Interviewer: "What does your father do?"
Slovak: "He's a fisherman."
Interviewer: "What kind of fish does he catch?"
Slovak: "Cod"
Interviewer (whispers to himself as he writes the answer down): "Cod"
By the end of his day, Slovak responds to the same "Why do you want to be a physician?" question with a less clichéd but more humorous answer, "Because I want to make lots of money."
Here's the key point. Almost no one in medicine today chose to enter this profession because we wanted to make a lot of money. As a matter of fact, I could certainly make the case that if money was the sole motivation, we would have been better off choosing another career! However, even if it's true that most, if not all of us, became physicians because we were interested in helping people (and not because of any potential future earnings), the fact that physicians make a good living (relatively speaking) was reassuring too.
I know what you're thinking. What's he getting at here? My point is that many of us in health care are intrinsically motivated to help and serve others. As I have posted about in the past, there are two kinds of motivation - intrinsic motivation and extrinsic motivation. Intrinsic motivation (also called "internal" motivation in some studies) refers to when we engage in a certain behavior or activity because we find it rewarding (the behavior or activity itself is the reward). Extrinsic motivation (also called "instrumental" motivation in some studies) refers to when we engage in a certain behavior or activity because we want to earn a reward or avoid punishment. Using the medical school example above, an intrinsic motivation to study to be a physician would be the desire to help people, while an extrinisc motivation would be to seek prestige or monetary rewards.
What happens when we try to combine both intrinsic (internal) and extrinsic (instrumental) motivation together to drive performance of a demanding, effortful activity (such as going to medical school to study to become a physician)? One would expect that these two types of motivation would be additive or synergistic. Unfortunately that is not the case. Studies consistently show that extrinsic motivation can undermine intrinsic motivation, a phenomenon that psychologists and social scientists call the "overjustification effect" and economists call the "crowding out effect". Most of these studies involve either laboratory or field experiments in which intrinsic motivation is either established beforehand or assumed, followed by the introduction of some reward (extrinsic motivation). The problem with these studies is that the real world rarely, if ever, works this way - case in point is my medical school example above!
With all of this in mind, investigators at Yale conducted an interesting observational study a few years ago, publishing their findings in the Proceedings of the National Academy of Sciences (see "Multiple types of motives don't multiply the motivation of West Point cadets"). The investigators conducted data from nine consecutive classes at the U.S. Military Academy at West Point (11,320 cadets from all but one class from 1997 through 2006). Each cadet participated in a survey that included questions to determine their motivation for studying at West Point and joining the Army. Two reasons of interest were cited - an individual's desire to become an Army officer and serve his or her country (intrinsic motivation) versus an individual's desire to take advantage of the quality education provided at West Point and the career opportunities that such an education would provide (extrinsic motivation).
The investigators then looked at whether each cadet extended beyond his or her mandatory five-year tour of duty, as well as whether they had been selected for early promotion (both factors which would be consistent with "high performance"). As expected, after controlling for a variety of other factors (age, gender, race/ethicity, parental income, SAT score, entering year, etc), the investigators found that a stronger internally based (intrinsic motivation) desire to attend West Point was strongly associated with high performance (extending service beyond the mandatory minimum of five years and being promoting early). Again, as expected (based upon the overjustification effect), cadets having both an intrinsic and extrinsic motivation to attend West Point were more likely to leave the Army after their five year mandatory minimum. In addition, cadets having both an intrinsic and extrinsic motivation were more likely to be passed over for early promotion. Finally, the higher the degree of extrinsic motivation to attend West Point, the less likely cadets would stay in the Army beyond five years and get promoted.
These results are consistent with prior studies, demonstrating that extrinsic motivation can undermine intrinsic motivation and lead to lower performance. The study is particularly important to this body of research. As the investigators write, "It is hard to imagine a meaningul domain of human activity that does not have instrumental consequences" (again, they are using the term "instrumental" to refer to extrinsic motivators, such as money, fame, prestige, or status). They go on to say that "because instrumental consequences cannot be eliminated from human affairs, what the results suggest is that attention should be paid to motives in addition to consequences, and that efforts be made to structure activities so that some consequences do not become motives."
How can leaders (and organizations) prevent consequences from turning into motives? First, leaders should emphasize the organization's purpose, particularly if the organization is mission-focused, as most health care organizations are today. Second, while instrumental consequences (extrinsic motivators) such as bonuses, raises, etc are important, leaders can also emphasize meaningful consequences that focus more on internal rewards (mastery of a skill, impact on others, etc). Finally, and I've spoken about this before (see my post, "Holes" for more in-depth discussion of this point), when individuals have a role in shaping their work activities, they are more engaged and focused on the meaning and purpose of the work, which drives intrinsic motivation even more!
As it turns out, the opening scenes of Gross Anatomy were not all that far off from the truth. Spoiler alert, Slovak goes on to learn about his true desires and motivation for studying to become a physician, focusing on the service aspects of the profession instead of the monetary rewards. Like the West Point cadets who wanted to serve their countries, Joe Slovak becomes a better physician in the end.
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