Episode Transcript
[00:00:00] Speaker A: I'm Dr. Robert Groves and welcome to
[00:00:02] Speaker B: QuickConnect, short commentaries on current issues in healthcare.
[00:00:08] Speaker C: Please enjoy.
Dan Pink addressed the issue of intrinsic motivation. I don't know anybody who does it any better. And his assertion is that as you go from algorithmic jobs to those that are more heuristic, the value of financial incentives tied to performance diminishes substantially.
And that's because as jobs become more interesting, creative and enjoyable, the vast majority of the literature suggests that trying to reward somebody for doing something that they already find creative, challenging and rewarding actually diminishes their motivation. And so Pink differentiates between intrinsic and extrinsic motivation. And later on he developed a notion that autonomy makes mastery and purpose are the real secrets. Makes you think of knowledge workers, makes you think of docs. And then my head immediately goes to many of the strategies and schemes that are used today to reward in particular C suite level executives and position.
And in particular a huge strategy over the last couple of decades, one that I've been a strong advocate for for is called pay for performance. And the notion is this. We take a set of metrics and we say if you hit these metrics, then you get a bonus. And then. Now the problem, of course, is that on its face, that's an external motivation. Now, in my mind at least, I separate this out from an external motivation that is an investment in the company that I'm serving. So if I can get a piece of stock, my motivations are perfectly aligned because today maybe my stock is worth X, but if the company as a whole does great and I can contribute to that as a knowledge worker, then I get to participate in the success of the company. On the other hand, the most common form of pay for performance is layered in on top of fee for service. So how does that work? Well, for example, big company X says to the docs, hey listen, if you get enough childhood vaccinations and you do enough mammograms and you do enough colonoscopies, and you do enough eye exams in diabetes, and you're checking that a 1C. If you can check all of these boxes, which are things that we all agree probably ought to be done, then you'll get a bonus at the end of the year. So there's a metric and it's tied to reward and punishment. In this case, a reward, or you could look at it as, I didn't get that money, so I'm being punished. Actually, if you wanted to take advantage of behavioral economics, what we do is we give them the money up front and say, if you don't hit these metrics, you're going to have to pay it back. Because we fear and despise loss far more than we anticipate and enjoy gain.
The issue that Dan Pink talks about, and I think it lays out a pretty convincing case for in his book Drive, his issue is motivation. And he goes through motivation 1.0, which is lack of an organizing system. And then I think he calls 2.0 Taylorism. So Frederick Taylor, the industrial engineering whiz that came up with scientific management, what he did was most of the jobs in the US at that time were the algorithmic type. And he said, well, if we want to improve performance, what we need to do is look at time motion studies and understand and optimize each step and make clear accountability for each step and then set expectations for the speed at which these tasks are performed and the quality with which these tasks are performed. And then we constantly monitor our employees.
That was highly successful at algorithmic jobs. We did see improvements in productivity. As Dan Fink said, it worked until it didn't. That actually stopped when the balance of jobs in this country shifted to more heuristic jobs. Jobs that require you to adapt to an ever changing environment and depend upon very local knowledge. It's about as heuristic as it gets in healthcare. And especially taking care of patients doesn't get any more heuristic than they are. And so you've taken something that's highly engaging, highly rewarding autonomy, which is slowly being usurped, mastery and puppets easy to find purpose with delivering health care to those in need. And so what is the likely impact of a financial incentive? Because I understand that we can show that it improves the efficiency of care delivery. Well, there's something interesting about the way our brains work. When you study an intervention for incentives, you look at a very short period of time and you measure something pure, something gets your arms around. So maybe it makes them less expensive doctors, but it would be impossible to tell if it makes them better doctors. The second issue is this.
[00:05:18] Speaker A: The pleasure circuit in our brain tends
[00:05:21] Speaker C: to dampen over time.
[00:05:22] Speaker A: And so what once may have seemed
[00:05:24] Speaker C: like generous rewards become less and less
[00:05:28] Speaker A: impressive to us over time. Now you add to that a phenomenon that was documented early on in intrinsic motivation research. They had a group and a control group. And these were very small studies, admittedly, but I think it's worth paying attention to is in terms of the direction of psyche. And they had a fun task with a puzzle that they were doing and the first group on day one they both came in, nobody got rewarded and they just played with the puzzle and they timed that.
[00:05:54] Speaker C: Then on day two or group A
[00:05:56] Speaker A: got rewarded for completing the puzzle, group B did not, and group A outperformed group B in this comparison. Then on a third visit they were told, look, we only had enough to fund the second part of the study. For the third part of the study, both groups will be doing this without pay. And what they found was that the group that had been paid and then
[00:06:15] Speaker C: withdrawn did worse than the group that
[00:06:18] Speaker A: had never had any pay in the first place or performance. Now perhaps that doesn't bode well for the transition from where we are to where we need to get to, but I think it does teach us that looking at immediate performance does not tell us anything about long term performance.
We don't know from directly measuring certain plans that have already been implemented, but what we know from the behavioral health literature is that we ought to be very concerned and we ought to consider the possibility that it has an impact on motivation that is not what we intend and that's Dan Paik and Drive is a tour de force of evidence. The supporting this notion that rewarding behaviors and heuristic work actually does the opposite
[00:07:06] Speaker C: of what we intend.
[00:07:07] Speaker A: It inhibits performance.
[00:07:15] Speaker B: You've been listening to the Groves Connection, your connection to the inside story on health care, featuring in depth interviews with those who know.
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[00:08:01] Speaker D: The professional ideas and opinions expressed in this podcast are mine and do not reflect those of any current or past employers. Thank you so much for listening and we hope you'll join us next time on the Groves Connection.
