Seventy years of behavioral science research has failed to overcome folklore about what motivates most Americans. Corporate language makes frequent use of the terms “bonus”, “incentive”, and “pay-for-performance (P4P)” in a context not supported by the scientific study of motivation. Indeed, many healthcare pundits are writing enthusiastically of financial schemes intended to motivate individual physicians to achieve greater levels of clinical achievement once ACA is fully implemented, most recently in the Wall Street Journal (Monday, June 17, 2013: Squaring Off: R2). But those writers don’t adequately understand (1) the human condition in general, (2) physician behavior in particular, or (3) the difference between what individuals can accomplish verses systems and teams.
I’ve written previously about this topic (“How do you get doctors to …?“, “What Role, Money?“, “Happy Doc = Happy Patient“). But this week I’m rereading Daniel Pink’s sentinel 2011 book, so I wish to revisit the concept of physician motivation. Here’s what Mr. Pink’s research says, as applied to clinicians:
#1 Autonomy: good bosses state “the why” and “the what” of the desired work-product, and then create conditions for people to do their best work to achieve those outcomes. It should be emphasized, unbridled physician autonomy has created many problems for patients through the centuries (physicians failing to use best practices often causes patient harm; for more information, read my three prior posts on Evidence Based Medicine [EBM]). A physician’s job is to solve as many patient problems today as possible. How those problems are solved is very much the business of the physician, necessarily guided by empathy, duty and The Scientific Method (PDSA cycles!). Solving complex problems like obesity and heart failure requires an inquiring mind and the willingness to experiment toward better solutions. Autonomy creates physician engagement – the fuel for creativity and discretionary effort.
#2 Mastery: nothing compares to the feeling we get following a well-reasoned diagnosis, or well-performed surgery, leading to the prompt resolution of the patient’s problem. To have the tools, time, and environment to constantly improve as a clinician, and to be our best each day, is a motivational drug unlike any other. That’s sometimes called Flow.
#3 Purpose: the opportunity to do “meaningful work” is a universal motivator for all. The relief of pain and suffering is meaningful work indeed. Have you written Your Sentence?
We find it comforting (or if you prefer, fair) in America to pay more to those individuals within a specific job class who achieve better individual performance (fine by me), but we mustn’t confuse our cultural concepts of compensation fairness with the science of professional motivation (drive). Furthermore, we must not confuse system-wide financial incentives, often necessary to pay for the human and technical infrastructure required for continuous performance improvement, with individual incentives; two common examples of the former include paying large multispecialty medical groups for better population-based clinical outcomes, and no longer paying hospitals for avoidable complications.
Moreover, money has no role in the performance management of individuals, particularly highly trained professionals such as physicians and surgeons. Individual underperformance against a set of clear job duties and expectations is typically due to (1) poor workflow or systems-design, (2) inadequate skill set or “fit”, or (3) weak bosses (including the tolerance of toxic workplace culture). Addressing the root cause of an individual clinician’s underperformance has nothing to do with money (“No bonus for you!”). Individual clinicians who produce reliably good results and promote a healthy workplace culture, get to remain in their position. Money is absent in that equation.