“Grabbing” Autonomy When the Learning Environment Doesn’t Support it: An Evidence-based Guide for Medical Learners

According to self-determination theory (SDT), environments which support the basic psychological needs for autonomy, competence, and relatedness will facilitate autonomous motivation, learning, and wellness. On the other hand, environments which introduce external controls and power dynamics into the equation will do the opposite. Educational studies support these principles, yet most have focused on learners’ need satisfaction as a passive process (e.g., via support or hindrance by educators), rather than the agentic pursuit that SDT emphasizes. In this commentary, I draw on my experience as a practicing physician and SDT researcher, and focus on how medical learners can “grab” more autonomy when the learning environment does not support it. I present a hypothetical case of a preceptor whose teaching style is controlling and unfortunately well-known to medical learners. I then unpack the case and outline different strategies that medical learners can use to navigate this type of interpersonal conflict.


Introduction
The controlling preceptor: a hypothetical case Please imagine that you are a senior medical learner about to start your Adult Emergency Medicine rotation.Today's shift is from 16:00-23:00 with a preceptor, M.L., who you have not worked with before.You nervously make your way to the Emergency Department (ED), where this preceptor greets you.They briefly ask which year you are in, and if there is anything you want to focus on, which leads you to believe they are interested in teaching and helping you to develop.Unfortunately, the next 7 hours does not unfold this way… The preceptor is nice to others, but with you, they are standoffish, impatient, and intimidating.Instead of encouraging you and providing structured guidance, independence, and choices, they scrutinize your work, limit you to seeing only new patients, and assign them to you without discussion: no re-assessments, entering of orders, following of investigations, calling consultants, or handling of discharges.Whenever you see a patient together, the preceptor also repeats your history and physical exam and excludes you from the conversation.They often pressure you with rapid-fire questions, use a harsh tone of voice, and dismiss your ideas and opinions.Your initial motivation is quickly replaced by anxiety about assessment, and it undermines your performance.In the end, your preceptor gives you a negative evaluation and provides no affirmation for what you did well.You finish the shift feeling frustrated and stressed about the formal evaluation to come.
Unpacking the case from a self-determination theory point of view This is a classic example of a preceptor whose style was controlling, counterproductive, and psychologically harmful 1,2 .They were demanding and disrespectful, and instead of adopting an unconditional positive regard, which still permits them to challenge and provide corrective feedback to learners 3,4 , they used a harsh tone of voice and punished the learner for making mistakes.The preceptor also provided no encouragement for what the learner did well.Instead of feeling excited about their learning, the preceptor made the learner feel pressured and incapable of being their true self.This led, in turn, to feelings of alienation and anxiety, priming the learner to fear making mistakes and letting their preceptor down 1,5 .Having to submit a mandatory evaluation to this preceptor, combined with being micromanaged and distrusted, ultimately undermined the learner's autonomy and performance 1,5 .In the end, the preceptor's feedback was destructive and the learner ended their shift feeling annoyed, deflated, and worried about the future.Does this scenario seem familiar?If so, you are not alone.This kind of preceptor behaviour is unfortunately still alive and well in medicine, and unintentional as it may be, it can be seriously harmful to medical learners.I, myself, have encountered this situation enough times throughout my medical training, and through trials and tribulations, have learned a thing or two about how to deal with it.Part of this discovery was learning about self-determination theory (SDT) and how its universal needs framework could help me maintain my own motivation and wellness, regardless of what was happening around (or to) me.The following section focuses on some of these aspects and how we can all adapt, as learners, to make the most of these negative situations.
A few notes here, before the "tips" section.First, the tips provided in this article do not necessarily just apply when the learning context is controlling -they can also apply in other situations where one's motivation and well-being are down.Second, this paper is geared towards medical learners; however, I also invite medical educators to consider this article.They play a key role in the teaching and learning process and also share the same human needs in common.Lastly, whether a student thrives in a need-thwarting context is usually mediated by fulfillment of basic psychological needs provided by that environment.The context I have outlined, however, is not the norm and usually only happens intermittently and for brief periods of time.Whether or not the average medical learner would maintain their wellness, independent of such a context over time, is thus of less relevance here.This article was written simply to help medical learners make the most of the situation, if and when the learning environment does not support their autonomy.
Practical tips for dealing with controlling learning climates Now some preceptors are just demanding and rigid in their ways, so trying to quickly adapt and incorporate their feedback should first be attempted, provided it does not compromise one's values and integrity.To negotiate a more motivationally supportive environment for oneself, suggesting a change in the flow of instruction from the preceptor is also an option.Reeve and Tseng 6 refer to this as "agentic engagement" and explain how working intentionally with the teacher like this can "pull" more autonomy support out of them.If tensions are felt to be too great, however -between what is best for one's learning and wellness versus what is best for achieving a desirable evaluation -know that this is true-to-life and there are other steps we can take to satisfy our need for autonomy.SDT's view is that "asserting" autonomy

Amendments from Version 1
I have taken the reviewers' helpful comments and made some changes to the original manuscript.First, I am now more specific with "preceptor" and "learner" in the hypothetical case, so that it is clearer who I am referring to.Second, I have added a few side notes, before the tips section, explaining the focus of the paper more specifically, and how the tips can be used not just with controlling learning environments but in general as well.Third, I have added a few sentences to speak to SDT's concepts of "need crafting" and self-setting intrinsic goals, including a new tip on this topic, at the end.These changes were made in an effort to clarify the writing, further specify the focus of the paper and how its contents can be useful to medical learners, and to expand on the practical tips section, to be more thorough.

Any further responses from the reviewers can be found at the end of the article
(fighting against the obstacles that prevent us from expressing our opinions, interests, and desires) is a natural response to need-thwarting environments 7,8 .Thus, trying to create opportunities to satisfy one's own basic psychological needs -a concept known as "need crafting" in SDT -may at times be particularly useful 9,10 .One may already be doing aspects of this in one's medical education.The aim here is to make the implicit more explicit, to facilitate that process.
Recognize the situation.First, knowing when the learning climate is "controlling" and what that concept means is helpful because naming the problem allows us to process it better 11 .Part of this is recognizing when and how the environment is hindering our sense of autonomy, competence, and relatedness.Research in SDT shows that authority figures tend to be controlling for two main reasons -either because of external pressures they are facing, which frustrate their own basic psychological needs, and/or because they believe that controlling others with incentives and pressures (i.e., out of "mustivation") is a better, easier way to motivate them than trying to inspire them and support their autonomy (i.e., out of "wantivation") 12 .Ironically, being autonomy-supportive is a skill that anyone can learn 13 , it has many reciprocal benefits for the teacher 14 , and it promotes better learning, performance, and wellness for medical learners, as well as quality of patient care 1,2,15 .
Lean into negative emotions.Second, understanding this preceptor's frustrating behaviour and how it would undermine anyone's performance, recognising it is psychologically harmful and counterproductive, and that it is generally not the learner's fault, are also key realizations.According to SDT, facing and trying to process these thoughts and feelings, rather than suppressing them or allowing them to overwhelm us, is a more autonomous and healthy approach to emotion regulation and coping 16 .This is especially true when our emotions are challenging or painful because it allows for an inward reflection that fosters self-awareness and self-acceptance 17,18 .It can also help to quieten our ego and promote self-compassion when our performance falls short of expectations 19 .Medical programs often teach socioemotional matters like mindfulness and resilience 20,21 .However, from my experience, they seldomly discuss them in the context of controlling learning climates and psychological need frustrations, which are strong predictors of motivation and well-being outcomes in medicine 22 .
Self-reflect and put things into perspective.Third, it is useful to remind oneself that this is a single shift, with a single preceptor, out of many hundreds or more in one's medical training.In other words, consider the subjectivity of evaluations, and the inherent personality factors that play into them.Here, it is also helpful to compare this preceptor and their assessment(s) to others one has worked with.To ask oneself if things are representative, off base, or if one is simply having a bad day, which happens to everyone.It is also valuable to consider how certain preceptor styles will set us up to succeed or fail before we even begin.For example, the above preceptor limited the learner to only seeing new patients, whose issues were undifferentiated and arguably the hardest part of working in the ED.If the same preceptor had let the learner take part in the ongoing care of their patients and encouraged them to take more responsibility for them, they would have better supported the learner's autonomy, learning, and well-being 1,23 .Either way, studies in SDT show that mindfulness and autonomy-supportive self-talk can help us to deal with this kind of situation 24,25 .Negative life experiences are also great opportunities for learning.Our integration versus defensiveness of them simply depends on whether we can meet our basic psychological needs or not 7,[26][27][28] .
Connect with patients and peers.Fourth, cultivate relationships with patients.They are presenting because they are unwell and the care and support we can provide them is often deeply rewarding 29 .Take the time that is afforded to get to know them.Collaborate with the nursing staff and others.When a preceptor is controlling, distant, or unsupportive, this is a sure way to "grab" some relatedness satisfaction, which supports our autonomy 30 .Patients, allied health staff, and other medical colleagues also tend to notice these efforts, and it can come back around to positively shape a preceptor's impressions and behaviours.While I do not recommend disrespecting your staff or venting to patients, taking the time to sit with and comfort them, and to express one's thoughts and feelings, can go a long way -both for them and for us, as physicians 7,29 .Of course, if there are other medical learners nearby who one can confide in and talk to, take that opportunity for emotional support as well.Provided that exchanges are socially appropriate and constructive, this too can help us claim a little more need satisfaction and confidence when we need it 31,32 .
Stay curious and remember the big picture.Fifth, there is nothing preventing us from staying up to date on what is occurring with our patients, and from watching out for certain investigations to come back (e.g., labs or imaging), based on our initial assessments.This can help to close the loop and promote our learning, grit, and self-determination 7 .
Depending on what was agreed upon at the beginning of one's shift (e.g., "everything goes for ordering tests except d-dimers, CT, or MRI"), one may also consider ordering new investigations if they are felt to be relevant.This shows a priority of patient care that can help to positively reframe the situation 33 , and to (re)shift one's perceived locus of causality (i.e., felt autonomy for behaviour) from external back to internal 25 .A limitation here is that some preceptors may perceive this kind of behaviour as overly assertive, so being cautious and using one's better judgment is recommended in this case.

Find closure through honest and constructive feedback.
Sixth, when one's formal evaluation gets completed, there will typically be the chance to provide some feedback in return.Tempting as it may be to denigrate the preceptor, use this opportunity to diplomatically share one's negative experience with the medical program instead, including who the preceptor was and how their style of supervision undermined one's learning, performance, and wellness.Consider qualifying the feedback with specific examples, along with ways that the preceptor could improve, to help facilitate better collaboration, engagement, and learning outcomes in the future.Ultimately, the preceptor is doing what they think is best (even if it is inefficient and psychologically harmful) and taking the time to recognize this, and that they are also learners, shows maturity, empathy, and integrity.According to SDT, altruistic behaviour like this can also help us to gain some closure and satisfy our basic psychological needs 34 .
Self-set intrinsic goals.Finally, research in SDT has shown that goal strivings are most successful and adaptive when they are based in autonomous (vs.controlled) motivation 35,36 .This happens when our goals are self-congruent, aligned with intrinsic, need-satisfying aspirations, and when they are supported by empathic (vs.directive) others.Focusing on intrinsic goals is a lot harder to do, however, when a preceptor fails to invest time in learning what a learner's goals are, when they use a controlling motivating style with learners, or when a learner is pressured to focus on performances and evaluations (extrinsic goals) over learning, serving others, and having fun (intrinsic goals).Hence, setting intrinsic goals before and after work shifts -e.g., that relate to self-development, relationships, and community contributions -can therefore help to support one's own self-determination and well-being.

Conclusions
As a medical learner, one will inevitably find oneself in controlling learning environments that can lead to feelings of being pressured, powerless, and frustrated.One may not be able to change the situation or the preceptor, but there are cognitive, emotional, and behavioural strategies that can be used to adapt and maintain one's motivation and wellness.Guided by SDT, the aim of this commentary was to discuss some of these strategies, and how to use them, when the learning climate is not supportive of autonomy.Identifying the controlling environment, proactively engaging with one's preceptor, using mindfulness and self-talk, connecting with patients and peers, taking personal responsibility for one's learning, giving constructive feedback to the program, and self-setting intrinsic goals.These actions can facilitate integration of the negative experience, support one's clinical learning and development, and help one to meet their basic psychological needs.
Thank you for the opportunity to review this commentary entitled ""Grabbing" autonomy when the learning environment doesn't support it: an evidence-based guide for medical learners".This is an interesting manuscript.However, before being suitable for indexing, the manuscript need some expansions and revisions.I appreciate the brevity of the manuscript, although the paper is on how to motivate one self, the manuscript focuses a lot on the context.The focus of the manuscript is on controlling (needthwarting) instructors.The focus could have easily been on a student with low motivation for completing a task, not mentioning the context.The reason why I highlight this is because the context exemplified here is very need-thwarting I would say.If actually this is the case that the average student would thrive independent of such a controlling context over time, more citations on similar studies are needed, or a more thorough description.I would recommend re-focusing the story here because although autonomy orientations (personality) predict wellness and thriving, this effect is usually always mediated by need-satisfaction (usually provided by the context).
Having said this, there are some additional "tips" that are missing from this manuscript.For one, I think the concept of need-crafting deserves to be mentioned because this is basically what the manuscript is about.Some recent papers by Laporte et al are recommended.There are also some papers by Koestner, and Cheon on setting self-set intrinsic goals, which also I encourage to consider in these tips 1,2,3,4,5 .Sheldon have papers on reflecting on ones relative autonomous motivation (organismic valuing process), which is think is also very interesting in terms of practical suggestions.I real strength in this paper is the focus on mindfullness for the integrative process.I guess emotional regulation could be mentioned more explicitly, especially if the author continues with a focus on the context?Another strength is the broad review of important literature in such a short manuscript.While I'm not familiar with the tone of this journal and the level of formality, my comments should obviously be evaluated in light of this, but I do believe the manuscript would be strengthened if a less context-situation is provided in the intro, and more additional SDT tips are provided.

Are arguments sufficiently supported by evidence from the published literature and/or the authors' practice? Yes
If evidence from practice is presented, are all the underlying source data available to ensure full reproducibility?Not applicable

Are the conclusions drawn balanced and justified on the basis of the presented arguments? Partly
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Self-Determination Theory, higher education, learning, achievement, autonomy-support I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.The tone of the article is a little more colloquial than one would normally find in an academic paper, but, given that it is aimed directly at the learner, that is probably appropriate.
I have only one concern, and that is a small issue around the language used in the opening part of the paper: While I appreciate the need for non-specific pronouns, when both parties in a conversation use the same pronoun, the author needs to be extremely careful.Given that this is a hypothetical case, the author has greater freedom than if a real case were being used.Please consider either using different pronouns or repeat the nouns, otherwise, a sentence like this requires several readings, and the reader becomes so bogged down in trying to understand who is who, that the message is lost: "They also provided no encouragement for ○ what they did well." In fact, in a later sentence, the grammatical structure of the sentence implies that the "their" in the opening subordinate clause refers to "the preceptor" in the main clause, making the sentence barely intelligible "Instead of feeling excited about their learning, the preceptor made the learner feel pressured and incapable of being their true self."At this stage, I think several readers would be tempted to simply give up.Reviewer Expertise: Medical Informatics I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

Reviewer Report 30
May 2023 https://doi.org/10.21956/mep.20549.r33168© 2023 Masters K.This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Kenneth Masters Medical Education and Informatics Department, College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Oman This is an interesting article offering guidance for medical learners in an adversarial clinical setting.

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So, a good and useful read, but a bit of clarity required in the opening scenario.Is the topic of the practical tips discussed accurately in the context of the current literature YesAre all factual statements correct and adequately supported by citations?YesAre arguments sufficiently supported by evidence from the published literature and/or the authors' practice?Yes If evidence from practice is presented, are all the underlying source data available to ensure full reproducibility?Not applicableAre the conclusions drawn balanced and justified on the basis of the presented arguments?YesCompeting Interests: No competing interests were disclosed.