The Importance of Supporting Autonomy in Medical Education

The highest ideals of medical practice require physicians not only to have excellent biomedical competence but also to deliver health care in a humanistic manner. This principle is embodied in the biopsychosocial model of medicine [1] and is reflected in the American Board of Internal Medicine's goals for clinical competence [2]. It has also led to a call for the practice of teaching medical students to be more humanistic in their interactions with patients. Such advocacy raises the question of whether it is possible to teach humanistic delivery of care while maintaining or enhancing students' acquisition of biomedical competence. Research in motivational psychology provides the basis for a preliminary answer to this question. Some of this research has been organized by the concepts and paradigms of self-determination theory [3]. We use the concept of autonomy support to represent the idea of being humanistic in both medical education and medical practice. In this article, we review motivational research to evaluate the hypothesis that when medical educators are more supportive of autonomy, their medical students become more supportive of autonomy in their treatment of patients and display greater conceptual learning and better psychological adjustment. The Self-Determination Model The concept of autonomy support describes an interpersonal orientation in which persons in positions of authority (such as educators or clinicians) take the perspectives of others into account, provide relevant information and opportunities for choice, and encourage others to accept more responsibility for their own behavior. This orientation involves minimizing the use of pressure so that others will be more inclined to initiate their own actions. In medical education, autonomy support involves use of an interpersonal approach to pedagogy that leaves medical students feeling more understood and more involved in an educational partnership. Although supporting autonomy has much in common with being humanistic or student-centered in education [4, 5], we use the concept of autonomy support rather than those similar concepts because well-validated paradigms and measures have been developed for the scientific study of autonomy support. The behaviors that are integral to autonomy support concern providing choices about how to behave, the information necessary to make wise choices, meaningful rationales for suggested behaviors, acknowledgment of feelings about behavioral options, and encouragement to choose and to persist [6, 7]. In contrast, being controlling means pressuring others to behave in particular ways while taking little account of their perspectives. By definition, controlling medical instructors pressure students to do assignments in specific ways and to accept specific points of view. It is generally assumed that these instructors also tend to be authoritarian and demanding in style and personal manner, use rewards and punishments as their primary motivational strategies, and often give feedback in critical and demeaning ways. Self-determination theory distinguishes not only between two types of educators but also between two types of student motivation: autonomous and controlled. To act autonomously means to behave with feelings of volition, willingness, and choice. By definition, medical students for whom learning is autonomous freely choose to read and study because they find the material interesting or important to their identity as physicians. Self-determination theory posits that when educators are more supportive of autonomy, their students become more autonomous learners. In contrast, to be controlled means to behave with the experience of pressure or demand rather than a sense of choice. Medical students who experience this kind of motivation for learning study assigned material because they feel coerced or pressured to do so by their instructors or by the feeling that they should (rather than that they want to) learn. According to self-determination theory, instructors who are more controlling promote controlled learning in their students. The term autonomy, which literally means the quality of being self-regulating, has often been used interchangeably with the term independence. Behaving autonomously does not, however, mean behaving independently. Rather, it means behaving of one's own volition and will, in accord with one's inner self. One need not be independent to be volitional; indeed, all medical students depend on their instructors for knowledge and guidance. The question of whether students depend on instructors is different than the question of whether students' behavior is autonomous or controlled. Corresponding to the confusion about the concept of autonomy has been confusion about the concept of autonomy support. Supporting autonomy does not mean being distant, withholding, vague, or permissive or leaving students to fend for themselves. Instead, it requires teachers to hold meaningful dialogues with students, to listen as well as to provide factual information and advice, and to suspend judgment while soliciting the opinions and concerns of students. Autonomy-supportive instructors may hold high standards, set limits, make recommendations, and give honest feedback, just as controlling instructors may, but autonomy-supportive instructors do these things in an understanding, encouraging, nonjudgmental style rather than a harsh, demanding, critical style. Research indicates that setting limits [8] and providing feedback [7, 9] can have motivational advantages as long as it is done in an autonomy-supportive manner-that is, in a manner that provides choice, acknowledges feelings, and helps students find their own answers and solutions. Self-determination theory is not the only theory of motivation that can be applied to medical education. Locus of control theory [10] and self-efficacy theory [11] are other examples. However, self-determination theory differs from these in that it distinguishes between types of motivation (autonomous and controlled). The other theories focus only on how to motivate people without considering the type of motivation being promoted. In contrast, self-determination theory has developed a more refined focus on how to promote autonomous motivation. We argue that it is important to consider the type of motivation because research shows that autonomous and controlled motivations differ greatly in their effectiveness. The Self-Determination Model and Education We reviewed studies testing the hypothesis that autonomy-supportive learning climates encourage medical students to become more autonomously motivated and to feel more competent in their learning. This hypothesis further suggests that these motivational states will, in turn, lead students to become more autonomy supportive (and, therefore, more humanistic) in their patient care, to learn more (that is, to be more biomedically competent), and to display better psychological adjustment (lower anxiety, higher self-esteem, and a more positive affect). The self-determination model is presented in Figure 1. Figure 1. The self-determination model applied to medical education. Some studies of the relation between autonomy-supportive teaching and educational outcomes were done in medical schools (University of Rochester, Wayne State University, University of Oklahoma, and Saint Louis University), although many were done in universities and secondary and elementary schools. Because the degree of convergence in the results of studies across these varied settings is high, results from settings other than medical schools are probably applicable to medical education. In a 2-year longitudinal study of 72 second-year medical students taking an interviewing course with 18 instructors [12], the students' autonomous motivation for learning, valuing of psychosocial aspects of medical care [13], and feelings of competence in interviewing patients were assessed at the beginning and end of the course. The students also rated the extent to which their instructors were supportive of autonomy (compared with controlling) by using a learning climate questionnaire. This questionnaire assessed how much the students felt understood and accepted by their instructors and how much they believed that their instructors gave them choices and encouraged them to ask questions. Results of this study indicated that medical students who viewed their instructors as more supportive of autonomy became more autonomously motivated during the 6-month course. Although the data were analyzed with simultaneous multiple regressions, we converted relevant statistics to partial correlation coefficients to convey the effect sizes. For the relation between autonomy support on the part of the instructor and autonomous motivation on the part of the student, the corresponding correlation coefficient was a moderate 0.30 [14]. Increases in the autonomous motivation of students were found to relate to the development of stronger psychosocial values and the self-perception of greater competence in interviewing. These latter two effect sizes, represented by correlation coefficients of 0.43 and 0.39, respectively, were moderately strong. Other analyses indicated that the effects of autonomy support on autonomous motivation and psychosocial values were maintained at 2 years of follow-up. The follow-up effect sizes of 0.33 and 0.35 were moderate. About 6 months after the interviewing course ended, the students in this study counseled a simulated patient about cardiovascular risk behaviors (smoking cessation, dietary restrictions, and regular exercise) and were rated by observers on how supportive of autonomy they were in their style of care. Results showed that the autonomous motivation on the part of the students at the end of the interviewing course was significantly and moderately related to their support of autonomy in dealing with the simulated patients 6 months later (r = 0.42). Finally,