독립변수이자 종속변수로서의 동기: 문헌 고찰(Med Teach, 2011)

독립변수이자 종속변수로서의 동기: 문헌 고찰(Med Teach, 2011)

Motivation as an independent and a dependent variable in medical education: A review of the literature

R. A. KUSURKAR1,2 , TH. J. TEN CATE1 , M. VAN ASPEREN1 & G. CROISET2

1University Medical Center Utrecht, The Netherlands, 2VU University Medical Center, The Netherlands

도입

Introduction

세 가지 주요 견해 (Mann 1999, Williams 외 1999, Misch 2002)가 이 리뷰의 출발점을 구성하는 이슈들을 조명한다.

• 의대생은 본질적으로 또는 외재적으로 어느 정도의 동기가 있나?

• 왜 우리는 알아야합니까?

• 어떤 유형의 동기 부여가 의학 교육에 유용합니까?

Three major viewpoints (Mann 1999; Williams et al. 1999; Misch 2002) bring to light the issues that form the starting point for the current review: 

• To what extent are medical students intrinsically or extrinsically motivated? 

• Why do we need to know? 

• Which type of motivation is useful in medical education?

의학 교육에 대한 연구는 일반 교육에서 풍부한 연구로부터 얻을 것이 많다. 그러나 의대생의 동기 부여가 일반 교육 학생과 다를 수있는 몇 가지 이유가 있습니다. 

• 임상 교육과 얽혀 있기 때문에 의학교육은 고등 교육의 전형이 아닙니다.

• 학생들이 다양한 일을 하고 자신만의 고유한 프로필을 만드는 다양한 선택을하는 일반 교육과는 달리, 의학 교육은 제한되고 명확하게 정의 된 직업으로 작동합니다.

• 교육과 학습이 이루어지는 환경은 매우 특이적입니다.

• 또한, 의대생은 의대 입학을 위해 많은 노력을 들이므로 시작부터 매우 동기 부여된 것으로 간주됩니다.

이러한 주장들이 특히 의과대학생에서 동기 부여를 연구하는 근거가됩니다.

Research in medical education can derive a lot from the wealth of literature in general education . There are several reasons why motivation of medical students could be different from general education students. 

• Medical education is not typical for higher education because of the intertwining with clinical work. 

• Unlike general education, where students have a wide variety of choices to do different things and create unique profiles for themselves, medical education works towards one restricted and clearly defined profession. 

• The environment within which teaching and learning occur is highly specific. 

• Also, medical students are considered highly motivated from the outset having gone through a considerable effort to enter medical school. 

These arguments underlie the rationale for studying motivation,particularly in medical students. 

동기 부여에 대한 많은 이론들이 있습니다. 주요 이론은

• 욕구 계층 구조 이론 (Maslow 1970),

• 성취 필요 이론 (Murray, Franken 1988 인용)

• 기대-가치 이론 (Atkinson 1966),

• 귀인 이론 (Weiner1974),

• 사회인지 이론 (Social Cognitive Theory, SCT) (Bandura 1986, 1989),

• 목표 이론 (Pintrich 2000)과

• 자기 결정 이론 (SDT) (Deci & Ryan 1985).

there are many different theories of motivation, the major ones being 

• Hierarchy of needs theory (Maslow 1970), 

• Need to Achieve Theory (Murray, cited by Franken 1988), 

• Expectancy-value Theory (Atkinson 1966), 

• Attribution Theory (Weiner1974), 

• Social Cognitive Theory (SCT) (Bandura 1986, 1989),

• Goal Theory (Pintrich 2000) and 

• Self-determination theory(SDT) (Deci & Ryan 1985). 

위에서 언급 한 이론의 대부분은 동기 부여의 수준에 근거하여 문제를 설명합니다. 반면, SDT는 동기 부여의 질을 토대로 이슈를 설명합니다. 개인의 동기 부여 수준이 높다하더라도 동기 부여의 성격에 따라 결과가 크게 달라질 것이라고 주장한다 (Williams & Deci 1999). SDT는, 교육 및 학습을 포함하여, 개인의 삶에서 동기 부여의 다양한 측면에 대해 일반적으로 적용되는 동기 부여 이론입니다.

Most of the above-mentioned theories explain issues on the basis of the level of motivation. SDT explains issues based on the quality of motivation. It argues that even if the level of motivation in an individual is high, different qualities of motivation will result in very different outcomes (Williams &Deci 1999). SDT is a general motivation theory which holds true for different aspects of motivation in an individual’s life,including education and learning. 

SDT는 인간은 자기 결정을 향한 자연스러운 경향이 있다고 가정한다. (Deci and Ryan 1985). 모티베이션은 스펙트럼의 한쪽 끝에서 본질적인 동기 부여와 동기 부여 (동기 부여의 부재 또는 부재)를 갖는 연속체 (그림 1)이다. 다른. 내재적 동기 부여는 개인이 개인적인 흥미 또는 즐거움을위한 활동을 추구하게합니다.

SDT postulates that human beings have a natural tendency to develop towards self-determination (Deci and Ryan 1985).Motivation is a continuum (Figure 1) with intrinsic motivation at one end of the spectrum and amotivation (lack or absence of motivation) at the other. Intrinsic motivation makes a person pursue an activity for personal interest or enjoyment. 

외재 동기 부여는 4 가지 단계로 구성됩니다.

• 외부적 조절,

• 주입된 조절

• 인정된 조절

• 통합된 조절

Extrinsic motivation is composed of four different stages: 

• external regulation,

• introjected regulation, 

• identified regulation and 

• integrated regulation. 

• '외부적 조절'은 학습에 대한 관심이 없이, 다른 사람들의 압력이나 기대로 인해 공부한다는 의미입니다.

• '주입된 조절'은 학습의 중요성을 깨달았지만, 학습의 원인은 외부에서 온 것을 의미합니다.

• '인정된 조절'은 학습의 중요성을 깨닫고, 그것을 인정하였으며, 조절 프로세스를 받아들임을 의미한다.

• '통합된 조절'은 학습의 중요성을 받아들임에 있어서, 그것이 자신의 일관된 자기 감각과 완전히 통합되었음을 의미합니다. 이 때 인과 관계의 위치locus는 이제 내부적이다.

• ‘External regulation’, in the case of education,means studying because of pressure or expectation of others,without interest in the study. 

• ‘Introjected regulation’ means there is realization of the importance of the study but the causation is perceived as external. 

• ‘Identified regulation’ means that the importance of study is valued, has been identified with and the regulatory process has been accepted.

• ‘Integrated regulation’ means that the acceptance of the importance ascribed to the study has been fully integrated into the individual’s coherent sense of self; the locus of causation is now internal. 

자기 결정은, 내재적 동기 부여에 해당하는 것으로, 자신이 스스로 자기자신의 동기를 결정한다는 것을 의미합니다. 즉, 동기는 스스로 생성되며 자율적입니다. 외적 동기부여에 대한 자기 결정 조절에서 External regulation은 가장 낮은 수준이며, integrated regulation은 가장 높은 수준이다.

Self-determination, the regulation type that fits with intrinsic motivation, means that one determines one’s own motivation; the motivation is  self-generated and autonomous. External regulation is the least and integrated regulation is the most self-determined regulation of extrinsic motivation. 

많은 연구에서 

• 내재적 동기 부여, 통합된 조절, 인정된 조절을 자율 동기autonomous motivation로, 

• 주입된 조절과 외재적 동기부여를 통제 동기controlled motivation로 나누었다. (Ryan & Deci 2000b). 

Amotivation은 사람이 행동의 의도가 결여되어있는 상태를 의미한다 (Deci et al., 1991, Ryan & Deci2000a, b).

Many studies have combined intrinsic motivation, integrated and identified regulation as autonomous motivation and introjected and external regulation as controlled motivation (Ryan & Deci 2000b). Amotivation signifies the state in which a person lacks the intention to act (Deci et al. 1991; Ryan & Deci2000a,b). 

내재적 동기 부여는 '자율성', '능력'및 '관련성'에 대한 내재적 요구에 기초합니다.

• 자율성 또는 자기 결정의 필요성은 자신의 행동에 대한 의지의 느낌과 관련이 있습니다.

• 역량의 필요성은 목표를 달성하는 능력에 대한 자신의 감정feeling과 관련이 있습니다.

• 관련성의 필요성은 일과 성취를 통해 자신의 삶에서 중요한 다른 사람들과 관계를 맺고자 하는 바람과 관련됩니다.

Intrinsic motivation is built on the inherent needs for ‘autonomy’, ‘competence’ and ‘relatedness’. 

• The need for autonomy or self-determination is related to the feeling of volition in one’s actions. 

• The need for competence is related to one’s feelings of capability in achieving the target. 

• The need for relatedness concerns the desire to relate to the significant others in one’s life through work and achievement.

이 세 가지 기본 심리적 요구를 충족 시키면 특정 활동을하도록 본질적으로 동기 부여됩니다. SDT는 바람직한 유형의 동기 부여로 자율적 동기를 부여합니다.

• 보다 깊은 학습 (Grolnick & Ryan 1987; Vansteenkiste et al. 2005a & b),

• 덜 표면적인 정보 처리 (Vansteenkiste et al. 2004),

• 높은 성취도 (Boggiano et al., 1993; Soenens & Vansteenkiste 2005),

• 드롭 아웃 의도 및 행동 감소 (Vallerand et al. 1997; Hardre & Reeve 2003),

• 더 큰 창조성 (Koestner et al., 1984)과

• 향상된 웰빙 또는 조정 (Black & Deci 2000; Levesque et al. 2004)

Fulfilment of these three basic psychological needs makes a person intrinsically motivated for a particular activity. SDT puts forth autonomous motivation as the desired type of motivation leading to 

• more deep learning (Grolnick & Ryan 1987; Vansteenkiste et al. 2005a & b), 

• less superficial information processing (Vansteenkiste et al. 2004), 

• higher achievement (Boggiano et al. 1993; Soenens & Vansteenkiste 2005), 

• decreased drop-out intention and behaviour (Vallerand et al. 1997; Hardre & Reeve 2003), 

• greater creativity (Koestner et al. 1984) and 

• enhanced well-being or adjustment (Black & Deci 2000; Levesque et al. 2004)

또한 SDT는 자율성, 능력, 관계성에 대한 감정에 따라 외부에서 내부로, 또는 그 반대로 동기가 바뀔 수 있다고 가정합니다.

SDT also postulates that motivation can change from extrinsic to intrinsic and vice versa depending on the feelings of autonomy, competence and relatedness a student experiences in his or her study (Deci1975).

일반 교육 문헌에 따르면 동기 부여는 학습 및 학습성과에 영향을 미친다

According to the general education literature, motivation influences learning and outcomes of learning

동기 부여 퀄리티의 변화는 학습 경험 (SDT)과 자기 효능감 (SCT), 성공과 실패의 속성 (Attribution Theory), 성공 또는 실패에 대한 기대, 실패 또는 기대에 대한 인센티브 가치(기대-가치 이론)에 달려 있으며, 이는 동기 부여가 종속 변수이기도 함을 나타냅니다.

Changes in the quality of motivation depend on the learning experience (SDT), and level of motivation altering, depending on the feelings of self-efficacy(SCT), attributions of successes and failures (Attribution Theory), expectation of success or failure and incentive value of success or failure (Expectancy-value Theory), suggests that motivation is also a dependent variable.

Methods

The inclusion and exclusion criteria were formulated by RAK, TJC and GC as described in Table 1.

(Figure 2)

결과

Results

총 460개 논문

The total number of papers found initially was 460;

제외돈 문헌들이 있음

Studies were excluded because they deviated from the focus of the review

총 56개논문이 포함됨

Thus, a total of 56 articles were finally included in the review.

독립변수로서 동기부여

Motivation as an independent variable

동기 부여는 어떤 행동을 취할지 뿐만 아니라, 그 행동을 얼마나 잘 할지를 통제합니다. SDT에 따른 목표 콘텐츠에는 두 가지 유형이 있습니다. 

• 내재적: 예. 지역 사회 공헌, 개인 성장, 건강, 제휴, 그들은 기본적인 심리적 요구의 본질적인 만족을 제공하기 때문에;

• 외재적: 예. 명성, 지위, 돈 (Vansteenkiste et al., 2006). 왜냐하면 그들은 자기가치의 외부 표현을 제공하기 때문이다.

Motivation not only controls action being taken, but also how well it is taken. Goal contents according to SDT are of two types: 

• intrinsic, e.g. community contribution, personal growth, health, affiliation, because they provide inherent satisfaction of the basic psychological needs; and 

• extrinsic, e.g. fame, status, money, because they provide external manifestations of self-worth (Vansteenkiste et al. 2006).

학습 행동

Learning and study behaviour.

Motivation has been reported to influence study behaviour and learning in medical students. 

• An achieving motive and strategy and having motivation for a career in medicine were found to correlate with greater time investment in study (Wilkinson et al. 2007a). 

• Autonomous motivation was found to be positively correlated with deep approach and reflection in learning and also the intention to continue studies, whereas it was negatively correlated approach with superficial (Sobral 2004). 

• Amotivation correlated was found to be negatively with reflection in learning and deep approach and positively with superficial approach (Sobral 2004). 

• Motivation was reported to directly influence a tutorial group’s cognitive processes (Dolmans et al. 1998).

• On the one hand, having higher motivation enhances learning; on the other hand, it was also found that in small group teaching the lack of motivation in a group member is perceived as inhibiting the learning process of other students in the group (de Grave et al. 2002). 

• A study in UK found that motivation to be a good doctor and avoid harm to patients is related to a vocational approach to study in medical students (Mattick & Knight 2009). 

• This means that students are stimulated to gain knowledge that will help them in their practice of medicine. 

• This study also reported that different intrinsic motivations, namely interest in medicine and learning, achievement and workplace utility, and extrinsic motivations, namely social competition or pressure and assessment, stimulate learning in medical students (Mattick &Knight 2009). 

Concerning study-related behaviour intrinsically motivated medical students tended to take more optional credit courses and peer-tutoring activities (Sobral 2008).

학업적 성공/수행능력

Academic success/performance.

긍정/부정 결론 모두 있음

Studies on strength or quality of motivation as a predictor of academic success have found both conclusive and inconclusive evidence. 

• Higher motivation (Moulaert et al. 2004) and also specifically higher intrinsic motivation (Sobral 2004) have been found to correlate with higher academic grades in both pre-clinical (Sobral 2004) and clinical years. 

• Motivation was found to predict performance in only one school in a US-based study, performed in two medical schools (Webb et al. 1997). 

• Strength of motivation to study medicine was found to be predictive of GPA in the third year, but not the first 2 years of medical study, in another study (Hoschl & Kozeny 1997). 

• Tutorial group productivity was found to be significantly higher in the groups having students with higher motivation as compared to those with lower motivation (Dolmans et al. 1998; Carlo et al. 2003). 

• Students entering medicine with intellectual challenge (SDT intrinsic goal content) as the most important motive were found to have higher GPAs (Price et al. 1994). 

• Academic performance other than grades/GPAs has also been studied. Strength of achievement motivation was found to be a better predictor of professional attainment in males than females (Lorber & Ecker 1983). 

• Defining academic success as howfar a student had progressed in his/her doctoral thesis in the final year of medical school, having higher extrinsic career motivation (striving for promotion, income, prestige, etc.) was found to predict greater advancement in the thesis (BuddebergFischer et al. 2003).

유의한 상관관계가 없는 연구들

There were other studies that failed to find significant correlations. 

• A Netherlands-based study found no significant correlation between motivation and academic success (Hulsman et al. 2007). 

• Neither extrinsic nor intrinsic motivation was significantly correlated with academic performance in a UK study (Popovic 2010). 

• On analysing admission interviews data of academically at-risk medical students, there was no significant difference in motivation of successful and unsuccessful students (Elam et al. 1999). 

• No significant difference was found in performance between students with high and low motivation (conditions created by using external motivators) and controls when tested on clinical case processing and recall of differential diagnosis (de Bruin et al. 2005). 

• Intrinsic motivation, which was measured by only one item, was found to be significantly negatively correlated (r ¼ 0.17) with academic success (Tan & Thanaraj 1993).

직업으로서 의학을 선택

Choice of medicine as a career.

Studies have been conducted to understand what kind of motivation or motives drive students to enter medical school. 

• 사람을 돕고, 존경받고, 없어서는 안되고, 과학자가 되기 위해서 의대 선택
  Four major underlying dimensions appeared, as found using the Medical Situations Questionnaire in the UK: helping people, being respected, being indispensable and becoming a scientist (McManus et al. 2006). 

• Similar motives (Karalliedde & Premadasa 1988) and intellectual content were found in other studies on pre-medical and medical students (Kutner & Brogan 1980; Harth et al. 1990; Todisco et al. 1995; Vaglum et al. 1999; Lovecchio & Dundes 2002; Wierenga et al. 2003; Rolfe et al. 2004; Khater-Menassa & Major 2005). 

• 사람을 도울 수 있는 능력
  The ability to help people appears to be the strongest motive (Kutner & Brogan 1980; Price et al. 1994; Todisco et al. 1995; Vaglumet al. 1999; Rolfe et al. 2004; Millan et al. 2005). 

• 30세 이상의 여자는 '지적 동기', '역량 발달', '성취감 얻기' 등을 위해 의학을 선택
  Women over 30 chose medicine to find intellectual motivation, develop competence and feel achievement (Kaplan 1981). 

• 간호학을 전공한 의대생들은 환자돌봄에 대한 책임감, 의학지식, 개인적 도전, 지위 때문에 선택
  Medical students, who had a background in nursing education, chose medicine mainly out of the desire for increased patient care responsibility, medical knowledge, personal challenge and status (Gussman 1982).

의학 내에서 전공 선택

Choice of a specialty within medicine.

• 일차의료/정신과 Motivation also influences the choice of a specialty. Students choosing primary care (Rogers et al. 1990; Kassler et al. 1991; Vaglumet al. 1999) and psychiatry (Vaglum et al. 1999) were driven by a people-oriented motive or diversity in diagnosis and treatment & 

• 첨단기술/비일차의료과 students (Khater-Menassa Major 2005) as compared to choosing high technology or non-primary care specialties, who were driven by science-oriented motive (Vaglum et al. 1999) or working with new technology (Khater-Menassa & Major 2005). 

• 비일차의료과 Other motives for choosing non-primary care specialties were better lifestyle, monetary rewards and prestige (Rogers et al. 1990). 

• Strong career motivation (BuddebergFisher et al. 2006) or higher intrinsic career motivation (Buddeberg-Fischer et al. 2003) were found to be independent predictors of choice of speciality. 

• Students not considering any primary care specialties showed significantly higher achievement and power motives (Buddeberg-Fisher et al. 2006).

의학을 지속하려는 의도

Intention to continue medical studies.

• 자율 동기 Autonomous motivation was found to correlate significantly positively with intention to continue studies, i.e. not dropping out of medical school, and amotivation was negatively correlated with intention to continue studies (Sobral 2004).

Motivation as a dependent variable

동기는 다른 요인에 따라 변한다

The hierarchical model of motivation by Vallerand and Ratelle (2004) has proposed and empirical evidence has been gathered to support the view that motivation can change and be manipulated, hence is a dependent variable.

바꿀 수 없는 변인

Variables that cannot be manipulated.

연령

Age.

This influences motivation for medical study. 

• 34세와 41세의 차이
  In an Australian study, differences in motivations for choosing medicine were found between mature-age (approximately 41 years) and normal-age entrants (approximately 34 years). 

• 41세 Most mature-age entrants cited intellectual satisfaction as their main reason followed by working with people and desire to help others. 

• 34세 Most normal-age entrants cited desire to help others followed by enjoyment through working with people and intellectual satisfaction (Harth et al. 1990).

성별

Gender.

Studies which look into gender differences in motivation for medicine were found. 

• 남성 Males report 

• interest in science (Robbins et al. 1983; Vaglum et al. 1999; McManus et al. 2006), 

• being indispensable (McManus et al. 2006), 

• helping people (Vaglum et al. 1999) and 

• having a career (Robbins et al. 1983) as the most important reasons motivating them for medicine. 

• 여성 Females report 

• helping people (Wierenga et al. 2003) and 

• having a career as the most important reasons (Robbins et al. 1983; Vaglum et al. 1999). 

• Other studies found that 

• 남-여 순위 비슷 
  ranking of motives like opportunity to help people (Kutner & Brogan 1980), scientific nature of medicine and intellectual challenge, in that order, by males and females was similar (Kutner & Brogan 1980; Price et al. 1994; Todisco et al. 1995); 

• 이타적 동기: 여>남, 경제적 안정: 남>여 
  however, more females than males were oriented towards altruistic motives and more males than females were oriented towards financial security (Kutner & Brogan 1980; Price et al. 1994) or prestige/status (Wierenga et al. 2003). 

• 인간-지향적 동기: 여>남, 자연과학동기: 남>여, 고소득: 남>여
  Others found that female medical students scored higher on the person-oriented motive (Vaglum et al. 1999; McManus et al. 2006), lower on natural science motive (McManus et al. 2006) and opportunity for higher income (Vaglum et al. 1999) and equal to male medical students on status-oriented motive (Vaglum et al. 1999). 

• Apart from gender differences in goal contents for medicine, gender differences in generalized motivation have also been studied. 

• 외부 커리어 동기: 남 Males were found to have higher extrinsic career motivation than females students (Buddeberg-Fischer et al. 2003). 

• 성취 지향: 여 Female medical to be have been found significantly more achievement to oriented as compared male medical students (Loucks et al. 1979). 

• Among tutorial groups, motivation of female students was also found to be significantly higher than male students (Carlo et al. 2003).

인종

Ethnicity.

This plays a role in motivational orientation. 

• In a study carried out in the US with high school students who were considering medicine as a career option, 

• white students were predominantly motivated by the ‘challenge of the medical profession’, whereas 

• black students by the ‘chance to help people’ (Wagoner & Bridwell 1989). 

• Black students rated ‘monetary benefits’ of the profession and status significantly higher than white students (Wagoner & Bridwell 1989). 

• This was in contrast with a UK-based study which found that non-white students score significantly higher on ‘Science’ and significantly lower on ‘Helping people’ as compared to white students (McManus et al. 2006).

사회경제적 지위

Socioeconomic status.

This, rather than ethnicity or gender, was found to play a definitive role in the perceptions of high school students about medical school and their motivation to apply, in a study in the UK (Greenhalgh et al. 2006). 

• 높은 SES: 내적 요인 
  Students from higher socioeconomic status tended to focus on intrinsic factors like challenge, achievement and fulfilment in medicine, whereas 

• 낮은 SES: 외적 보상
  students of lower socioeconomic status tended to focus on the extrinsic rewards like expected income (Greenhalgh et al. 2006).

성격특성

Personality traits.

자기주도성/자기초월성
The temperament dimension of persistence and the character dimensions of self-directedness and self-transcendence (which are expected to enhance the learning process) are associated with intrinsic academic motivation in medical students (Tanaka et al. 2009).

교육배경

Educational background.

A study in Finland found that non graduate entry students had higher achievement motivation as compared to graduate entry students (Kronqvist et al. 2007).

학년

Year of medical curriculum.

This was also found to influence motivation for joining and continuing medical study. 

• Contrary to common beliefs and other studies mentioned above, a UK-based study found that 

• 1학년 first-year medical students were more oriented towards prestige, money and success, whereas 

• 4학년 final year students were more oriented towards relief of suffering and importance for mankind (Powell et al. 1987). 

• Another study, based on the US, found that first-year medical students had higher achievement orientation than students after their third year. This finding was attributed to a shift in the motivational structure from achievement to self-gratification needs (Burstein et al. 1980).

교사와 부모의 서포트

Teacher and parent support.

A qualitative study in the UK among firstand second-year medical students to identify factors influencing students’ motivation to apply to medical school showed that parent support and encouragement had a positive effect and lack of teacher support had a negative effect (McHarg et al. 2007).

조절할 수 있는 변인

Variables that can be potentially manipulated.

자율성

Autonomy.

학습을위한 자율성 지원은 SDT에 따라 학습을 위한 내재적 동기 부여를 개발하는 초석과 같습니다. 학습의 자율성은 학생들이 정의 된 한계의 경계 내에서 자신의 의지의 교육 활동을 계획 할 수 있음을 의미합니다.

Autonomy support for learning is like a cornerstone for developing intrinsic motivation for learning according to SDT. Autonomy in learning means that the students can plan their educational activities of their own volition, within the boundaries of defined limits.

자율성 서포트

Autonomy support. 

• 전공 선택 A study done on US medical students found that autonomy support by instructors during clerkships enhanced students’ motivation to select a residency in that particular field of medicine (Williams et al. 1997). 

• 내과/외과 선택 The choice of internal medicine (r ¼0.29) and surgery (r ¼0.34) clerkships in this study were significantly correlated with the students’ perceptions of autonomy support on these corresponding clerkships. 

• 자율 동기와 역량 Autonomy support by teachers was a significant predictor for both, students’ autonomous motivation and competence for a study course in another study (Williams & Deci 1996). 

• 학습 Intrinsic motivation for a course was positively correlated with autonomy in learning (r ¼0.354) in a study in France (Pelaccia et al. 2009). 

• PBL이 더 내적동기부여 Students in a problem-based learning (PBL) curriculum found themselves to be intrinsically motivated because of autonomy in their learning, as opposed to students in a traditional curriculum who found themselves to be extrinsically motivated because of a controlling learning environment (White 2007).

교육과정

Curriculum. 

• A PBL curriculum was found to motivate students to learn for learning’s sake, i.e. intrinsic motivation, because of autonomy in their learning. 

• 전통적 교육과정은 통제적 학습환경
  Traditional curriculum motivated students towards obtaining high grades, i.e. extrinsic motivation. These students’ perceived a controlling learning environment (White 2007). 

• A German study found that students’ motivation is higher in blended PBL as compared to traditional PBL, both through quantitative and qualitative data (Woltering et al. 2009). 

• Blended learning carefully e-learning modules complements face-to-face classes with and when incorporated into a PBL curriculum gives higher autonomy to students in their learning.

환자 책임감

Patient responsibility. 

• Interns perceived greater responsibility for patient care in a general practice learning environment and this was responsible for their greater motivation for learning (Cantillon & MacDermott 2008). 

• Greater responsibility also means more autonomy in patient handling and treatment.

역량

Competence.

자기효능감

Self-efficacy. 

• Intrinsic motivation was found to be positively correlated with perceived self-efficacy or competence (r ¼0.419) (Pelaccia et al. 2009).

선발 절차

Selection procedure. 

• 선발과정을 거친 경우
  Students entering medicine through a selection procedure were found to have significantly higher strength of motivation and lower certificate orientation (extrinsic goal content) than students entering through either weighted lottery or outstanding high school GPA (Hulsman et al. 2007). 

• 까다로운 선발절차를 거쳤다는 인식
  Awareness of having been chosen through a demanding selection procedure might have a positive effect on students’ self-efficacy beliefs and identity formation, inspiring them to develop a strong level of commitment to medical study and health care. 

• 반드시 성적이 높은 것은 아니지만, 더 많은 교과외활동에 참여하게 함
  Though this selection procedure did not necessarily make students achieve higher grades than the others, they engaged more in health-related extracurricular activities (Hulsman et al. 2007), which appears to be intrinsic goal content and the motivation appears to be autonomous.

평가 유형

Type of assessment. 

• 기준-기반 평가시스템 > 상대평가 시스템
  Standards-based assessment system was found to be associated with beneficial effects on deep motive and deep strategy for learning and professional identity (Wilkinson et al. 2007b). Thus, students were motivated to use deep approach to learning when evaluated against pre-set standards as opposed to when evaluated against each other. 

• 사전에 설정된 기준과의 비교
  Comparison with pre-set standards and meeting those standards could stimulate feelings of competence in learning as opposed to comparison with peers which could result in feelings of personal failure and incompetence.

보상

Rewards. 

• It was found that nearing the end of the medical study, the percentage of students agreeing that a degree with honours was a motivator for learning and not a demotivator was significantly lower than students in the beginning of the study. 

• 아너 시스템 (긍정적) An honours system does not necessarily motivate students and may demotivate a significant number of them over the time course of the study (O’Neill et al. 1999). 

• 아너 시스템 (부정적) An honours system could work in a negative way for students who know that they are not likely to get honours, by making them feel incompetent in learning.

지식 습득

Knowledge acquisition. 

• A study on small group learning found that increase in knowledge and understanding of subject matter increases students’ motivation for the study and interest in the course content (Draskovic et al. 2004). 

• 학습 역량을 느낄 때 더 동기부여됨 
  This means that the students were more motivated for learning when their feelings of competence in their learning were strong.

과제의 가치

Task value. 

• 과제가 가치있다고 느낄 때
  Intrinsic motivation was found to be positively correlated with perceived task value of training study (r ¼0.546) in a in France (Pelaccia et al. 2009).

• 그룹으로 PBL 활동
  Similarly, in a study from UK, students in PBL groups felt motivated for group working as they perceived that it was responsible for delivering their learning (Willis et al. 2002). 

• So, the perceived task value of training periods in the former study and PBL group working in the latter study was high and led to feelings of competence in learning.

관계성

Relatedness.

부모/선생/동료/환자

This could have a special significance in be medical education. Significant others could not only parents, teachers, peers, but could also be patients.

조기 임상 노출 

Early patient/clinical contact. 

• 이론과 실천을 연결
  Early contact with patients stimulates students’ motivation for biomedical and further study by connecting theory to clinical practice (Diemers et al. 2008; Von Below et al. 2008). Thus, students were inspired towards their future work as doctors.

웰빙

Well-being. 

• Well-being was found to affect motivation in daily work and overall career; 

• lower well-being lead to feelings of ambiguity in career choice and 

• higher well-being lead to greater zeal towards purpose in medicine and intrinsic passion for work (Ratanawongsa et al. 2008). 

• 웰빙은 '(전문직, 가족, 사회, 신체적, 정신적, 영적 및 재정적 영역을 포함하여) 레지던트의 개인 생활 및 직업 생활의 여러 부분 간의 균형'으로 정의되었습니다.
  Well-being in this study was defined as ‘a balance among multiple parts of residents’ personal and professional lives, including professional, family, social, physical, mental, spiritual and financial domains’. 

• This could be thought of as a doctor who has strong feelings of relatedness with his family and colleagues would have higher motivation. Autonomous motivation has been found to lead to enhanced well-being in general education studies (Black & Deci 2000; Levesque et al. 2004).

요약

Summary of findings

Table 2

1. 학습 및 학습 행동

1. Learning and study behaviour

- 자발적인 동기 부여는 학습에 대한 깊은 접근, 학습에 대한 성찰, 학업 지속에 대한 의도와 양의 상관 관계가 있었다

- 동기 부여가 소그룹 학습에서 영향을 미침 - 좋은 의사가되는 동기 부여가 학습에 대한 직업 접근을 자극 함

- 동기 부여가 피어 튜터링, 교과외 활동, 학업 및 기타 활동과 긍정적 인 상관 관계가 있음

– Autonomous motivation was positively correlated with deep approach to study, reflection in learning and intention to continue studies 

– Motivation influenced learning in small groups – Motivation to be a good doctor stimulated vocational approach to learning 

– Motivation correlated positively with peer tutoring, extracurricular activities, academic and others

2. 학업 성취도

2. Academic success/ performance

- 높은 동기 부여와 학업 성적간에 긍정적 인 관계가있는 9 개의 연구

- 다른 연구들은 유의한 상관 관계를 발견하지 못했으며, 유의한 부적 상관 관계를 발견했지만, 내재적 동기는 설문지에서 단 하나의 항목으로 측정되었다

– Nine studies found positive relation between higher motivation and academic performance 

– The other studies either did not find significant correlations or one found significantly negative correlation, but in this study intrinsic motivation was measured with only one item in the questionnaire

3. 커리어로서의 의학 선택

3. Choice of medicine as a career

- 동기 - 사람들을 존중하고, 반드시 필요하며, 과학자가 되고싶은 것

- 사람들을 돕는 것이 가장 강한 동기입니다.

- 30 세 이상의 여성과 간호사가 개인적인 도전을 위해 의학에 입문한다

– Motives – helping people, being respected, being indispensable and becoming a scientist 

– Helping people is the strongest motive 

– Women over 30 and nurses join medicine for personal challenge

4. 의학 분야의 전문 분야 선택

4. Choice of specialty within medicine

- 1 차 진료 특기가 인간 지향적 동기에서 선택됩니다.

- 첨단 기술 전문 분야 선택은 과학기술 지향적 동기에서

– Primary care specialities are chosen for peopleoriented motive 

– High technology specialities are chosen for science oriented motive

5. 의학 연구를 계속할 의향

5. Intention to continue medical studies

- 자율 동기는 학습을 계속하려는 의도와 양의 상관 관계가 있으며, 무동기는 음의 상관 관계가있다.

– Autonomous motivation positively correlated with intention to continue studies and amotivation correlated negatively

Table 3

1. 연령

- 성숙한 나이와 정상 연령 진입자는 의약품 선택에 대한 동기에서 차이가있었습니다.

1. Age 

– Mature-age and normal-age entrants had differences in motivations for choosing medicine

2. 성별

- 남성과 여성은 의과대학 진학 동기 유형이 다르며 유사점도 있습니다.

- 여성은 동기 부여의 강도가 높고, 남성은 외인성 동기가 더 높은 것으로 밝혀졌습니다

2. Gender

– Males and females had different type of motives for joining medicine, also some similarities

– Females were found to have higher strength of motivation and males were found to have higher extrinsic motivation

3. 민족성

- 의학에 합류하기위한 흑인과 백인 학생들의 주된 동기는 달랐으며 두 연구의 결과는 상반되었습니다

3. Ethnicity

– Predominant motives of black and white students for joining medicine were different and the findings of the two studies were contradictory

4. 사회 경제적 지위

- 사회 경제적 지위가 높은 학생은 의학 연구를 선택하는 본질적인 요인에 초점을 맞추는 반면,
  사회 경제적 지위가 낮은 학생은 외래 보상에 대한 의학적 연구를 선택했습니다.

4. Socioeconomic status

– Higher socioeconomic status students were found to focus on intrinsic factors for choosing medical study whereas lower socioeconomic status students chose medical study for extrinsic rewards

5. 성격 특성

- 끈기, 자기 주도성, 자기 초월성이 의대생의 내재적 학업 동기와 관련이있다

5. Personality traits

– The temperament dimension of persistence and the character dimensions of self-directedness and self-transcendence are associated with intrinsic academic motivation in medical students

6. 교육 배경

- 대학 입학생은 대학원 입학생보다 성취 동기가 높았습니다.

6. Educational background

– Non-graduate entry students had higher achievement motivation as compared to graduate entry students

7. 학년

- 한 연구에서, 1 학년 학생은 외적 보상에 더 집중되어 있었지만, 4 학년 학생은 인류를 돕는 방향이 더 중요했습니다

- 다른 연구에서는 1 학년 학생이 3 학년 학생보다 성취 동기가 높았습니다.

7. Year of medical curriculum

– In one study, first-year students were more oriented towards extrinsic rewards of the medical profession, whereas final-year students were more oriented towards helping mankind

– In the other study, first-year students had higher achievement motivation than third-year students

8. 교사와 학부모 지원

- 학생의 의학 선택에 학부모 지원을 받는 것은 긍정적, 교사 지원을 받지 않는 것은 부정적 역할을한다.

8. Teacher and parent support

– Having parent support and not having teacher support play a positive and negative role, respectively, in students choosing for medical study

---

9. 자율성

9. Autonomy

자율성 지원

- 의학 연구에서의 자율성 지원은 특정 전문 분야의 선택과 학습을 위한 내재적 동기 부여를 자극하는 것으로 밝혀졌습니다

과정

- PBL 교과 과정은 내재적 동기를 자극하고 전통적인 교과 과정은 외적 동기를 자극하는 것

- 혼합 된 PBL은 전통적인 PBL에 비해 학생들의 동기를 높입니다.

더 큰 환자 책임

- 더 큰 환자 책임은 학습 동기 부여에 크게 기여했습니다.

Autonomy support

– Autonomy support in medical study was found to stimulate choice of a particular specialty and intrinsic motivation for learning

Curriculum

– PBL curriculum was found to stimulate intrinsic motivation and traditional curriculum was found to stimulate extrinsic motivation

– Blended PBL increases students’ motivation as compared to traditional PBL

Greater patient responsibility

– Greater patient responsibility was responsible for greater motivation for learning

10. 능력

10. Competence

자기 효능감: - 내재적 동기는 자아 효능과 양의 상관 관계가 있었다

선택 절차: - 입학 시험을 통해 입학하는 학생의 동기가 높습니다.

평가: - 평가 유형이 학습 동기 유형에 영향을 미칩니다.

보상:- 보상은 여러 학생을 demotivate시킬 수 있다

지식 습득: - 지식이 증가했다고 인식하는 것은 동기 부여를 증가시킨다.

과제 가치에 대한 인식

- 본질적인 동기 부여는 과제 가치에 대한 인식과 양의 상관 관계가있는 것으로 나타났습니다

- PBL 그룹의 작업 가치 인식으로 그룹 작업 동기 증가

Self-efficacy: – Intrinsic motivation was positively correlated with selfefficacy

Selection procedure: – Students entering through medical entrance exam have higher motivation

Assessment: – Type of assessment influences type of motivation for study

Rewards: – Rewards may demotivate significant number of students

Knowledge acquisition: – Perception of increased knowledge increases motivation

Perceived task value

– Intrinsic motivation was found to be positively correlated with perceived task value

– Perceived task value of PBL groups increased the motivation for group working

11. 관련성

11. Relatedness

조기 환자 / 임상 접촉: - 조기 환자 접촉은 학생들의 동기 부여를 자극합니다.

웰빙: - 복지의 느낌은 동기 부여를 향상시킵니다.

Early patient/clinical contact: – Early patient contact stimulates student motivation

Well-being: – Feeling of well-being enhances motivation

Figure 3

고찰

Discussion

의학 교육에서의 대부분의 연구는 '동기 부여가 학업 성과와 관련이 있음'을지지하는 증거를 발견했습니다. 동기 부여와 학습 성공 간의 관계는 일반 교육에서 잘 입증되었다 (Dickinson 1995; Vansteenkiste et al. 2004, 2005b; Hustinx et al. 2009).

Most studies in medical education have found evidence in favour of ‘Motivation correlates with academic performance’. The relationship between motivation and learning success has been well-substantiated in general education (Dickinson 1995; Vansteenkiste et al. 2004, 2005b; Hustinx et al. 2009).

• 이타 적 동기, 지적 내용 및 연구에 대한 관심은 학생들을 의학적 연구 및 직업으로 이끌어내는 내재적 목표 내용 (SDT)이며, 그러한 학생이 의학 선택에 대한 동기는 자율적autonomous이다

• 학부모의 압력, 지위, 소득 및 위신은 외재적 목표 내용 (SDT)이며 그러한 학생이 선택한 의학 대한 동기는 controlled됩니다.

• Altruistic motives, intellectual content and interest in the study are all intrinsic goal contents (SDT) that drive students towards medical study and profession and the motivation that such students exhibit in their choice of medicine is autonomous. 

• Parental pressure, status, income and prestige are extrinsic goal contents (SDT) and the motivation exhibited by such students in their choice of medicine is controlled.

• 전반적으로 1 차 진료 전문 분야를 선택하는 학생들은 내재적 인 목표 내용에 따라 자율적 인 동기 부여에 의해 좌우되는 것처럼 보인 반면, 

• 비 1 차 진료 전문 분야를 선택하는 학생은 과학 지향 동기 / 신기술 활용에 대한 바람 등 부분적으로는 내재적 목표에 의해 선택하지만, 부분적으로는 외재적 목표(즉 생활 방식, 돈, 명성)에 의한 것입니다.

• Overall, students choosing primary care specialities seem to be driven by intrinsic goal contents and hence autonomous motivation, 

• whereas students choosing non-primary care specialities seem to be driven partly by intrinsic goal contents, i.e. science-oriented motive/working with new technology, and partly by extrinsic goal contents, i.e. lifestyle, money, prestige.

나이가 동기에 영향을 준다는 것을 발견 한 연구가 한 번뿐이었습니다.

There was only one study that found that age influences motivation.

이 연구에서 이 차이는 35 세 대 45 세인 참가자들 사이에서 발견되었습니다. 대부분의 국가에서 평균 23 세의 미국과 호주를 제외하고는 의학 연구에 진입 한 평균 연령은 약 17 세입니다. 이 점에 비추어보면 위 연구는 대부분의 의대생과 무관 한 것처럼 보인다

in this study this difference was found between entrants who were 35 vs. 45 years of age. In most countries, the average age at entry into medical study is around 17 years, except in the US and Australia where it is around 23 years. In the light of this, the study by Harth et al. (1990) seems irrelevant to most of the medical student population

동기의 성별 차이에 대해서는 여성 의대생이 [남성 의대생보다] 동기부여의 강도가 높고 동기 부여의 질이 좋아 보인다는 상당한 증거가있다.

Concerning gender differences in motivation, there is considerable evidence that female medical students seem to have higher strength and better quality of motivation than male medical students.

민족성과 사회 경제적 지위 또한 충분히 자세하게 조사되지 않았으며, 모순 된 결과는 일반화 가능성이 제한적이다. 마찬가지로, 교육 배경, 성격 특성, 커리큘럼의 연도, 교사 및 학부모 지원과 같은 변수는 일반화하기에는 너무 적은 수의 연구가 있습니다.

Ethnicity and socioeconomic status also have not been explored in enough detail and because of contradictory findings have limited generalizability. Similarly, variables like educational background, personality traits, year of curriculum, teacher and parent support have too little number of studies to be generalizable.

이 검토에서는 부양 가족의 관점에서의 동기 부여와 의학 교육에서의 독립 변수를 보는 데있어 장점이 뒷받침되었습니다. 동기 부여가 독립 변수 인 지원과 학습 및 학업 성과와 같은 중요한 결과에 영향을 미치는 지원은 동기 부여를 종속 변수로보고 변수에 영향을 미치는 변수를 탐색하는 데 중요합니다. 동기에 대한 연구는 독립 변수로는 상당히 많은 것으로 보이지만, 종속 변수로서의 동기 부여에 관한 연구는 거의 없다.

The merits in viewing motivation from the point of view of a dependent and an independent variable in medical education were supported by this review. Having support that motivation is an independent variable, influencing important outcomes like learning and academic performance, is important in order to look at motivation as a dependent variable and explore variables influencing it. There seems to be a fair amount of research on motivation as an independent variable, but research on motivation as a dependent variable is scarce.

Further implications

SDT는 의학 교육 과정 개혁, 학습 환경의 구성, CME 및 평생 학습을 위한 좋은 토대가 될 수있는 일반적인 동기 이론입니다.

자율적 인 동기 부여를받은 학생들은 직업에 대한 더 큰 만족감을 느끼게되어 스트레스와 소모 가능성을 낮추게됩니다. 의료기관의 문화에 의료계의 가치를 통합하면 외적 목표 내용을 본질적인 목표 내용으로 옮기고 돈, 지위, 권력에서 지역 사회 봉사로 초점을 바꿀 수 있습니다.

The SDT is a general theory of motivation which can be a good foundation for medical educational curricular reforms, structuring of the medical learning environment, continuing medical education and lifelong learning.

Autonomously motivated students’ would experience greater satisfaction with the profession, leading to lowering of stress and burnout possibilities. Integration of values of the medical profession into the culture of medical institutions could also help in shifting extrinsic goal contents to intrinsic goal contents, changing the focus from money, status and power to community service.

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Med Teach. 2011;33(5):e242-62. doi: 10.3109/0142159X.2011.558539.

Motivation as an independent and a dependent variable in medical education: a review of the literature.

Kusurkar RA1, Ten Cate TJ, van Asperen M, Croiset G.

Author information

1

Center for Research and Development of Education, University Medical Center Utrecht, The Netherlands. R.Kusurkar@umcutrecht.nl

Abstract

BACKGROUND:

Motivation in learning behaviour and education is well-researched in general education, but less in medical education.

AIM:

To answer two research questions, 'How has the literature studied motivation as either an independent or dependent variable? How is motivation useful in predicting and understanding processes and outcomes in medical education?' in the light of the Self-determination Theory (SDT) of motivation.

METHODS:

A literature search performed using the PubMed, PsycINFO and ERIC databases resulted in 460 articles. The inclusion criteria were empirical research, specific measurement of motivation and qualitative research studies which had well-designed methodology. Only studies related to medical students/school were included.

RESULTS:

Findings of 56 articles were included in the review. Motivation as an independent variable appears to affect learning and study behaviour, academic performance, choice of medicine and specialty within medicine and intention to continue medical study. Motivation as a dependent variable appears to be affected by age, gender, ethnicity, socioeconomic status, personality, year of medical curriculum and teacher and peer support, all of which cannot be manipulated by medical educators. Motivation is also affected by factors that can be influenced, among which are, autonomy, competence and relatedness, which have been described as the basic psychological needs important for intrinsic motivation according to SDT.

CONCLUSION:

Motivation is an independent variable in medical education influencing important outcomes and is also a dependent variableinfluenced by autonomy, competence and relatedness. This review finds some evidence in support of the validity of SDT in medicaleducation.

PMID:

 

21517676

 

DOI:

 

10.3109/0142159X.2011.558539