Anyone who has taught medical students is familiar with their overwhelming desire to perform well and to be recognised for that performance. This is particularly true in high-stakes assessment. Most students believe they need high marks in order to be competitive, to ‘get it right’, and to display their true abilities. Drawing on Teunissen and Bok's1 analysis of Dweck's2 theory of students' self-theories, and the effect of students' theories on performance, we might conclude that this obsession with performance is evidence of their entity self-theories. Students holding entity self-theories believe their intelligence is fixed and cannot be changed, and see assessment as an opportunity to demonstrate that intelligence. As their ability has been previously recognised in their selection into medical school, failure and even error are not acceptable, and their occurrence reflects on them as people. By contrast, students who hold incremental self-theories believe they can improve their intelligence by working to understand learning tasks. For them, failure is an opportunity to understand where they have made mistakes and to correct them. It does not reflect on their worth as individuals. Most students believe they need high marks in order to ‘get it right’ and to display their true abilities Teunissen and Bok1 follow Dweck and Grant3 in proposing that these two different ways of thinking – different self-theories – are related to different goal orientations. Entity self-theorists are more likely to hold performance-oriented goals, in which the desired outcomes are success and self-display. Incremental self-theorists are more likely to hold learning-oriented goals, in which the outcome is mastery of the task, and the task and the performance of it are separate from the self. This difference in goal orientation is important as different learning goals lead to different learning strategies and reactions to feedback. People with a learning goal orientation are more likely to apply deep learning strategies, seek feedback and see feedback as helpful, whereas people with a performance goal orientation are more likely to apply shallow learning strategies, not to seek feedback, and to view feedback negatively and personally when it is given. Different learning goals lead to different learning strategies and reactions to feedback Is it possible that the high levels of achievement attained by most medical students foster entity self-theories? This seems unlikely. If all medical students were entity theorists, the insights offered by Dweck's work,2 and applied by Teunissen and Bok,1 would be of little value in medical education. On the contrary, these insights about medical students' motivations are valuable for medical educators and students alike. It is not helpful, however, to see the world as simply divided into entity self-theorists and incremental self-theorists. To do so would be to fall into the trap of believing that an incremental self-theory is every bit as fixed and unmalleable as an entity self-theory. It would also ignore the role of context in people's engagement with their environments and performance tasks. As Dweck observes: ‘…although these beliefs are relatively stable individual differences, they are also highly dynamic.’2 People's self-theories are plastic and can change with circumstances and educational input. It is important to keep in mind that self-theory is a theory of motivation, developed to explain what drives people to succeed.4 It may be entirely appropriate to have a performance goal orientation in certain contexts. In their clinical interactions, for instance, students need to have belief in their own ability and confidence in how they perform. When learning a new clinical skill, however, students need to be open to feedback and even criticism. Here, an incremental theory is more appropriate. In fact, an entity approach might prevent skill acquisition. People's self-theories are plastic and can change with circumstances and educational input Although beliefs and confidence do not belong exclusively to either entity or incremental motivations, medical practitioners cannot entirely isolate themselves from their medical performance. Students also, however, need to be able to learn from their mistakes and to understand that failure does not strike at the heart of their being, but offers an opportunity for growth and change. Failure, like success, can bring challenges and opportunities.4 The original research underlying Dweck's theory5 focused on the reactions of children faced with failure. How closely can the reactions of adults in vocational learning be equated with those of children? How robust is the allocation to either entity or incremental self-theory and does it change over time for an adult? Perhaps most importantly for medical educators, is the connection between self-theory and goal orientation fixed, or can self-aware adults hold to an entity self-theory but change their goal orientations in response to contextual demands? Are learning styles and reactions to feedback aligned with specific goal orientations or can they also change over time? It is difficult to fully assess the implications of such theoretical associations without understanding these relationships across situations and over time. Is the connection between self-theory and goal orientation fixed or can self-aware adults change their goal orientations in response to context? Despite these questions, the concept of self-theories is likely to be of great interest in medical education. Selection into medical programmes has evolved over the past few decades from the use of prior academic performance alone to the inclusion of aptitude tests and interviews that consider the personal qualities of the candidate. It may be tempting to add a measure of self-theories to selection instruments. However, this would be contrary to Dweck's thesis2 that people's self-theories and motivations are malleable and can change with intervention. For clinical teachers, it might be useful to bear these contrary self-theories in mind when interacting with individual students. Awareness of these motivational tendencies has bearing on how feedback is structured, and in assisting students to use feedback productively. The examination of self-theories during training may also be of use, particularly if it is matched with interventions that might move individuals to incremental self-theories and more learning-oriented goals. This notion has to some extent already been explored in reflective practitioner approaches,6 but specific behavioural outcomes have not been assessed with either approach. Awareness of these motivational tendencies has bearing on how feedback is structured The potential for self-theories to be important to medical practice is significant and therefore the use of this theoretical and empirical work to build programmes of research examining the influence of these self-theories on medical practice is critical.1 For this to be effective, other related theoretical frameworks considering reflective practice and effective feedback must also be considered. Research focused specifically on medical students and practitioners under particular conditions of study and practice is needed to tease out the various possibilities offered by different theoretical perspectives. As Robert Sternberg observed, ‘…the main constraint on achieving expertise is not some fixed prior level of capacity but purposeful engagement.’7 Helping our students to understand that this purposeful engagement is not only productive but also satisfying may involve making them aware of their self-theories and learning goal orientations. It does not mean that we hang out a notice declaring ‘Entity theorists need not apply’. We thank Teunissen and Bok1 for their thought-provoking review and encourage the medical education community to consider their material in the context of medical education curriculum implementation, assessment and research.
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