Professional conduct of physicians and medical students requires a high degree of psychosocial competence. Non-cognitive capabilities -- such as communication skills, psychological sensitivity, and the ability to successfully tolerate and cope with ongoing stresses and frustrations -- are essential for effective interactions with a wide range of patients and co-workers.
Medical curricula and residency programs in Western countries increasingly reflect the bio-psychosocial model proposed by Engel [1
] and include significant behavioral science components. The curriculum that is currently advocated requires students to shift from the traditional bio-medical, disease-centered focus to a patient- or relationship-centered orientation [2
]. However the integration of non-cognitive components in medical education may be challenging for many medical students. If students fail to comprehend the relevance of psychosocial topics to medical practice, their learning motivation will be poor, because motivation is often related to the relevance of learning processes [3
]. In practice, students are often reluctant to study communication skills and may display initial (or even lasting) resistance and skepticism as they are instructed to change their orientations and behavior [4
As psychosocial competence and frustration tolerance are important goals in healthcare professions, it is important to understand better how they might be enhanced in medical educational environments. Since all learning is driven by motivation (i.e. the willingness to exert effort toward educational goals, often despite difficulties and setbacks), we applied in the present study a motivational theory perspective: specifically, goal orientation theory. The aim was to investigate how self-reported psychosocial abilities and frustration tolerance might be associated with different motivational orientations among first-year medical students.
Goal Orientation Theory
is a well-established perspective on students' motivation [5
]. According to this theory, motivation can be defined by the general goal orientations students follow in the process of learning. For example, when two individuals engage in the same task; one may do so in order to demonstrate his/her abilities to others, while the other may wish to enjoy the activity and acquire new skills. These two individuals are expected to demonstrate different behaviors and affects toward the task. The first may invest effort only in tasks he/she will be able to perform well by demonstrating his/her relative abilities -- even by using unacceptable behaviors such as cheating [8
] -- while the second may choose challenging tasks that will enable him or her to improve their knowledge and make significant inter-personal progress.
Scholars have attempted to classify and define those orientations. Within the goal-orientation literature, three goals are commonly known. In Mastery, the purpose is to acquire new knowledge or skills, characterized by those who enjoy merely participating in the act of learning. For example, a student who aspires to learn new concepts in Math or to solve equations that he did not succeed in the past, is considered as mastery orientated student. The goal of Performance-Approach is to gain a positive external evaluation, typified by those who wish to gain public recognition of their abilities. In this case the student will be eager to outperform his friend and to get recognition of relative abilities; his standard of success would be normative. In Performance-Avoidance, the purpose is to avoid negative external evaluation--those oriented as such wish to avoid being considered incapable. A student with this goal orientation will avoid situations in which his performance will be evaluated in relation to others [9
]. These three goals are referred to as general orientations (i.e. general attitudes toward the task), rather than specific targets. Thus, when someone is mastery-oriented, his/her general approach toward the task would be general self-improvement, rather than attaining a specific target (e.g. improving course grades by 10 points). Conversely, when one is performance-approach orientated, he/she would focus on demonstrating superior relative abilities (e.g. getting the highest course grades). One with performance-avoidance orientation would make an effort to hide his/her lack of ability (e.g. avoiding participation or asking questions that may result in negative evaluation of his/her knowledge).
Recently, mastery-avoidance goal has also been discussed in the literature. It has been suggested that the purpose of this goal is to avoid deterioration of knowledge or skills that had been previously acquired. However, the definition and measurement of mastery-avoidance is still under dispute [11
]; therefore, it was not included in the current study.
The findings regarding the benefits of goal orientations for various learning processes were consistent over the years and suggested that among the three orientations, the mastery orientation is the most adaptive performance goal in various learning environments [12
]. For example, it was found that university students' levels of mastery goal orientation predicted their performance of a task requiring long-term retention of information. Conversely, performance-avoidance was negatively related to performance on that task [13
]. Other studies found that students who reported holding mastery goals were more likely to use superior learning strategies such as deep information processing of new knowledge and elaboration (i.e. attempting to link the new information with old knowledge that had already been acquired) [14
]. This was also found in relation to those who held performance goals and tended to use inferior strategies such as memorizing [15
]. Such findings suggest that students who are orientated toward self-improvement will not just attempt to memorize the learning materials; rather they will strive to achieve better understanding of said materials, will make them more personally meaningful, and remember them for longer periods of time after learning.
It should be noted that the goal orientation theory was found applicable for many other contexts. Associations have been found between goal orientations and test anxiety [16
], well-being in school (i.e. peer relationship, impulse control, and emotional tone) [17
], inter-personal conflict solution strategies [18
], establishment of intimate peer relationship [19
] and even achievements [13
]. These studies found that mastery goal orientations were more advantageous in the long term.
In the present study, we aimed to explore the usefulness of applying goal orientation theory to studying the effects of medical education, in the present case specifically, a physician-patient communication course. A recent study conducted in the context of medical education applied for the first time the goal orientations theory. Its findings supported the hypothesis that mastery goal orientations are likely to be associated with more beneficial outcomes in medical students' training, as compared to other goal orientations. In that study, mastery goal orientations were associated with positive outcomes (e.g. students' interest, effort, etc.) and were negatively associated with negative outcomes (e.g. tension and test anxiety) [22
In the present study we explored possible associations between concepts from goal orientation theory and two potential outcomes of participation in a physician-patient communication course: desirable one - psychological medical abilities, and a negative one - low frustration tolerance.
Psychosocial medical abilities
were defined as the level of interest, confidence, clinical abilities and sensitivity in addressing the psychosocial aspects of patient care [23
]. This is an important aspect of students' interpersonal self-efficacy (i.e. the beliefs in one's future professional expertise as a physician) that was recently established as relevant to learning communication skills among medical students [24
Low frustration tolerance
(LFT) is a concept rooted in rational-emotive behavior therapy (REBT) models and denotes an irrational thinking pattern. REBT views psychological rationality as "that which aids and abets people achieving their basic goals and purposes"; and irrationality as "that which hinders or obstructs people from achieving their basic (long-range) goals and purposes" [25
]. LFT specifically denotes intolerance of physical or emotional discomfort i.e. the inability to accept unpleasant physical sensations and symptoms, such as pressure, numbness and pain [26
]. LFT is the tendency to exaggerate life's frustrations and inconveniences, viewing any form of discomfort as almost intolerable and to be avoided whenever possible. This tendency leads to dysfunctional behavioral consequences such as procrastination, resistance to change and lack of compliance with medical recommendations [26
This conceptualization of LFT suggests that a high LFT score at the end of the communication course implies lower student ability to cope with demands and stress. Medical students as well as physicians are faced on a daily basis with countless stresses and frustrations. Successfully coping with these challenges is essential for effective professional functioning.
Based on the conceptualization of the mastery orientation as the more adaptive performance goal [10
] and LFT as a dysfunctional discomfort avoidance tendency [26
] we formulated the following hypotheses:
Hypothesis 1: The more adaptive goal orientation (mastery goal) would be found positively linked to desirable outcomes (in this case, perceived psychosocial ability) and negatively linked to the negative/maladaptive characteristic (low frustration tolerance, LFT).
Hypothesis 2: Conversely, the less adaptive goal orientations (i.e. performance-approach and performance-avoidance) would be found negatively linked to the desirable outcome (PMI) and positively linked to the maladaptive characteristic, LFT.