Tuesday, February 08, 2011

What motivates us to do quality work?

Yesterday DB wrote about this topic with a focus on why external pressures in medicine, even so called positive incentives, tend to be counterproductive. He linked to the video below in which Dan Pink presented some interesting research in this area. It's counterintuitive---until you really think about it.

Money really is a motivator. But not in the way much of the corporate world thinks. And not in the way the central planners think. In order to motivate effectively with money, according to Pink, an individual must be paid handsomely, at least enough so that money is no longer a worry. This is not a new concept. Maslow understood it when he wrote about the hierarchy of human needs.

On top of that, Pink says, you need challenge, autonomy, mastery and a sense of purpose. Fyodor Dostoyevsky said “If it were considered desirable to destroy a human being, the only thing necessary would be to give his work a climate of uselessness”.

I had the opportunity to experience this for myself when I first entered practice. (This will sound like a fairy tale. I'm not making it up.) When hired fresh out of residency by the medical group I would stay with for almost 20 years (until they were absorbed by a large integrated delivery system which hired me as a hospitalist) I was told by one of the senior members about something they called the “clinic philosophy.” It held that group members who showed up for work at a reasonable hour four days a week and took care of their hospitalized patients should all be paid the same. Collections and production didn't matter. There were no RVUs. The salary was good and benefits were generous. The philosophy also held that the clinic would take all possible external “baggage,” financial and administrative, off the shoulders of the physician. No worry about license fees, malpractice insurance, hiring nurses, technicians, coders or the like. All taken care of. Also according to the philosophy, the clinic would provide the environment and resources the individual doctor needed to practice in an effective and professionally satisfying way. The stipend for dues, subscriptions, textbooks and CME was virtually unlimited. We had whatever we wanted. Few questions were ever asked. One day I decided we needed a cardiology department (which I, being the only internist in a group of family practitioners, would run) equipped with a treadmill and holter monitor system. Done.

It was professional nirvana. Everyone worked harder, and was happier doing so, than they would have under a more direct incentive system. Physician turnover was virtually non-existent and the clinic was a cash cow. Those were some of my most professionally rewarding years. But all good things eventually come to an end. External pressures mounted. The old guard lost influence as new people brought new ideas. The “philosophy” gave way and devolved to a more traditional system based on production and RVUs. My own compensation, as well as my professional satisfaction, declined sharply. The hospitalist job came along just in time. I had experienced Dan Pink's principles first hand.

By the way, listen closely starting at around 7:20. The portion which follows will have special meaning for those who have made the leap from Windows to Linux!

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