Expectancy-Value theory was originally proposed by John William Atkinson in the 1950s and 60s as an attempt to understand different behaviors of students including persistence, decision making when given multiple opportunities to choose from, and the effort of striving for success [1]. This work was later expanded by Jacquelynne Eccles in the 1980s and today, is considered to be a major model for understanding how the student’s motivation is affected by the anticipated outcomes of action and the value that the person holds for those outcomes within the classroom. The theory, originally developed for explaining student actions, has been expanded upon over the years and applied to other fields including communication, business management, economics, and marketing. While these other versions have expanded the theory to include other major factors and have looked at the potential implications on understanding the mindset of adults outside of the learning space [2], the major utilization of this theory and the majority of the research was performed within the field of education.

In the classic version, which this paper will use, Expectancy-Value theory postulates that the student’s achievement within the classroom is determined by two major factors: Expectancy, the individual’s belief in their own ability to achieve a goal, and the Value, the foreseen direct or indirect benefits of achieving this particular stated goal [3]. The values that the student places on the activity and on the outcome and the student’s expectancies interact with other factors, including prior experiences, the behaviors of others, and stereotypes, to predict important outcomes. These vitally important outcomes include the student’s eventual and short-term academic achievement, their continuing interest, and their engagement with the course materials.

Two components of expectancies

Within the work of Wigfield & Eccles [1] there are two major components of expectancies: expectancies for success and beliefs about ability. The expectancies for success are those beliefs that the individual student holds concerning how well they will perform on assignments or requirements within a course, both in the near and far future. This component of expectancy is measured similarly to the way that Bandura [4] measured personal efficacy expectations. This runs counterfactual to the claims made by Bandura and other critics who state that the expectancy value theory only focuses on the expected outcome, as in this case the measure is on the personal or efficacy expectations of the individual student.

The second component of expectancy is the beliefs about ability, which is composed of the student’s assessment of their own proficiency within the subject or materials that they are currently engaged in. Within the formal theory, this differs from proficiency on a specific assignment or task and focuses instead on a larger domain. According to the work done by Wolgast [5], children do not know the difference between these two levels and develop this understanding between a larger set of knowledge and their competency within it and the smaller upcoming tasks as they age. This, however, becomes less and less relevant as the child ages and by the time the students are full adults, this difference is clearly understood and in practice.

The four components of task-value

Within the Expectancy-Value Theory there are four major components of Task-Value: Attainment Value, Intrinsic Value, Utility Value, and Cost. These four components interact and affect the eventual total value that the person places on taking the action to achieve the outcome. If the cost component of the value outweighs the benefits that might be offered the student if they were to accomplish the task, then the student will not move forward with taking the action to try to accomplish the required task at hand.

Attainment value, based on the perspectives of value by Rokeach [6] and Feather [7], is the importance that the individual student places on their doing well on the required task. This also includes the specific importance for the individual’s engagement within the activity and its effects on the individual’s “self-schema”. The self-schema becomes involved within the attainment value for the reason that the action of engaging with tasks provides opportunity for the student to demonstrate particular aspects of the individual’s ideal or actual self. Some of the aspects that can be demonstrated include femininity, masculinity, competency in a subject or skill, race, and/or ethnic identity. Those tasks which allow for a clearer and visible demonstration of these aspects are often given a higher attainment value than those that do not because of this interaction with the self-schema.

The second component of value is intrinsic value. Intrinsic value is defined as the inherent enjoyment that is derived from participation within the action or activity – the general subjective interest that the person has with the material or with the subject. Over the years there have been many theorists that have added to the understanding of intrinsic value and this portion of value has much crossover with intrinsic motivation [8,9] and with the ideas of flow and interest [10-12].

The third component of value is the Utility value. This aspect of value is made up of how the individual believes that the outcome of the efforts will apply to their goals. These goals can either be the student’s future goals (i.e. career goals), their current goals (i.e. ability to play sports), or a mixture of both (e.g. keeping a scholarship to mitigate debt). The utility value does not take into consideration whether the student actually is interested in engaging within the activity, but instead looks only at the usefulness of the completion of the activity even if completion of the task is not enjoyable. One example of this is the completion of organic chemistry course work within the pre-medicine degree, most students do not enjoy this course or the work required to be successful within the course. However, they complete the work in order to have the pre-requisite courses to apply to medical school. Because utility value looks at the usefulness of the completion of the work as a means to an end, this portion of total value could be considered to be the “extrinsic” reason for taking action to accomplish the task [8,9]. In a recent study [13], this portion of value was used to broadening student participation within the sciences and encouraging more to consider careers within the sciences. The researchers found that by linking the course material to different utilities, including current personal life and eventual careers, students were more likely to engage within the materials and those who were struggling experiences an increase of their grades by two thirds of a letter grade [13].

The fourth and final component of value is cost. Cost is often described as the negative portions of value and is made up of the amount of effort that the student must exert to accomplish the task, the lost opportunities that the student must accrue to accomplish the task versus engaging in another behavior or other tasks, and other negative consequences that result from taking action to accomplish the task. Some of these negative consequences include the fears (i.e. fear of failure or fear of public speaking) and anxieties (i.e. performance anxiety or social anxiety) that the student must push through to successfully complete the task and the resulting social repercussions that can occur for the work that they are doing within the course in order to accomplish the tasks that are presented them. As a result, according to Eccles et al. [3], cost is a highly important and key component of total value within the minds of the students.

In 2002, Eccles and Wigfield expanded on the Expectancy-value theory and took a look at other theories within the field of educational psychology and how these theories interacted within the framework of Expectancy-value theory. In this piece of work, the authors broke the major educational psychology theories into four categories. These categories were, theories focused on task value (theories focused on intrinsic motivation, goals, interests, and self-determination), theories focused on expectancies for success (control theory and self-efficacy theory), theories that integrated cognition and motivation (the social cognitive theories of self-regulation and motivation and theories of motivation and volition), and theories that demonstrated an integration of both values and expectancies (attribution theory and self-worth theory). Eccles and Wigfield also discussed in this work how the theories of Expectancy-value and self-regulation could be integrated into a larger general theory of motivation [14].

Modified versions of the theory

Other versions of this theory either expand on the central concepts or try to envision them in other ways. In one version of this theory, motivation is described as the product of the expected success of the endeavor and the values placed on both the task and the reward of the task [15]. In the version by Vroom [16], instrumentality, or the belief that the effort will achieve the desired goal, is the additional factor in motivation – this is the version of expectancy theory which is used within the field of organizational behavior and some fields in higher education [17]. One of the more recent models stated that relationships have a strong impact on the development of expectancies and values. This model stated that the behaviors, beliefs, and attitudes of those who were influential in the lives of the students had significant impact on the development of the students’ values and expectancies, indicating that they are at least at a minimum relationally dependent [18,19]. According to Heckhausen [20,21], there are four (4) different types of expectancies which are the outcomes of an individual’s actions that are immediately seen as a direct result of the action that the individual performs. These expectancies are: Action-outcome, Situation-outcome, Outcome-consequence, and Action-by-situation-outcome. The immediate results are then shadowed by assorted effects including but not limited to evaluation by one’s self or others. The consequences of the actions are attributed an incentive value, thus, the motivation of the students to take any action is dependent on the values of the consequences of those said actions.

Application of theory within the clinical space

 Having seen the work that has been accomplished thus far it can be seen that the application of this theory has been well explored within the classroom, but has not been studied well within the medical school environment and the clinical environment. Some studies have been performed on retention of students within biological classrooms and others on residency program motivation, but little research has been done on medical school itself using this theory [22,23]. One area within the medical school model that might have great benefit with the use of this theory is the highly contentious Honors grade. This grade of honors, which is introduced to students in the clinical year of medical school, as an additional level of achievement, has been under large amounts of scrutiny as many institutions phase out any forms of grades outside of the Pass/Fail system. While, grading systems vary widely among medical institutions nationwide, there have been a movement towards a pass/fail system to help facilitate a more cooperative culture among medical students. During the clinical years, as an effort to increase the student’s motivation and help with distinguishing students as higher achievers than their peers, the Honors grade is added as an additional grade to the Pass/Fail system at Dell Medical School.

Because of the high stakes that are placed on trying to achieve a distinction from one’s peers to be competitive for residency placement, many students feel the need to pursue the Honors grade. Nevertheless, this bar contains a level of subjective grading which can influence the students’ motivation and has been hotly debated at the Dell Medical School for several years and in the larger field of medical education for several years. One of the other areas that makes this topic so contentious is the fact that the Honors grade is not found in the first-year curriculum, which is graded without a subjective evaluation. Because the clinical year is where the Honors grade is added to the curriculum, the students’ expectancy for achieving the Honors bar and the value they place on the grade can be observed before the clinical year and after the clinical year.

Research question

1. How do Medical Students expectancy and values change after the Honors Bar introduction during the second year in the clinical environment?

Participants

The participants for this study will be comprised of the fifty (50) medical students at the Dell Medical School starting their second year of medical school. These students when they registered for courses within the medical school agreed to fill out surveys at the end of each course and at the beginning and end of each school year – these surveys are required and failure to fill out the survey comes with the penalty of a professionalism citation. They also agreed during registration that their grade data including performance on examination could be used within the school for quality improvement projects for specific courses and for the material from their surveys to be used in conjunction with grade related data for improving the overall curriculum of the school. In this survey, the students give answers to questions including their belief on their own clinical skills, their belief in their ability to achieve an Honors Grade in the clerkships, and their likelihood to pursue the Honors Grade; these surveys use a Likert scale. As a result, the existing surveys can be adjusted to include pertinent questions to allow for the researchers to both ask their questions and to draw conclusions from the overall data that is collected as part of the student requirements at the school.

This type of methodology for the recruitment of students has already been performed both in the recent past and over the last four years as a way to see if course material needed to be spread out to increase learning and for other quality improvement projects at the medical school. This is considered to be the standard practice within the Dell Medical School and has been used since the school opened with some of the faculty within the medical education department being both researchers for best methods and administrators. Therefore, in performing this experiment to better understand the effects of the Honors grade on the students’ expectancies and, as a result, on their motivation is within the scope of this already existing system.

Measures

Using survey questions, two major areas will be observed in the Medical Students: their expectancies for success (defined as achieving the honors bar within a clinical clerkship) and their subjective task value of the honors grade. These survey questions will be based on currently verified methods from the literature with minor modifications for the medical sphere. Finally, these surveys will be distributed through the One45 system in use at the University of Texas at Austin’s Dell Medical School at the beginning and end of each of the clinical clerkships, just like they are distributed currently.

Expectancies for success: To measure their expectancy for success, the medical students will be asked questions based on the Academic Efficacy Scale from the Patterns of Adaptive Learning Survey [24]. These questions will assess the medical students’ judgments about their ability and confidence to perform at the Honors level (e.g. how sure are you that you can achieve the Honors cut off score on the National Board of Medical Examiners’ shelf exam for this clerkship?) and will encompass both the objective and subjective grading criteria.

Subjective task value: For the medical students’ Subjective Task Values (STV), the measures will be derived from the previous work of Eccles and colleagues [25-27]. There will be questions focusing on the different areas of the STV: Attainment Value (e.g. getting an honors grade is a part of my identity), Intrinsic Value (e.g. I am interested in this particular specialty as my eventual career specialty), Utility Value (e.g. getting an honors grade will help in my career), and Cost (e.g. I will have to give up a lot to receive the honors grade within this clerkship). This will allow for the researchers to see the individual components of the student’s value of the Honors bar within the clinical environment of the clerkship.

Procedure

For this study, the participants will be working on their clerkship materials and will be given a self-evaluation survey at the beginning of their second year of medical school, a survey at beginning of each clerkship, and a survey at the end of the second year. These surveys are already a part of the Dell Medical School curriculum and the modification through the addition of these specific questions about the honors grades within their clerkships. The survey given at the beginning of the year is the exact same survey given to the students at the end of the second-year curriculum to see what differences that the students saw within their own performance between the beginning of the school year and the end of the school year. This information will be collected using the standard One45 software system that the Dell Medical School uses for the students to ensure both confidentiality and anonymity. This system codes the students in such a way that only the raw data is available to those reading the survey.

Clerkship surveys: At the end of each clerkship, students are required to fill out surveys on their performance and their experienced effort. Additional questions on how they felt the clerkship either supported them or was unable to provide adequate support for their learning are also included within this survey. This survey will be utilized with some minor modifications to include specific questions for the study. Again, this will be collected using the One45 software system that the Dell Medical School uses for the students to ensure both confidentiality and anonymity. As a result of this, again, only the raw data will be available for the researchers to use for statistical analysis.

Data analysis: The information from the surveys will be collected and then analyzed using standard statistical methods similar in nature to that of Safavian & Conley [28] using SPSS statistical software. The students’ expectancies and values will also be mapped using a moving average graph to show how these average values change over the period of a year with the Honors grade. The independent variable for this will be the addition of the Honors Bar and the dependent variable will be the students’ expectancy and value. This will allow the medical education staff to see the effects that the addition of the Honors bar has on the students’ overall motivation, the effect Honors bar has over the period of a year, and be given the ability to understand whether or not it accomplishes the goals that they have hoped to achieve through the creation of this additional grade.

For this particular study, it is the researcher’s belief that he will see the students developing lower and lower average expectancy values for their expectancy for success as the year progresses. He thinks that there will be an initial high expectancy where the vast majority of the students’ expectancy and value for the honors bar will be high and then the expectancy will plummet sharply and remain low after the first two clerkships of the total six that the students take over the course of the year. The averages for the students’ value for the Honors bar will remain relatively stable with some drop in the value, specifically in the components of Attainment Value and an increase in the Cost portion of the overall subjective task value. The author believes that the students will experience the nadir of the expectancy after the third clerkship, around the winter holiday with some minor increases in both the expectancy and the value, but not to the level that they had at the beginning of the year. The final survey result collected at the end of the year will show an overall lower average score for both the expectancy and the value than the beginning of the year survey’s averages. These average scores will be higher than the scores from around the December holidays, but still lower than from the beginning of the second year (Figure 1).

This study looks to see the expectancy-value theory of motivation put forward by Atkinson and Eccles applied in the clinical space as a potential tool for understanding the effects that curriculum design can have on the motivation of the students. This application of the theory within the clinical space is a novel application of the theory outside of the didactic classroom. The major goal is to understand better the grade of Honors within the clinical clerkships and to determine if it achieves the desired goals of increasing student motivation within the clinical environment. This also allows for a determination of whether a pass/fail system is enough to encourage high performance or whether the addition of a higher grade increases the likelihood that students are motivated to work harder within the clinical space.

Thirdly, according to the theory, if the student’s expectancy for success is decreased, then their motivation will also be decreased. This can lead to several negative issues for the students (i.e. poor academic performance, increased levels of stress, increased subjective levels of burn out, etc.). These negative effects of demotivation are important to the student affairs departments at schools nationwide and are areas that these department look to address on a regular basis, usually through the use of counselor programs and mandatory wellness lectures. However, if one of the root causes of this demotivation is addressed, then the educators will be able to prevent many of the symptoms that develop later on such as poor performance in courses or burn out.

Implications for theory and practice

The major implications coming from this study pertain specifically to how the Honors grade is perceived by other institutions and the national residency match program. For many specialties, the use of Honors as a distinction is one of many factors used to select qualified individuals to work as resident physicians. If this is shown to be a major demotivator for students and has a diminishing return on the students’ mental health, further research can be directed towards its role as part of the larger mechanism for physician burn out and suicide rates.

Another major implication of this study is a potential increase in the current understanding of how the student’s motivation eventually translates into the working person’s motivation. The time spent in the clinical environment is set up to mirror the work of the full-fledged physician with time spent acquiring a proper medical history, performing a full physical exam, determining a care plan, coordinating care between different specialties, and developing a plan for discharge. Clinical education continues long past the traditional schooling with many of the students continuing to receive further training and retraining to maintain board certifications on a regular basis. As a result, in seeing how this theory applies to the clinical space, there is a potential for medical educators to both understand how this theory applies to students in the medical field and further development of this theory in the working clinical world. It also allows these educators to determine if the incentives such as the Honors grade has the desired effect of increasing the motivation of the students and if this should be continued for use once a student is no longer in medical school. Many work programs have minor awards that are often used to motivate employees. However, if the Honors grade is a mirror of some of these reward programs, this might shed light that these programs only work to demotivate employees instead of increasing their motivation to work hard.

The biggest limitation for this study is the fact that the cohort of fifty (50) medical students is very small for a study that looks to generalize the results for the entire field of medical education. However, this makes this study an excellent preliminary study, but any and all generalizations coming from this study must acknowledge its small sample size. One of the most striking limitations to this study is that the Honors grade at Dell Medical school is different from Honors grades at other institutions; so any and all assumptions about the conclusions of this study must be viewed through this lens. Another major limitation is the lack of control for the different aspects of the curriculum. There are many potential factors that can cause demotivation among students from personality issues with faculty, to issues with course materials, therefore, there is no way to directly link a students’ overall motivation with only the effects of the Honors grade. Also, within this is the fact that Honors as a grade is opted into, therefore, not every student will be affected by the addition of this grading criteria within the clinical year. Finally, Dell Medical School is the second most difficult school in the United States to matriculate to. Less than one percent of students that apply ever begin classes; because of this exclusivity, generalizations must take into account the nature of the students that are enrolled at the institution and how the student that attends Dell Medical School might differ from other students found nationwide or globally.

For future research projects, the next best direction would be to see how the Expectancy-Value theory evolves with students’ training levels. As a student physician transitions to resident physician, their overall workload increases and the amount of care that they are providing also increases. Seeing the value that the physician holds for the work and effort they put into patient care and into continuing education (reading of the newest literature) is an important area of research. An understanding of the burn out of physicians and how their experiences in medical school including the inclusion of the Honors grade during their education is also important. Finally, understanding how the expectancy for success and how the physician relates this to their daily motivation as resident and eventually fully practicing physicians, is key to understanding long term motivation in a field that does not allow for the practitioners to fall behind on continuous learning.

The authors have no conflicts of interest to declare.