Medical student motivation in specialised contexts

During their clinical years, medical students rotate in diverse environments, each with unique factors motivating or demotivating learning. Student motivation to learn in specialised clinical settings has not been robustly described. One framework to understand motivation to learn is self‐determination theory (SDT), which posits that intrinsic motivation requires fulfilment of three innate psychological needs: competence, relatedness and autonomy. Referencing SDT, the authors aimed to understand factors influencing student motivation to learn in the specialised context of internal medicine (IM) subspecialty consult services, with the goal of optimising teaching and learning during these experiences.


| INTRODUCTION
Throughout medical school, medical students experience a diverse array of clinical settings, each with unique and often specialised clinical content.Student motivation to learn during each of these experiences may vary based on several factors, including the clinical focus, the student's career interests, the teaching received and team dynamics.During their final year of medical school, students often complete clinical electives in specialised fields with goals including career exploration, professional development and the pursuit of individual interests. 1,2One setting for such electives is on inpatient internal medicine (IM) subspecialty consult services.On these services, IM subspecialists (e.g., gastroenterologists, nephrologists and endocrinologists) do not take primary responsibility for patient care but instead offer expert guidance to the primary teams caring for hospitalised patients.Inpatient consultations are well suited for student learning as teaching is recognised as a facet of consultation medicine. 3,4Inpatient consult electives can improve students' specialty knowledge and offer opportunities for direct observation and feedback. 5e framework to understand student motivation during clinical rotations is self-determination theory (SDT), which posits that three innate psychological needs-competence, relatedness, and autonomy-must be satisfied to support intrinsic motivation (Figure 1). 6,7Competence is the need to feel effective, relatedness is the need to feel connected with others, and autonomy is the need to behave of one's own volition.Ryan and Deci 8 review the large body of literature demonstrating that, in educational environments, supporting these needs improves learners' intrinsic motivation.0][11] Indeed, students' perceptions of their competence and autonomy support during IM versus surgical rotations were predictive of their chosen specialties. 12perts in the field of SDT have offered perspectives on how needs-supportive practices can be applied to health professions education. 7,13,14Original qualitative work examining health professions students' experiences and the specific factors that promote or undermine their needs satisfaction across learning contexts remains limited.
Prior work includes studies surveying and interviewing dental, nursing, and medical students.[17][18][19][20][21] Through the lens of SDT, inpatient specialty consult electives pose inherent and potentially demotivating challenges for student learning such as specialised knowledge, the unfamiliar skill of consultation, 22,23 lack of clarity around the student's role on the team, inadequate structure and feedback, 24 and perceived 'distance' between the student and their specialised supervising clinicians as compared to closer near-peer residents on core clerkships.Furthermore, medical students typically experience a progression of responsibility-they are entrusted with more clinical duties as they advance through their training. 25,26This progression may be undermined when students rotate on specialty services where they lack the requisite advanced knowledge to practise competently and autonomously.Together, these challenges may undermine fulfilment of students' basic psychological needs.
The purpose of this study was thus to gain insight into factors that influence students' motivation to learn in specialised clinical contexts and, in particular, inpatient IM subspecialty consult electives (herein called 'consult electives').Better understanding may enable educators to improve student experiences and enhance motivation, thereby promoting learning.We further aimed to apply the SDT framework to aid in the identification of teaching strategies to promote student motivation.Our research question was as follows: What aspects of specialised clinical learning experiences on consult electives promote and hinder medical students' motivation to learn?

| Approach and research paradigm
We conducted a qualitative study using semi-structured focus groups of fourth-year medical students.We opted to conduct focus groups and not individual interviews as we believed the conversations between participants and sharing of experiences would yield ideas and observations beyond what could be obtained through one-on-one interviews.Throughout the research process, we followed published standards for reporting qualitative research. 27We followed an interpretivist research paradigm because we valued the students' experiences in their own words as well as our own lenses as a medical student and inpatient faculty educator. 28We used SDT as a sensitising framework for abductive thematic analysis. 28,29

| Context
The University of California, San Francisco (UCSF), is an academic urban medical centre with approximately 160 medical students per year participating in a four-year curriculum.In their final year, students choose electives to advance their knowledge and skills, often in specialised areas.Student roles on these electives always include direct patient care and vary from moderately autonomous to highly supervised, depending on educator preference.

| Participants and recruitment
Between November 2020 and January 2021, one investigator (SMF) sent email invitations to all UCSF fourth-year medical students soliciting voluntary participation from those who had completed at least one consult elective.We defined IM subspecialties as those in which the American Board of Internal Medicine offers certification: cardiology, endocrinology, gastroenterology, infectious disease, haematology/oncology, nephrology, palliative care, pulmonology, and F I G U R E 1 Self-determination theory describes the innate psychological needs of learners that must be fulfilled to support their intrinsic motivation to learn, namely, competence, relatedness, and autonomy.rheumatology.We did not include critical care as this is mostly a primary service at UCSF.Out of approximately 160 students contacted, 12 agreed to participate.Participants were provided with an information sheet and received a $20 electronic gift card.

| Procedures
We created a semi-structured focus group guide using standard principles and informed by SDT (see Box 1 and Appendix S1). 30 In January 2021, SMF moderated three focus groups on Zoom, each with four students.
We chose SMF as the moderator rather than a neutral moderator because we felt SMF's position as a student peer who had experienced consult electives and as a member of the research team who was passionate about this topic might promote trust and comfort for the participants and evoke honest and open responses related to shared experiences.Prior to leading the focus groups, SMF was trained by SB.They also met after the first focus group to review the transcript, and SB provided feedback to SMF that she incorporated in the subsequent focus groups.After obtaining participants' verbal consent to proceed, we utilised the whiteboard feature on Zoom to allow students to engage in brainstorming and discussion in response to an open-ended question about learning during their consult electives.If these topics did not come up organically, we then asked a series of questions about whom students learned from, what resources they used to learn and how their experiences on consult electives compared to their experiences on other inpatient services (Box 1).The focus group guide included multiple prompts under each question to assist the moderator in facilitating discussion if needed, but these were not asked specifically in each session (Appendix S1).The focus groups were recorded, and the audio files were professionally transcribed.Information sufficiency occurred as we analysed the third focus group. 31,32We collected standard demographics information from participants using a brief survey.

| Data processing and analysis
We (authors SMF and SB) conducted an abductive thematic analysis. 29,33We reviewed the transcripts independently and assigned codes using open coding.After coding the first transcript, we met and resolved any discrepancies through iterative discussion and created a codebook.We then coded the final two transcripts, met after each transcript was coded and modified the codebook based on our analysis.After codes were finalised, we identified themes through iterative discussion.Throughout the processes of transcript coding and thematic analysis, we referenced SDT while remaining open to ideas outside this framework.To aid in co-construction of themes with the participants, we sought feedback from the participants on our analysis, in line with our goal of accurately synthesising their experiences.

| Researcher reflexivity
At the time of this study, SMF was a fourth-year UCSF medical student who had completed core clerkships and three consult electives and had experienced positive and negative examples of teaching and learning on those rotations.She was a peer of the participants and, as she both conducted the focus groups and participated in the thematic analysis, was inherently not blinded to the identity or specific comments of the participants.SB is a hospital-based (inpatient) oncologist and clinician educator who supervises fellows, residents and medical students on UCSF's inpatient oncology consult service and runs the oncology consult elective for medical students.He had seen a list of participants' email addresses for the purposes of distributing research incentives and had interacted with some of them through his roles in clinical education but was blinded to their identities in the transcripts.Together, we brought student and educator perspectives to this work, which was important for maintaining a balanced viewpoint during data analysis.Specifically, SMF identified with many of the student quotations and was able to interpret their meaning through the lens of her own recent experiences, while SB was able to draw upon his years of experience as both a learner and an educator working on consult services to place the student role in the greater context of the consult team during analysis.Both perspectives affected theme development.Throughout the data analysis process, we explicitly reflected on our own experiences and perspectives to ensure that, although they were used to interpret the focus group data, they did not override the voices of the participants.

| RESULTS
The participants (Table 1) had experiences across various IM subspecialties: cardiology, endocrinology, gastroenterology, haematology, infectious disease, nephrology, oncology and pulmonology.Most 5. How was learning on an inpatient consult elective different from learning on inpatient primary services?6.Is there anything that we should have talked about but did not?a The full focus group guide can be found in the Appendix.
Eachquestion had sub-prompts that could be used to stimulate discussionif needed.participants had completed one to two consult electives.Through analysis of the transcripts, we identified three themes encapsulating the factors that influence student motivation to learn on consult electives: (1) teaching at the appropriate level, (2) integration into the team and the workflow, and (3) self-directed learning and career exploration.
We identified three themes encapsulating the factors that influence student motivation to learn on consult electives.

| Theme 1: Teaching at the appropriate level
Specialty rotations are inherently challenging because they present medical students with advanced knowledge and complex clinical situations with which they have little to no experience.Considering these challenges, students felt supported in their learning when they were taught (1) straightforward frameworks to structure core/foundational knowledge and (2) real-world approaches to managing more complex, uncertain or specialised clinical scenarios.Students recognised the gap between their pre-existing knowledge and the knowledge within a specialised field.In different scenarios, this gap might serve as a motivator for or, as one student shared, a barrier to learning: The discourse and the level of complexity of the patients were so far over my head … part of that was just the nature of being on a consult service where everything is a little more specialized and complicated … I felt like I was starting low and they were so high, it was like I wasn't even really able to meet in the middle.

| Foundational knowledge
Some students felt they did not know where to begin learning on consult electives and appreciated direct teaching around key foundational topics.For instance, one student found it difficult to wade through the multitude of HIV medications independently and would have benefitted from a brief discussion with an attending or fellow to frame the knowledge (S8).Students viewed several forms of teaching as effective, including chalk talks (where educators utilise a whiteboard or equivalent to facilitate their teaching points), discussions, and Socratic teaching during rounds (where the educator asks the student a series of questions to gauge their current understanding and guide their learning).Guidance towards resources to accomplish core learning was also helpful, such as a reading list of key studies to know or online learning modules to complete.In general, when teaching was targeted to a medical student level, learning was optimal, and motivation was promoted.In contrast, student participation in didactics targeted at fellows was important for integrating students into the team (see Theme 2) but often not of high educational value for students due to the specialised content.
When teaching was targeted to a medical student level, learning was optimal, and motivation was promoted.

| Complex approaches
For complex cases, students valued learning real-world approaches to applying primary data and expertise to clinical care.Students' experiential learning on consult electives included how to approach complex T A B L E 1 Characteristics of participants in a 2020-2021 study about motivation to learn involving 12 University of California, San Francisco, medical students who had completed various inpatient internal medicine subspecialty consult electives.There were many components to integrating a medical student into the consult team.

| Logistics
Students identified several logistical barriers that prevented them from feeling fully integrated into the team.Examples included not knowing the schedule and not being told about fellow didactics they could attend.One student, who did not have access to certain areas of the hospital where patients were located, shared: I just always had the sense that having a med student there was an afterthought.There wasn't a good avenue for me to interact with the admin people … little logistics like that can eat up a lot of time and brain power. (S6)

| Positive relationships with team members
Having positive relationships with team members motivated student engagement and learning.On smaller consult teams, students valued opportunities to work closely with attendings, fellows and interdisciplinary team members such as specialty pharmacists and nurse practitioners.One student described the team as a 'small environment' with a 'warm tone' that supported learning (S11).Ensuring students had a defined role, setting clear expectations, including students in the team's clinical work, and identifying teachable moments promoted positive relationships between students and team members and fostered student motivation to learn.Conversely, students felt demotivated to learn when they perceived that team members were not interested in, or did not have time for, teaching due to competing priorities.

| Responsibility for patient care
Students were motivated when they could contribute to the team, which most often occurred through patient care involvement.Students were motivated to learn so they could help the team with difficult clinical decisions: The way that I can offer something back is by just doing some digging [into the medical literature] and at least being able to show up the next day and say, 'Here are the pieces that are relevant and we're going to solve the puzzle that way'.

(S7)
Additionally, students were motivated to convey accurate recommendations to requesting teams and to answer follow-up questions from the requesting team correctly.Students who were less involved in patient care felt less integrated into the team's work and were thus demotivated to learn.

| Grades and evaluations
Four-week electives were graded on an honours/pass/fail scale, while 2-week electives were graded pass/fail (i.e., not graded).One barrier to integrating students and forming good relationships was grades and evaluations.Students who were not graded appreciated the 'lowto no-pressure setting' in which to learn and felt 'less performative' (S5); it was a 'breath of fresh air' (S10).But for students who were graded, the grade caused stress, impaired learning, and hampered the opportunity to build authentic relationships with team members.

| Elective length
One factor that modified the impact of integration into the team was the length of the elective, which was either 2 or 4 weeks.
During 2-week electives, full integration was less paramount, and students often felt they could focus on learning without fully investing in team relationships and mechanics.It was more important for students to be integrated into and build relationships with the team during four-week electives.One student also recognised four-week electives as an opportunity to, 'gain more of a sense of competence for […] basic consults', (S9) as there were opportunities for repetition of material.Conversely, hindrances to team integration were more detrimental during 4-week electives due to length of exposure.

| Theme 3: Self-directed learning and career exploration
On consult electives, students were motivated by the ability to drive their own learning, which started with selection of the elective(s) to enrol in.Reasons for selecting a particular elective included career exploration and development, preparation for future practice (including other fourth-year rotations and residency), and desired improvement in self-identified areas of weakness.During consult electives, students could often select learning topics of interest to them.
On consult electives, students were motivated by the ability to drive their own learning.

| Co-construction of themes
We contacted the 12 participants by email to elicit feedback on the proposed themes above to aid in co-construction of the results. 34ong the seven who responded, support for the proposed themes was unanimous.No participants suggested changes to the proposed themes, and thus, no changes were made in response to their feedback.

| DISCUSSION
The themes from this study offer educators insight into factors promoting and hindering the drive to learn that fourth-year medical students experience in specialised clinical environments.The themes further contribute to an understanding of how the three innate psychological needs outlined by SDT can be satisfied in the consult elective setting.The overlap of the themes across multiple innate needs highlights that fulfilment of competence, relatedness, and autonomy is interconnected.

| Application of SDT
The innate needs posited by SDT can be satisfied in the learning environment of consult electives, and individual factors may fulfil one, two or all three needs (Figure 2).

| Competence
Competence is the need to feel effective.Students felt competent when team members taught foundational knowledge with appropriate framing (Theme 1).When the level of teaching was too advanced or when students did not receive adequate guidance on how to frame core topics, students felt a lack of competence and thus felt demotivated to learn.Students also felt competent when team members helped students understand their approach to complex or uncertain clinical scenarios (Theme 1), while not sharing their approach with students hindered fulfillment of the need for competence.Additionally, students felt competent and motivated to learn when clear roles and expectations enabled them to contribute to the team and patient care (Theme 2).Lastly, students felt competent when they could research valuable information of particular interest to them and bring it back to the team (Theme 3).

| Relatedness
Relatedness is the need to feel connected with others.Students felt a sense of belonging and connectedness when they were integrated into the team, including participating actively in patient care, encountering few barriers to participation, and being invited to join teaching sessions and other team activities (Theme 2).Conversely, students did not feel they belonged and were demotivated to learn when they felt unwanted or excluded from the team's work.Additionally, providing teaching at the medical student level (Theme 1) and supporting students' self-directed learning efforts (Theme 3) also fostered a sense of belonging by demonstrating respect for the students and an investment by the team members in helping students learn and grow.
F I G U R E 2 Factors in the specialised clinical learning environments of internal medicine subspecialty consult electives that fulfil medical students' innate psychological needs as outlined by selfdetermination theory, thereby promoting intrinsic motivation to learn.These factors were identified in a 2020-2021 study of 12 medical students at the University of California, San Francisco.Within each large box, an overall theme identified in the study is listed on the left, and factors that falls within each theme are in grey bars to the right.The width of each grey bar demonstrates which need(s), listed above, the factor fulfils.

| Autonomy
Autonomy is the need to behave of one's own volition.One practice that satisfied students' need for autonomy was providing clear roles and expectations (Theme 2).With this structure in mind, students were then able to act independently and manage their own time and tasks effectively.By contrast, grades are recognised within the SDT framework as a controlling structure that undermines autonomy and motivation; the absence of grades supported student autonomy in this study (Theme 2), corroborating prior findings within and outside SDT. 8,35Another factor that promoted student autonomy and motivated learning was allowing students the freedom to choose electives and immerse themselves in topics they wished to explore (Theme 3).
Indeed, just the provision of electives has been recognised to support medical students' autonomy. 36Finally, when students were directed to high-yield resources, they subsequently felt empowered to pursue self-directed learning (Theme 1).

| Fulfilment of innate needs in specialised clinical settings is interconnected
Through this work, we gained insight into how medical students' innate needs may be satisfied and their motivation to learn promoted on consult electives.We found that fulfilment of the three innate needs of SDT was interconnected in these learning environments; practices that led to satisfaction of one need often led to satisfaction of multiple needs.Indeed, the themes identified in this study spanned autonomy, competence, and relatedness (Figure 2).For instance, teaching at a learner-appropriate level may enhance both the student's sense of competence and as well as their perceived value and connection to the team, or relatedness.For students immersed in a specialised clinical environment, a feeling of belonging may be connected to a sense of intellectual acceptance or the idea that the student is 'speaking the same language' as the more advanced team members.If the teaching level is too high, students may feel intellectually excluded from the team.Other work has demonstrated that teaching learners via preferred methods is perceived as autonomy-supportive. 37lfilment of the three innate needs of SDT was interconnected in these learning environments.
Similarly, when the student role and expectations are clear, students will feel both more competent in their role and also more able to function autonomously as a team member.In a specialised clinical environment where tasks are complex, students must first understand their role and feel capable of fulfilling their assigned responsibilities before they can progress to feeling able to carry out those responsibilities autonomously.The ability to function autonomously then feeds back to help the student feel more competent.Thus, autonomy and competence in specialised clinical settings are interconnected.The idea that autonomy and competence are interrelated and both promoted by structure or scaffolding is well established in the SDT literature. 8,38It has further been shown that autonomy-supportive medical school environments lead to fulfilment of the other needs and promote student wellness. 17 a final example, self-directed learning in specialised clinical settings fulfils all three needs when students bring learning back to the team, when that learning is recognised and valued by the team, and when the information contributes to the clinical care the team provides.Thus, becoming an autonomous learner on the team can actually contribute to a sense of intellectual belonging as the student contributes valuable knowledge to the team.Prior research in health professions education has likewise demonstrated that autonomysupportive environments promote autonomous learning and lead to better fulfilment of competence. 18In specialised learning environments, as in other educational environments, the three needs reinforce each other, in addition to contributing independently to students' intrinsic motivation to learn.Understanding this interplay is important for fostering a learning environment that supports learner motivation.

| Recommendations
Based on this study and the principles of SDT, we propose strategies to help educators create learning environments that satisfy students' psychological needs and promote motivation in specialised clinical contexts such as IM consult electives, which may present barriers unique from those in core clerkships (Table 2).For example, a written syllabus can be provided to students at the start of a clinical rotation that provides a list of core topics for them to learn and resources they can utilise as well as a detailed description of their expected role on the team.The list of topics and resources is an example of level-appropriate teaching (Theme 1) and fulfils their need for autonomy, while the delineation of clear roles and expectations is an example of how students can be integrated into the team (Theme 2) and fulfills all three psychological needs.Another recommendation is to include students in multidisciplinary discussions, which students identified as a key type of teaching they sought on consult electives (Theme 1) and made them feel a part of the team (Theme 2).This recommendation fulfils learners' needs of competence and relatedness.Additional recommendations are included in Table 2.
T A B L E 2 Recommendations for educators to promote medical student motivation to learn during inpatient internal medicine subspecialty consult electives, derived from themes that emerged from a 2020-2021 study of 12 medical students at the University of California, San Francisco.

Theme Recommendation Examples
Teaching at the appropriate level Teach frameworks around knowledge that is known • Provide a list of topics students should encounter on their rotations and resources they can use to learn about them (e.g., learning modules or recommended literature).• Ensure there is some teaching targeted to the student (i.e., not all teaching should be targeted to fellows).It may be brief, may occur in the process of patient care and should emphasise straightforward frameworks.
Teach an approach to utilising primary data to understand the unknown • Model how multiple sources of data are integrated to offer patient care recommendations.
• Make sure students are present during conversations with other care teams such as pathology, radiology, lab medicine and pharmacy.

Integration into the team and the workflow
Define student roles and expectations • Provide a written syllabus prior to the start of the rotation with details of student roles/ expectations (including how many patients they will follow, what is involved in following a patient, etc.).• Have any supervising fellows and attendings check in with the student during the first 1-2 days of the rotation.• Identify tasks appropriate for students to complete.

Clarify logistics
• Ensure students know when/where to meet their teams.
• Tell students about learning opportunities such as fellow didactics and division conferences they may attend.• Make sure students have access to all areas of the hospital they will need to follow patients.
• Assign a contact person to help resolve logistical issues.

Include students in patient care tasks
• Assign students to appropriate patients so they can participate actively in clinical care.
• Include students when communicating about patients they are following, including in-person, phone and written communications to other practitioners.• Include students in multidisciplinary case discussions and meetings.

Self-directed learning and exploration
Leave space for selfdirected learning • Include students in deciding which patients they will follow and what topics they will be taught.
• Encourage students to do independent learning on issues related to the patients they are following.
• Guide students to appropriate resources.
• Invite students to share their learning with the team.
Engage students in discussion about their career goals • Inquire about what students hope to gain from the experience.
• Provide insight into the specialty career path, such as balance between inpatient and outpatient practice.
We propose strategies to help educators create learning environments that satisfy students' psychological needs and promote motivation.

| Implications
Optimising students' experiences in specialised clinical environments may affect subsequent recruitment into specialty career paths.Early and positive experiences with specialties and exposure to role models and mentors affect specialty career choices. 39,40Many students engage in such rotations with the goal of career exploration, and positive experiences may prompt them to consider pursuing a particular field.Specific to SDT, Williams et al. 12,41 found that autonomysupportive teaching during clerkships led students to feel more competent and increased their likelihood of pursuing a field, though this work examined decisions to apply at the general rather than subspecialty level.

| Limitations
This single-institution study was limited to IM consult electives, and findings may not translate across contexts.Though information sufficiency was achieved, the number of participants was small and selfselected.These participants may not represent the full spectrum of student perspectives on consult elective learning.The perspectives of faculty educators and fellows were not explored.

| CONCLUSIONS AND FUTURE DIRECTIONS
This study explored the factors that promote and hinder medical student motivation to learn during consult electives.We developed key

BOX 1
Focus group questions a 1.When you think about learning during medicine subspecialty consult electives, what comes to mind?(Participants reflected independently and wrote ideas on a virtual whiteboard and then discussed.)2. Who did you learn from? 3. What resources did you use to learn? 4. What impacted your motivation to learn on the consult elective(s)?(It was okay for participants to interpret motivation differently-ability, engagement, etc.) clinical scenarios-often the reason for specialty consultation-and how to integrate multiple types of information to propose management recommendations.Approaches included conducting a specialtyspecific history and physical examination, performing in-depth chart review, referencing specialty-specific guidelines, reviewing primary literature, and interpreting data in consultation with radiologists and pathologists.One student noted:We definitely had more time to read into the literature, go visit the lab and look at samples under the microscope, and go to radiology and really go through specific findings … In the consult field it was sort of rolled into their workflow, so it was nice to experience that.(S2)3.2| Theme 2: Integration into the team and the workflowMedical students may inherently feel more out of place on consult electives since they are often working with fellows and attendings who are years ahead of them in training and not near-peer residents.There were many components to integrating a medical student into the consult team, and failure to integrate students negatively impacted motivation and learning.

3.2. 1 |
Clear role/expectations Consult rotations often lacked a defined student role and clear expectations, which created a challenging work environment and hampered motivation and learning.This was particularly true in comparison to core rotations where students felt their role was well delineated.Students reflected on expectation-setting: It can be very helpful if you work with a new person, and they come to you and they let you know their expectations … I think it shows that they're invested in your learning on a personal level.And I also think it provides you with a roadmap to success … I think most people will not do that, but when they do it, I think it's always a very positive sign for how things are going to go.(S9) Clear expectations allowed students to feel confident in knowing how to succeed and form positive relationships with the team.

3. 3 . 1 | 3 |
Self-directed learning There was ample opportunity on consult electives for students to pursue self-directed learning.The specialised nature of consult electives facilitated learning by allowing students to focus on a single field within medicine.Students dove deeply into topics, most often inspired by patients whose care they were involved in and clinical scenarios that necessitated thorough literature review.Additionally, because consult teams are not generally responsible for day-to-day patient care tasks, students had bandwidth to engage in self-directed learning.One student shared: On my primary medicine [acting internship], I was learning how to be an efficient [acting intern].I [was] learning how to do tasks, whereas I felt on my subspecialty [electives] I could really focus on actually learning and reading cool papers and asking interesting questions rather than feeling I had to know the answer to everything.(S5) Elective directors and consult team members facilitated selfdirected learning by guiding students to specialty-specific resources and guidelines and by creating opportunities for students to share their learning with the team.3.3.2 | Career explorationThrough their consult elective experiences, students gained insight into how their practice might look in various specialties.One student was able to 'try on the different specialties and see what … fits' (S11).Having selected a consult elective with the goal of career exploration was also a motivator.One student shared:Having it be a subspecialty that I'm interested in … really motivated my learning, being able to take a deep dive into something that I'm interested in exploring as a potential career.Preparation for future practice Students were motivated to learn in order to prepare for future practice as both senior medical students and physicians.Some students used specialised electives as opportunities to learn material they could then apply on their general medicine acting internship.Many students had the goal of preparing for residency and their future career, which they anticipated might be in or related to the elective's specialty.One student shared: I want to figure out how to be a good future intern … So, I think that was the big motivating factor … who am I going to be in the future and how am I going to use this to learn.(S10) themes and proposed potential strategies for educators to improve the student learning environment during specialised clinical experiences.Based on the results of this study, the three innate psychological needs of competence, relatedness, and autonomy may overlap and reinforce each other in specialised learning environments.Future studies could explore faculty and fellow perspectives, incorporate direct observation of teaching and learning on IM consult electives and in other specialised clinical settings, and expand the investigation beyond a single institution to provide further insight into this underexplored educational environment.