Why Controlling Teaching Persists in Medical Education: A Self-Determination Theory Perspective.

Autonomy-supportive teaching is widely promoted in medical education for its benefits to learner motivation and well-being. Yet many learners continue to experience clinical education as controlling, even in environments that explicitly endorse learner-centred values. This persistent gap suggests that barriers to autonomy-supportive practice extend beyond lack of knowledge or skill. This paper offers a theory-informed analysis of why psychologically controlling teaching persists in high-stakes clinical learning environments. Using Self-Determination Theory (SDT) as its organizing framework and drawing on complementary perspectives from psychological reactance, stress and coping, motivating styles, and medical education systems, the paper advances four interconnected arguments. Controlling teaching may emerge when educators experience pressure, threatened agency, responsibility, and uncertainty; be reinforced when authority and instructional structure are mistaken for psychological control; be legitimized through professional norms that associate control with competence; and be reproduced through assessment, administrative, and curricular systems. Its persistence is understandable because controlling approaches often produce the immediate outcomes educators seek-compliance, efficiency, predictability, and reduced uncertainty-even while carrying longer-term motivational costs. Control is therefore conceptualized not simply as an individual pedagogical failure, but as a downstream behavioural expression of pressure travelling through educational systems. By making these mechanisms visible, the paper provides a conceptual foundation for developing autonomy-supportive practices that remain viable under pressure and offers practical implications for educators, faculty development, and educational systems.