Drive within Physicians

motivation - money

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.

daniel pink drive

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:

autonomy - fishbowl

#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.

mastery - asymptote

#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?

fairness - scales

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.

critical conversations - sillouettes

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.

2 thoughts on “Drive within Physicians

  1. Hi there Rob,

    Many thanks for your blog posting! It raises some essential points about motivation.

    I especially like the sentences that you’ve written about doing work that is meaningful to us personally. I wonder how each person can connect their sentence about what meaningful work is, with the vision of Kaiser? It’s important to connect a person’s vision with their employers.

    It’s wonderful to see you refer to some of the research on motivation. The work of Edward Deci and Richard Ryan (see Self-Determination also says that autonomy is only useful in increasing intrinsic motivation when both competency and relatedness are present alongside autonomy. These are also needed to want to attain mastery.

    Competency is the belief that one has the skills to do one’s job, in addition to possessing the actual skills to get the job done successfully. This can be facilitated via training.

    Relatedness is a challenging area for businesses to deal with because it involves colleagues showing each other, and patients, genuine care and love, and bonding with each other emotionally in a safe climate that promotes honesty; this requires employees’ personal development and growth.

    The upshot is that patients are more compliant with taking their medications when they know what to do, and are given autonomy (Williams, 2002), while also experiencing relatedness from medical staff. Staff also respect each other when they show each other relatedness, and this helps them to enjoy their work, and it buffers the effects of stress, lowering employee sickness absence.

    In addition to improving the atmosphere at each Kaiser venue, relatedness between physicians, hospital staff, and patients may facilitate patients talking themselves into change – the type of change that Kaiser’s Thrive philosophy is promoting. See Motivational Interviewing for more initial evidence of this.

    How do you see Kaiser supporting greater relatedness Rob?

  2. Rob,

    I only partially agree with your view on physician bonuses. I believe that gnereally physicians seek autonomy as well as financial stability. Unfortunately for many primary care physicians financial stability is absent which leads to displeasure in their career. The secondary issue however is that there are current disincentives to good practice built into the system. For example, good primary care physicians should reach out and follow up with their patients and also consultants by phone but this time which can be quite substantial is specifically excluded from all reimbursement schemes. Moreover many of the low work, high reimbursement patients who’s short visits previously subsidized our unreimbursed time on the phone have been effectively removed from our practice by physician extenders including PA/NP clinics. Bonus payments which are often designed to pay us more for meeting specific targets that save payers money such as generic utilization percentage are now set so high that they may threaten care of patients who cannot achieve targets with generic medicines. These targets while quite reasonable above 85% or even 87% may in fact be detrimental to patient care as they extend beyond 90%.

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