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

Figures & data

Figure 1. The self-determination continuum (Ryan & Deci 2000a).

Table

Practice points

Motivation can be viewed as both, an independent and a dependent variable in medical education. Motivation as an independent variable influences learning and study behaviour, academic performance, choice of medicine as a career, choice of specialty and the intention to continue medical study. Research on motivation as a dependent variable in medical education is scarce, though the existing research seems to suggest that the learning environment plays an important role in enhancing motivation. A need for more research in this area is identified.

Table 1.  Inclusion and exclusion criteria for studies to be included in the review

Inclusion criteria

Exclusion criteria

1. Studies/reviews on motivation which report empirical research on pre-medical, undergraduate, graduate and post-graduate medical students 2. Studies identifying motivation for medical school/medicine/branches of medicine 3. Quantitative research studies with well-formulated definitions and operationalization of concepts, analysis of data, specific measurement of motivation 4. Qualitative research studies with well-defined concepts, reliable methods (2–3 coders and consensus reached), well-reasoned conclusions and analysis

1. Studies which were not empirical in nature like viewpoints 2. Studies on populations other than on pre-medical, undergraduate, graduate and post-graduate medical students 3. Studies which did not measure motivation with a valid method 4. Studies which measured motivation for very specific aspects like reading, etc. 5. Quantitative studies which did not have complete statistical analyses

Table 2.  Summary of findings – motivation as an independent variable

Serial number	Motivation as an independent variable influences	Total number of papers (Reference numbers of papers included as per the table in the appendix)	Major findings
1.	Learning and study behaviour	7, size of correlations some small and some moderate (papers 7, 9, 16, 26, 40, 41, 51)	– 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.	Academic success/performance	14, small size of correlations (papers 1, 5, 6, 9, 11, 15, 16, 23, 30, 33, 35, 41, 42, 48)	– 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.	Choice of medicine as a career	14 (papers 13, 14, 17, 18, 20, 22, 25, 29, 28, 35, 39, 44, 45, 50)	– 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.	Choice of specialty within medicine	6 (papers 1, 2, 19, 20, 38, 45)	– Primary care specialities are chosen for people-oriented motive – High technology specialities are chosen for science oriented motive
5.	Intention to continue medical studies	1, moderate size of correlations (paper 41)	– Autonomous motivation positively correlated with intention to continue studies and amotivation correlated negatively

Table 3.  Summary of findings – motivation as a dependent variable

Serial number	Motivation as a dependent variable is influenced by	Total number of papers(Reference numbers of papers included as per the table in the appendix)	Major findings
Cannot be manipulated
1.	Age	1 (paper 14)	– Mature-age and normal-age entrants had differences in motivations for choosing medicine
2.	Gender	10 (papers 1, 5, 22, 24, 28, 35, 37, 44, 45, 50)	– 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.	Ethnicity	2 (papers 28, 41)	– Predominant motives of black and white students for joining medicine were different and the findings of the two studies were contradictory
4.	Socioeconomic status	1 (paper 12)	– 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.	Personality traits	1 (paper 43)	– 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.	Educational background	1 (paper 21)	– Non-graduate entry students had higher achievement motivation as compared to graduate entry students
7.	Year of medical curriculum	2 (papers 3, 34)	– 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.	Teacher and parent support	1 (paper 27)	– Having parent support and not having teacher support play a positive and negative role, respectively, in students choosing for medical study
Can be manipulated
9	Autonomy
	Autonomy support	4 (papers 32, 49, 54, 55)	– Autonomy support in medical study was found to stimulate choice of a particular specialty and intrinsic motivation for learning
	Curriculum	2 (papers 49, 56)	– 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	1 (paper 4)	– Greater patient responsibility was responsible for greater motivation for learning
10.	Competence
	Self-efficacy	1 (paper 32)	– Intrinsic motivation was positively correlated with self-efficacy
	Selection procedure	1 (paper 16)	– Students entering through medical entrance exam have higher motivation
	Assessment	1 (paper 52)	– Type of assessment influences type of motivation for study
	Rewards	1 (paper 31)	– Rewards may demotivate significant number of students
	Knowledge acquisition	1 (paper 10)	– Perception of increased knowledge increases motivation
	Perceived task value	2 (papers 32, 55)	– 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.	Relatedness
	Early patient/clinical contact	2 (papers 8, 46)	– Early patient contact stimulates student motivation
	Well-being	1 (paper 36)	– Feeling of well-being enhances motivation

Figure 2. Scheme of literature search and results.

Figure 3. Diagrammatic representation of empirically found variables that affect motivation or that are affected by motivation.

Table A1. &Research papers included in the review.

No.	Study reference	Country setting, N	Research objectives	Findings relevant to the review	Type of study
1	Buddeberg-Fischer et al. (2003)	Switzerland, 719 medical graduates	How do gender and personality traits contribute to their academic achievement and further career planning?	Women plan their career more purposefully than men. Gender, personality traits and career motivation play an important role in academic achievement and career planning	Questionnaire-based, Quantitative
2	Buddeberg-Fisher et al. (2006)	Switzerland, 522 residents	To investigate the influence of gender, personality traits, career motivation and life goal aspirations on the choice of medical speciality	Gender, career motivation and life goals are predictors for speciality choice	Quantitative
3	Burstein et al. (1980)	USA, 246 medical students	To study the characteristics of medical students as a product of professional maturation and personality as opposed to sampling errors	A shift in the motivational structure from achievement to self-gratification needs was found from year 1 to 3	Questionnaire-based, Quantitative
4	Cantillon and MacDermott (2008)	Ireland, 4 interns, 4 staff involved in the programme	To determine the factors that contribute to most motivating effective learning in a general practice setting	Interns perceived greater responsibility for patient care in a general practice learning environment and this was responsible for their greater motivation for learning	Qualitative. This study had a very low sample size, i.e. 4 interns, though the quality of the study and interpretations were sound
5	Carlo et al. (2003)	Canada, 115 first-year medical students	To explore student perceptions and gender differences in perception about effect of motivation, cohesion, sponging, withdrawal, interaction and elaboration on group productivity	Tutorial groups were found to be more productive if the students in the group had higher motivation as compared to those with lower motivation. Female students had significantly higher motivation than male students	Questionnaire-based, Quantitative
6	de Bruin et al. (2005)	The Netherlands, 24 fourth-year medical students and 24 expert doctors	To determine the possible influence of motivation on clinical case processing and recall	There were no differences between the control, low and high motivation conditions in diagnostic accuracy, number of summaries in recall and study time on the cases. These conditions were produced by using external motivators	Quantitative
7	de Grave et al. (2002)	The Netherlands, 200 medical students from year 1 to 4	To explore students' perceptions of incidents in tutorial groups and of the tutor's role in these incidents. Students perceive that lack of motivation in a group member in small group teaching inhibits the learning process of others	Motivational influences have a particularly strong impact on tutorial group function	Questionnaire-based, Quantitative
8	Diemers et al. (2008)	The Netherlands, 24 third-year medical students	To explore what effects early patient contacts have with regards to knowledge construction and development of clinical reasoning skills	Early patient contacts motivate students for medical study	Qualitative
9	Dolmans et al. (1998)	The Netherlands, 39 tutorial groups of students	To expand understanding of cognitive and motivational influences on tutorial group processes	Tutorial group productivity is significantly higher in groups with higher motivation. Motivation also influences cognitive processes in the group significantly	Questionnaire-based, Quantitative
10	Draskovic et al. (2004)	The Netherlands, 89 first-year medical students	To explore the relations between the variables comprising learning mechanisms in small groups	If students feel that the group sessions have brought about a positive change in their knowledge and understanding of subject matter, their motivation for the study and interest in the course content will increase	Questionnaire-based, Quantitative
11	Elam et al. (1999)	USA, 51 at-risk medical students	To determine retrospectively the predictive values of cognitive and non-cognitive variables collected during admissions	There was no significant difference between motivations of academically successful and unsuccessful students on t-test	Mixed methods research, Qualitative data quantitatively scored and analysed
12	Greenhalgh et al. (2006)	UK, 68 high school students	To investigate what going to medical school means to academically able 14–16 year olds from different ethnic and socioeconomic backgrounds	Pupils from higher socioeconomic groups viewed medicine as having high intrinsic rewards like personal fulfilment and achievement and those from lower socioeconomic groups thought more about the extrinsic (financial) rewards of medicine	Focus group study, Qualitative
13	Gussman (1982)	USA, 33 medical students with nursing background	To find out why medical students, who have completed nursing education, choose to enter medical study	Motivations for entering medical study were increased patient care responsibility, medical knowledge, personal challenge and status	Questionnaire-based, Quantitative
14	Harth et al. (1990)	Australia, 121 mature-age and 270 normal-age medical entrants	To compare motivation to study medicine between mature-age and normal-age medical entrants	Most mature-age entrants cited intellectual satisfaction as their main reason followed by working with people and desire to help others. Most normal-age entrants cited desire to help others followed by enjoyment through working with people and intellectual satisfaction	Questionnaire-based, Quantitative
15	Hoschl and Kozeny (1997)	Czech Republic, 92 medical students	To identify variables like pre-medical education grades, admission procedure and personality structure domains with predictive validity for academic success over 3 years of study	Motivation to study medicine is predictive of GPA in the third year, but not the first 2 years of medical study, though the explained variance in GPA was small, i.e. 6%	Partly questionnaire-based and admission interview committee reports, Quantitative
16	Hulsman et al. (2007)	The Netherlands, 418 first- and second-year medical students	To establish how Selection procedure students compared with Random Selection and Direct Access students on motivation, academic achievement, study behaviour and extracurricular activities	Selection procedure students were significantly more highly motivated but this was not reflected in academic achievement, though motivation did affect study behaviour and health care-related extracurricular activities. No significant correlation was found between motivation and academic success	Quantitative
17	Kaplan (1981)	USA, 37 medical students, who were women over 30 years	To study motivations of medical students, who were women over 30, decide to study medicine	Motivations for studying medicine were intellectual stimulation, developing competence and to feel achievement	Questionnaire-based, Quantitative
18	Karalliedde and Premadasa (1988)	Sri Lanka, 154 medical students	To obtain information on the socioeconomic background and aspirations of medical graduates on entry to the medical schools in Sri Lanka	Attraction of medicine as a science and caring for the sick were the prime factors for choosing a career in medicine	Questionnaire-based, Quantitative
19	Kassler et al. (1991)	USA, 293 fourth-year medical students	To determine what factors distinguish medical students who choose primary care careers	Primary care specialty was chosen for direct and continuity of patient care and psychosocial aspects. High technology specialties were chosen for higher income, prestige, research opportunities and better quality of life	Questionnaire-based, Quantitative
20	Khater-Menassa and Major (2005)	Lebanon, 127 graduating medical students	To highlight factors considered by medical students while making a career choice and to compare these between primary care and non-primary care candidates	Intellectual content and helping people appeared to be among the top motivations for medicine and diversity in diagnosis and therapy vs. working with new technology were the reasons for choosing primary vs. non-primary care specialties	Questionnaire-based, Quantitative
21	Kronqvist et al. (2007)	Finland, 25 graduate entry and 120 non-graduate entry medical students	To look at the study performance of students with different educational backgrounds with special emphasis on graduate entry students	Non-graduate entry students had higher achievement motivation as compared to graduate entry students. This finding cannot be generalized as the sample size of graduate entry students (N = 25) was very small	Questionnaire-based, Quantitative
22	Kutner and Brogan (1980)	USA, 338 medical students	To explore the relevance of certain factors to the decision to enter medicine for women medical students	Similar motives were found between males and females for entering medicine, namely interest in people, help others and independence in work	Mixed methods research
23	Lorber and Ecker (1983)	USA, 400 physicians with data from medical school	To analyse effects of achievement motivation, performance in medical school, peer evaluation, prestige of internship and family responsibilities on professional attainment	Achievement motivation was a better predictor of professional attainment in men than in women	Questionnaire-based, Quantitative
24	Loucks et al. (1979)	USA, 246 medical students	To explore whether there are differences between personality traits of female and male medical students	Female medical students were significantly more achievement oriented as compared to male medical students	Questionnaire-based, Quantitative
25	Lovecchio and Dundes (2002)	USA, 97 pre-medical students	To study why students either persevere in their pre-medical studies or seek alternative careers	Pre-medical students were attracted to medicine by scientific interest, intellectual challenge and the power to help others	Questionnaire-based, Quantitative
26	Mattick and Knight (2009)	UK, 15 second- and 13 third-year medical students (follow-up study)	To capture the full range of intentions and motivations for learning that exist within populations of medical students	Motivation to be a good doctor and avoid harm to patients stimulates a vocational approach to study in medical students. 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	Qualitative study
27	McHarg et al. (2007)	UK, 15 second-year medical students	To identify the influences contributing to students’ decisions to study medicine	Parent support and encouragement had a positive effect and lack of teacher support had a negative effect on students' motivation to apply to medical school. The results of this study cannot be generalized owing the fact that the sample size is low (N = 15) and it is a highly selected sample	Interview-based, Qualitative
28	McManus et al. (2006)	UK, 2867 prospective medical students	To explore the nature of the generic motivations for studying medicine in those considering medical careers, and to examine how those motivations differed between different types of individual in terms of demography and personality	Four major underlying dimensions for choice of medicine as a career appear: helping people, being respected, being indispensable and becoming a scientist. Differences were found according to gender and ethnic origin. Males report interest in science and being indispensable as the most important reasons motivating them for medicine non-white students score significantly higher on ‘Science’ and significantly lower on ‘Helping people’ as compared to white students	Questionnaire based, Quantitative, Sizes of correlations between gender and motivations for joining medicine are small (r < 0.2, though statistically significant)
29	Millan et al. (2005)	Brazil, 60 first-year medical students	To determine the reasons for choosing the medical profession and investigate their socioeconomic and psychological profiles and gender differences	Most students had chosen medicine out of altruistic or person-oriented motives followed by intellectual curiosity	Interview-based, Qualitative data assessed quantitatively
30	Moulaert et al. (2004)	The Netherlands, 777 years 1–6 medical students	To investigate the relationship between several aspects of deliberate practice like planning, study style, motivation and self-reflection and study achievements among undergraduate students	Motivation significantly correlated (r = 0.3) with academic performance	Questionnaire-based, Quantitative
31	O’Neill et al. (1999)	UK, 1290 medical students	To look at students' perceptions and effects of awarding degree with honours	More students from the earlier years agreed that a degree with honours was a motivator for learning and the number decreased as they approached final year. An honours system does not necessarily motivate students and may demotivate a significant number of them over time-course of the study	Mixed-methods study
32	Pelaccia et al. (2009)	France, 302 medical and nursing students with a ratio of 1:2	To assess the impact of training periods in the emergency department on the motivation of health care students to learn in the field of emergency medicine	Experiential learning without negative outcome events increases intrinsic motivation for a course. Intrinsic motivation is positively correlated with high perceived task value (r = 0.546), self-efficacy (r = 0.419) and autonomy in learning (r = 0.354)	Questionnaire-based, Quantitative
33	Popovic (2010)	UK, 436 first-year medical students	To identify any connection between students' ethnicity, affluence and academic performance	Neither intrinsic nor extrinsic motivation was significantly correlated with academic performance	Questionnaire-based, Quantitative
34	Powell et al. (1987)	UK, 30 first-, third- and final- year medical students	To study medical students’ perceptions of medicine and its specialties	First-year students are more oriented towards prestige, money and success, but final-year students are more oriented towards relief of suffering and importance for mankind. Though this study was of good quality, the findings have limited generalizability as the sample size was very small (N = 30)	Questionnaire-based, Quantitative
35	Price et al. (1994)	Australia, 399 first-year medical students	To correlate motivational and demographic factors with performance in medical study and its completion	Altruistic reasons were the most important for most males and females, though more females were oriented towards them than men and more men than females were oriented towards financial security. Students entering medicine with intellectual challenge as the most important motive were found to have higher GPAs, though the variance in GPA explained was low, i.e. around 5% (r = 0.05)	Questionnaire-based, Quantitative
36	Ratanawongsa et al. (2008)	USA, 26 residents	To explore residents’ concept of well-being and how it affects their work	Well-being affects motivation in daily work and overall career; lower motivation leading to feelings of ambiguity in career choice and higher well-being leading to greater zeal towards purpose in medicine and intrinsic passion for work	Qualitative
37	Robbins et al. (1983)	USA, 144 third-year and 74 fourth-year medical students	To assess similarities and differences between male and female medical students with respect to fear of success, interests and attitudes towards medical school	Males found interest in science, helping people and having a career, most important motivations to join medicine; whereas women ranked helping people first	Questionnaire-based, Quantitative data assessed quantitatively
38	Rogers et al. (1990)	USA, 266 medical students	To seek factors that influence medical students to choose primary care or non-primary care specialties	Motives for choosing primary care specialties were longitudinal patient care opportunities, whereas motives for choosing non-primary care specialties were better lifestyle, monetary rewards and prestige	Questionnaire-based, Quantitative
39	Rolfe et al. (2004)	Australia, 608 medical students and graduates	To compare the medical school experiences, research and academic achievements and practice outcomes of graduates who entered medical study with high school background vs. tertiary background	Working with people, intellectual satisfaction and helping others and were the most important motives for joining medicine for both high school and tertiary entrants. Significantly more tertiary entrants entered for professional independence than high school entrants and more high school than tertiary entered because of parental pressure. Also significantly more high school entrants had doubts about wanting to be a doctor as compared to tertiary entrants	Questionnaire-based, Quantitative
40	Sobral (2008)	Brazil, 247 first-year medical students	To study the scope of student-selected components in a medical programme and analyse their relationships with achievement and motivation	Higher intrinsic motivation was related to more optional course credits and peer-tutoring activities	Quantitative study
41	Sobral (2004)	Brazil, 297 first-year medical students	To describe the patterns of medical students’ motivation early in the undergraduate programme and to examine their relationships with learning features and motivational outcomes	Medical students portray distinct patterns of autonomous and controlled motivation that seem to relate to the learners’ frame of mind towards learning as well as the educational environment. (GPA in pre-clinical years and motivation correlation r = 0.14).	Quantitative
42	Tan and Thanaraj (1993)	Malaysia, 128 second-year medical students	To explore interactions between study orientations and preferences for different kinds of learning environments	Intrinsic motivation was significantly negatively correlated with academic grades, but it was measured with only one item in the questionnaire	Quantitative
43	Tanaka et al. (2009)	Japan, 112 second-year medical students	To examine the relationships between personality traits and intrinsic academic motivation	The temperament dimension of persistence (r = 0.237) and the character dimensions of self-directedness (r = 0.369) and self-transcendence (r = 0.223), which are expected to enhance the learning process, are associated with intrinsic academic motivation in medical students	Questionnaire-based, Quantitative
44	Todisco et al. (1995)	Australia, 645 first-year medical students	To investigate gender differences in motivations of students at entry into medical school	Both male and female medical students ranked desire to help others as the most important motivation, followed by scientific nature and intellectual challenge of the profession	Ranking-based, Quantitative
45	Vaglum et al. (1999)	Norway, 379 first-year medical students	To study motivation of students for going to medical school	Most important motives influencing the decision to study medicine are helping people, desire for challenge and interest in human biology. Female medical students scored higher on the person-oriented motive, lower on natural science motive and equal to male medical students on status-oriented motive. Differences were also found in motives for choosing specialties	Questionnaire-based, Quantitative
46	Von Below (2008)	The Netherlands, 60 students, 15 facilitators	To assess and analyse students' and clinical facilitators' experiences of the Early Professional Contact course	‘Early Professional Course’ increased student motivation for biomedical and further study. Students were inspired for their future work as doctors	Questionnaire-based, Quantitative
47	Wagoner and Bridwell (1989)	USA, 180 high school students	To assess general motivational factors for choosing a career and to explore if there are ethnic differences	Differences were found between white and black medical students motivations to choose a medical career. Black students gave significantly higher ratings to earning potential, job security and status of a physician than white students	Questionnaire-based, Quantitative
48	Webb et al. (1997)	USA, 206 first-year medical students	To examine relationship between medical school performance and non-academic variables like leadership, expected difficulty in medical school and motivation	Non-academic variables like leadership, motivation and expected difficulty level predicted about 11% variance in academic performance in only one school and the size of correlation of motivation and performance was small (r = 0.22) and not significant	Questionnaire-based, Quantitative
49	White et al. (2007)	USA, 36 medical students	To explore links between medical students’ use of self-regulated learning as it relates to motivation, autonomy and control by comparing PBL and traditional curricula	PBL curriculum motivated students to learn for learning's sake, i.e. intrinsic motivation. This could be because of the autonomy they find in their learning. These students were able to channelize their motivation for effective transition from the classroom to the clerkship. Traditional curriculum motivated students towards obtaining high grades, i.e. extrinsic motivation. This could be because of a controlling environment by the faculty. The transition from classroom to clerkship for these students was more difficult	Interview-based, Qualitative
50	Wierenga et al. (2003)	West Indies, 193 medical students	To study motivation for and concerns about studying medicine and future career plans of students	Main motivations were joining medicine were people oriented, interest in human biology and defined profession. Males had significantly higher orientation than females towards prestige/status, whereas women had higher orientation towards working with people	Questionnaire-based, Quantitative
51	Wilkinson et al. (2007a)	New Zealand, 173 fourth-and fifth-year medical students	To determine how time in study relates to motivation and study approaches	Higher achievement motivation, certainty of career choice and lack of confidence are associated with greater time investment in study	Quantitative
52	Wilkinson et al. (2007b)	New Zealand, 1258 medical students	To evaluate the impact of standards-based assessments on medical student learning	Standards-based assessment system was found to be associated with beneficial effects on deep motive, deep strategy and professional identity	Questionnaire-based, Quantitative
53	Williams et al. (1997)	USA, 207 fourth-year medical students	To determine whether autonomy support by instructors during Internal medicine and surgery clerkships could predict that those students would choose that particular specialty	Choice of internal medicine (r = 0.29) and surgery (r = 0.34) clerkships were significantly correlated with the students' perceptions of autonomy support on their corresponding clerkships. The correlations, though significant, were small in size. Autonomy support enhances students' motivation to select a residency in that particular field of medicine	Questionnaire-based, Quantitative
54	Williams and Deci (1996)	USA, 56 second-year medical students with follow-up data after 2 years	To test whether instructors who are perceived as more autonomy supportive will facilitate students becoming more autonomous in their learning	Autonomy support by teachers was a significant predictor for both, students’ autonomous motivation and competence for a study course	Quantitative
55	Willis et al. (2002)	UK, 16 second- and third-year medical students	To focus on producing a qualitative description of the cognitive and motivational influences on group processes and how they contribute to a successful PBL group	Students in PBL groups felt motivated for group working as they perceived that it was responsible for delivering their learning	Qualitative study
56	Woltering et al. (2009)	Germany, 97 and 88 third-year medical students in blended PBL and traditional PBL, respectively.	To determine whether blended PBL increases students’ motivation and supports their learning process	Students’ motivation is higher in blended PBL as compared to traditional PBL, both through quantitative and qualitative data	Mixed-methods study

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