Thursday, November 8, 2012

Drive: The Surprising Truth About What Motivates Doctors to Provide Better Care to Elders?

I've recently started reading Daniel Pink's Drive, and it makes me repeatedly want to jump up and down shouting "Yes! Exactly!"

It also leaves me repeatedly thinking this:
Everyone pushing for better primary care for elders should read (or reread) this book.
As in:
  • Accountable Care Organizations, the great shining hope for healthcare improvement, who will want better care for elders in order to reduce their financial risk (a rather sordid reason to improve care, but there it is).
  • Quality champions, who are trying to figure out how to rejigger systems so that clinicians do better. (Teach them to work in teams!)
  • Policy wonks, who are very into incentivizing providers these days. (Pay clinicians an extra $10 per member per month! That'll do the trick!)
  • Healthcare entrepreneurs, many of whom seem to believe that primary care clinicians will be shelling out for their innovations in order to compete more effectively in meeting the demands of empowered and engaged consumers. (Hello? Have you heard of the primary care provider shortage in Massachusetts?)
  • Concerned patients and caregivers, who are certainly right to demand better care, and will need engaged and motivated clinicians with whom to forge fruitful collaborations. (Your doctor is probably not going to feel like being more helpful to you because she gets dinged by her ACO when the quality metrics don't pan out).

For those who haven't read Drive or aren't familiar with the basic premise, this is a book that summarizes a recent evolution in how psychologists understand what motivates individuals.

Basically, people used to think that individuals were motivated by essential biological drives (survival, procreation, etc) and then also by rationally responding to extrinsic factors such as rewards (i.e. money) and avoidance of punishments (i.e. fines).

However, psychologists eventually noticed that people often engaged in behaviors for which there was no obvious benefit, other than the enjoyment of engaging in the activity. And in some cases, this activity led to very significant, important products, such as Linux (open-source software) and Wikipedia.

This third drive has been called intrinsic motivation. My guess is that if you are reading this post, you've probably already heard about this drive, and maybe even come across some of the literature that suggests that in physicians (a group in which many start with high intrinsic motivation to do their work), use of external motivators may damage intrinsic drive (see here & here).

So my question to all is, if we know about this third drive, then why are most of the suggestions for improving primary care (which should be the foundation of good care for frail elders) rooted in manipulating extrinsic motivators?

Here's a quote from Pink:
[Organizations] continue to pursue practices such as short-term incentive plans and pay-for-performance schemes in the face of mounting evidence that such measures usually don't work and often do harm.
Pink goes on to define work as algorithmic (follow a set of instructions) versus heuristic (experiment with possibilities and devise a novel solution). 

Which do you think requires more intrinsic motivation? That's right, heuristic work.

And does providing comprehensive, compassionate, collaborative care with a medically complex patient and his or her family sound like an algorithmic task to you, or a heuristic one?


This to me, is a no-brainer. Obviously there is much medical care that can and should be done by algorithms.

But not all medical care can be done algorithmically, especially when patients are elderly, complex, embedded in a care circle, and require personalized care and shared decision-making. 

To have quality medical care for elders, primary care providers should be doing complex collaborative problem solving with the patient and family.

That's heuristic work. That requires intrinsic motivation.

So every time you come across some system, tool, or technique for improving primary care, I suggest you ask yourself:

"How can we use this is a way that improves the clinician's intrinsic motivation, or at least doesn't snuff it down too much?"

We should also be talking about how to bolster and support clinicians' intrinsic motivation to work effectively with patients. Remember, over 50% burnout in front-line clinicians in a recent survey. Unless you truly believe it's possible to have quality primary care for elders without engaged clinicians, something must be done.

Speaking of what should be done, Cassel and Jain published a Viewpoint in JAMA this past summer which addresses some of the above:
Those advancing physician-level interventions are looking to change how physicians do their jobs. A more global approach—in keeping with more attention to intrinsic motivation—would be to change how physicians perceive their job. Physicians who are satisfied with their work lives provide better care....To reach sustainable quality goals, however, close attention must be given to whether and how these initiatives motivate physicians and not turn physicians into pawns working only toward specific measurable outcomes, losing the complex problem-solving and diagnostic capabilities essential to their role in quality of patient care, and diminish their sense of professional responsibility by making it a market commodity. Rewards should reinforce, not undermine, intrinsic motivation to pursue needed improvement in health system quality.
Ok. I'm going to be thinking about intrinsic motivation as I think about implementing tech and systems to improve geriatric care.

Btw, yours truly is writing this blog on her own time, for no money. Intrinsically motivated :)

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