To the Editor:
Medical education currently is in a state of active reform. Instead of advancing from one level of training to the next after a specific amount of time, there is a movement to base advancement decisions on an individual’s demonstrated competence. The progression from competency-based education to milestones to entrustable professional activities encompasses the work of many innovators in education, all seeking to improve the way future physicians are educated and assessed for the transition to independent practice. In this vein, Yudkowsky and colleagues1 are championing the reinvention of an old innovation—mastery learning standards in medical education. Their work is to be commended, as this type of assessment is likely to gain popularity thanks to its focus on supporting an individual’s pace of achievement without the traditional emphasis on timing. The concept of mastery learning is easily applicable to many clinical and procedural skills, as benchmarks for these are often concretely delineated. Where guidance is still needed, however, is in determining how to apply mastery learning standards to less tangible skills that occur in clinical practice outside of a simulation lab or structured examination setting. It is here that self-determination theory (SDT) and motivation are key players.
SDT is rooted in the human tendency to develop towards intrinsically motivated and self-directed behavior.2 To be comprehensive as an educational tool, part of mastery learning must address the learner’s progress from extrinsic to intrinsic motivation. Based on my current experience as a fellow in neonatal–perinatal medicine, still gaining skills and exploring my own motivation, the integration of these two systems seems logical, if not natural.
The goal in medical education must be to train future physicians in a system that values and promotes mastery and autonomy. These two concepts cannot be separated—simply mastering a task is not enough. It is motivation driven by autonomy, competence, and relatedness that, when coupled with mastery, produces a learner ready for independent practice. This could be accomplished by faculty and learners using mastery learning to scaffold2 a program of graduated autonomy throughout medical education.
Implementing mastery learning is a great start to further advance education, but would be even better if the ideals of SDT and fostering autonomy were effectively integrated. We must strive to create both competent and self-motivated graduates, ready for lifelong learning.
Rebecca Y. Petersen, MD
Second-year neonatal–perinatal medicine fellow, Saint Louis University, St. Louis, Missouri; [email protected]
1. Yudkowsky R, Park YS, Lineberry M, Knox A, Ritter EM. Setting mastery learning standards. Acad Med. 2015;90:14951500.
2. Hoffman BD. Using self-determination theory to improve residency training: Learning to make omelets without breaking eggs. Acad Med. 2015;90:408410.