to know one another, which fosters relatedness. Second, by setting expectations for respective team members' roles, you can communicate early that autonomy in care is a priority, which then allows you to both hold yourself accountable to your promise of autonomy and set boundaries that later enable you to be more intrusive in care when needed for the patient. Third, day one is the optimal time for team members to set goals. Setting goals encourages the learner to strive for competence that is appropriately challenging and gives you something to purposefully observe and give feedback on throughout the rotation. Within the Table, there are additional recommendations for language that can be used at any time during patient care. I have found it to be immensely helpful to turn back and review these 3 needs when I notice a resident seems to be struggling. Ask yourself: Am I allowing the right amount of autonomy? What am I doing to encourage the trainee to develop competence? Am I facilitating relatedness within our team and the greater clinical environment? At the end of a rotation, attendings may also ask the learner to give feedback on how well they (the attending) did in facilitating these 3 needs during the rotation.
The literature supporting SDT's relationship with motivation and well-being should encourage our community to more broadly integrate it into our teaching and supervision. Further studies are needed to understand more objectively which specific interventions within the clinical setting result in improved motivation.
In conclusion, the well-being of our trainees is multifactorial but significantly impacted by the environment in which they work. Strategies such as those suggested in the Table can foster motivation in our trainees, which may result in gains for the trainees themselves, the teams they work with, and the patients they so much want to treat.