A Brief History of SDT in Health Professions Education

Self-Determination Theory (SDT) has a long and evolving history in health professions education (HPE), grounded in foundational motivation science and progressively applied to learning, assessment, teaching, professional identity formation, and well-being across medicine and the health professions. Over several decades, SDT-informed scholarship has developed increasing theoretical sophistication, empirical breadth, and practical relevance, positioning motivation not as a fixed learner trait but as a dynamic outcome of educational and healthcare environments.

Early Foundations: Internalization, Autonomy, and Professional Values

Early applications of SDT to medical education can be traced to the mid-1990s. Seminal work by Edward L. Deci and Geoffrey C. Williams demonstrated how medical learners internalize the biopsychosocial values of patient-centred care, and how autonomy-supportive educational climates foster higher-quality, more enduring forms of motivation (Deci & Williams, 1996; Williams & Deci, 1998). These studies showed that when learners experience respect for their perspectives, meaningful rationales, and opportunities for choice within structure, they are more likely to integrate professional values into their identities rather than merely comply with external expectations.

Related longitudinal and experimental studies demonstrated that medical students’ specialty choice and career intentions were shaped not simply by aptitude or prestige, but by the degree to which preceptors supported autonomy versus control, with autonomy-supportive mentoring promoting deeper internalization and more adaptive forms of motivation (Williams et al., 1994; 1997). These early findings established a foundation for understanding professional identity formation as a motivational process shaped by interpersonal and institutional contexts.

Conceptual Expansion: SDT as a Framework for Medical Training

In the 2000s and early 2010s, SDT became increasingly articulated as a unifying framework for understanding how medical training environments influence learning, emotional development, and well-being. Patrick and Williams (2009) argued that medicine’s historical focus on intellectual mastery had often neglected the psychological and emotional dimensions of becoming a physician, contributing to emotional suppression, burnout, and diminished patient-centredness. SDT offered a way to integrate cognitive, emotional, and professional development through systematic support of autonomy, competence, and relatedness.

This conceptual expansion was further advanced by Baldwin (2012), who emphasized that autonomy-supportive clinical teaching is not incompatible with high standards, structure, or accountability, but rather enhances learners’ capacity to engage with challenge, feedback, and responsibility. Later conceptual work extended this lens beyond pedagogy to ethics and healthcare culture. Neufeld and Rigby (2024) clarified the critical distinction between autonomy and independence in medical education, showing how conflating these concepts leads to both under-supervision and unnecessary control. Neufeld (2025) further extended this work into bioethics and clinical care, arguing that autonomy support must be understood as an active, relational practice grounded in perspective-taking, structure, and moral responsibility.

Systematic Reviews and Consolidation of the Evidence Base

As empirical work accumulated, systematic reviews synthesized SDT’s growing role in HPE. Kusurkar and colleagues demonstrated that motivation operates both as an outcome of educational environments and as a powerful predictor of learning, performance, specialty choice, and persistence in training, highlighting that autonomy support, feedback style, and relational climate are modifiable determinants of educational success (Kusurkar et al., 2011; 2012).

Subsequent systematic reviews by Orsini and colleagues expanded the field across medicine, dentistry, and interprofessional education, documenting associations between SDT-consistent teaching practices and deep learning, engagement, vitality, and well-being (Orsini et al., 2015; 2016). This synthesis was later extended to educators themselves through the BEME systematic review on clinical teachers’ motivation, which showed that faculty motivation is shaped by the same psychological needs as learners and is central to sustaining high-quality teaching cultures (Orsini et al., 2024).

Broadening Applications Across Roles and Contexts

Over the past decade, SDT research in HPE has diversified substantially. Studies have examined admissions processes, minority learner experiences, motivational profiles, clinical supervision, interprofessional education, and faculty motivation to teach. This work has shown that learners and educators vary meaningfully in the quality of their motivation, with implications for resilience, performance, engagement, and professional identity formation.

Parallel research has extended SDT beyond learners to physicians as teachers and lifelong learners, demonstrating that clinicians who experience greater psychological need satisfaction at work show higher teaching engagement, stronger learning orientation, and greater professional fulfillment (Babenko et al., 2018; Ding et al., 2019). These findings reinforce SDT’s relevance across the full continuum of health professions development.

Assessment, Supervision, and Training Culture

SDT has also played a central role in reframing assessment, feedback, and supervision in medicine. Ten Cate (2013) highlighted how feedback and entrustment can collide with learners’ psychological needs when implemented in controlling or opaque ways, particularly in high-stakes training environments. Subsequent empirical and qualitative studies have shown that when EPAs, feedback, and coaching are delivered in autonomy-supportive, transparent, and relationally grounded ways, they can strengthen competence, trust, and intrinsic motivation rather than undermine them (Hoffman, 2015; Sasek et al., 2023).

Building on this foundation, Neufeld, Guldner, and Smith (2025) extended SDT into contemporary competency-based medical education (CBME), integrating concepts emphasized by other SDT scholars such as agentic engagement (Reeve) and change-oriented feedback (Mageau et al.) to show how modern assessment systems can either promote ownership and growth or drift toward surveillance and compliance. This work situates SDT as a core framework for redesigning assessment cultures in ways that support learning, professional identity, and patient-centred practice.

Integration With Healthcare, Communication, and Patient Outcomes

Although this page focuses on education, SDT research in healthcare has deeply shaped HPE. Large bodies of work in medicine, physiotherapy, and allied health have demonstrated that autonomy-supportive communication improves adherence, glycemic control, smoking cessation, and engagement in rehabilitation (Williams et al., 2002; 2004; Murray et al., 2015). Meta-analyses and reviews have shown that these effects are mediated by psychological need satisfaction and quality of motivation (Ng et al., 2012; Sheeran et al., 2020).

These findings have directly informed how communication skills, supervision, and patient-centred care are taught across HPE programs, linking learner motivation to downstream patient outcomes.

Emerging Directions: Culture, Emotion, and Systems

Recent work has increasingly focused on the emotional and cultural dynamics of training. Studies examining emotion regulation, mistreatment, burnout, and depression in residents have demonstrated that controlling climates foster suppression and distress, whereas autonomy-supportive cultures promote resilience, empathy, and ethical engagement (Zheng et al., 2025; de Goot et al., 2025).

At the same time, SDT is now being used at institutional and national levels to guide wellness strategies, leadership development, and systems change, alongside growing efforts to translate SDT into practical tools for faculty development, assessment design, and organizational learning (Neufeld, 2025).

Together, this body of work positions SDT as a foundational science for understanding and improving learning, professional development, and care across the health professions—linking educational climates to the quality of motivation, the formation of professional identity, and the well-being of both clinicians and patients.

Productive Tensions and Complexity in HPE 

Health professions education involves inherent tensions that cannot be “solved,” only navigated. SDT provides a lens for understanding and working with these realities:

• Autonomy vs. patient safety
• Growth vs. assessment and accountability
• Structure vs. control
• Efficiency vs. human connection
• Standardization vs. individual development

Rather than eliminating these tensions, SDT helps educators and leaders design environments that protect motivation and ethical practice within them.

Common Misconceptions About SDT in HPE 

• Autonomy = giving learners more choice → ❌ Autonomy includes meaningful rationale, structured guidance, and perspective-taking

• Autonomy means independence → ❌ Autonomy refers to experiencing volition and psychological ownership, even within close supervision or directiveness

• Relatedness = belonging → ❌ Belonging is one component of relatedness, but relatedness also involves feeling seen, respected, and accepted for who one is, not only for how one performs or fits in

• Competence = confidence or skill → ❌ Competence refers to feeling effective, capable of learning, and able to grow; novices can feel highly competent when development is supported, and experts can have low competence satisfaction when growth is stalled

• SDT lowers standards → ❌ SDT supports high expectations and performance paired with psychological support

• Motivation is a trait → ❌ Motivation is largely shaped by educational and workplace environments

• Well-being competes with performance → ❌ Well-being and performance are often mutually reinforcing

Clarifying these misunderstandings is essential for effective and ethical application.