Family Medicine Vital Signs

By Susan Cochella, MD, MPH

Have you read Daniel Pink’s book Drive: The surprising truth about what motivates us?  Pink argues that humans are most productive, effective, and happy when driven by internal motivation. He describes a state of hyperproductive “flow,” in which we are so immersed in a task that everything else disappears.  He provides decades of research and several real-world examples to illustrate this mindset.  He contrasts this internally-derived “Motivation 3.0” with the less powerful “Motivation 2.0”, which involves the classic rewards and punishments we are used to.

He also details several limits to the application of this theory, which are realistic.  Even so, the fundamental concepts square with my sense of reality.  Most interesting are the elements of Motivation 3.0 – purpose, autonomy, and mastery.  How incredible does it feel, and how incredibly productive can we be, when we engage in something we choose freely, are passionate about, and are really good at?  (and no, not everything in life is going to be this way, but when it can be – Wow!)

Since reading Drive, I have been walking through life with new perspective – I love feeling good and being productive, so I can use this wisdom to move in that direction.   How can I stay more in touch with my internal motivators? I see ways we use these concepts in patient care too.  There are likely several ways we all diminish others’ internal motivators too.  How can I be more aware and intentional about how and when I do this?

About my own motivation, the purpose part comes easily – I love being able to care for my patients, teach family medicine, and share the collegiality of our incredible group.  I am grateful for a job that so fits my values and strengths.  However, the autonomy piece can be hard.  Knowing options and asking for what I need is critical.  Some tasks truly fit my role, skills, and our group’s priorities, but others don’t.  I have made the mistake of committing to things the entire group wasn’t behind, and I paid a price. Assuring resources for success is also important, especially regarding time. If the task is a high enough priority but there’s not room on my plate, then what can change?  This is a negotiation process that requires a set of skills I didn’t have when I started as faculty, but they are learnable and essential.  Managing my commitments is something I need to own as my responsibility – I am owning my needs for autonomy and mastery.

The triple diamond difficult part of autonomy for me is when saying “no” to something painful is not an option.  This happens in our group just as it does in any clinical or academic group.  For instance, extended clinic hours into evenings and weekends can disrupt personal and family life, and thus upset a tenuous work-life balance.

How can I prevent this from stifling the meaning I find in my work?  Tapping into the purpose I find in my work is a start, but it alone is not enough. The autonomy piece is where the rub is. Even though I can’t say “no I won’t participate in extended clinic hours”, maybe I can reframe this for a more positive approach. What can I do with the time I do have control over?  Maybe there are things there that I can impact.  While the answers will take some time to find, it feels better and I know I will be more effective by focusing on an area where I have control.

Let’s shift gears.  The clinic is a place where we already use these concepts of autonomy, purpose, and mastery effectively through motivational interviewing. The highly motivated smoker gets resources and sets a quit date – they’re ready for it – but the pre-contemplative smoker doesn’t.  I see a respect for autonomy in this, and a patient-centered approach to purpose.  For the less motivated patient to succeed, the benefits of quitting must be dealt with from their perspective, and when we high-five them after they cut down by 5 cigarettes, we celebrate an important small step and help to build confidence – an important part of mastery.

How about clinical controversies? Patient satisfaction and pay-for-performance are certainly related to motivation.  We all suffer emotionally when a patient is dissatisfied, whether the source of their disappointment was within our control or not.  There’s also discomfort at having our salaries tied to our patients’ hemoglobin A1C results or blood pressures.  Ultimately, this is about both how we are paid and getting feedback on our performance.

Daniel Pink has an interesting take on both of these issues.  With pay he advises a solid base salary and notes that the best managers set salaries a little above average.  He is not against performance metrics – we all need feedback to improve our performance and pursue mastery – but complex salary calculations or large amounts of pay linked too closely to one element of performance can distract us from focusing on the big picture of performance, which is often so multifaceted that a simple formula has trouble capturing it.  His basic premise in regards to pay is to make pay fair and get the issue “off the table” so people can focus on their work. I couldn’t agree more.  Doctors need simple pay structures with fair, reliable salaries.  We also need metrics on our performance so we can work together to improve.  Lastly, we need leadership that goes the extra mile to improve care processes while keeping these performance metrics in perspective.  It is not an easy task, so we need to find the best leaders we can and support them in this endeavor.

One of the things I most want for myself to learn from this book is how to become someone who sees and honors the internal motivation others demonstrate.  I want to understand and stop doing things that stifle others’ constructive motivation.  Here’s my plan: When others’ actions or words surprise me, I will pause to consider what is motivating them.  Often there is something positive in there that I don’t notice on first glance.  I will do more asking and active listening at those times, and keep my own ideas to myself for a little longer.

So what’s the verdict on Drive?  For me, it’s a compelling lens to view people and institutions through.  There are some practical changes I can make to do things better, though the metrics we have are imperfect.  We need to use the best metrics we have and be cautious about assuming cause and effect, as bias is strong when we act on our own ideas.  So what am I doing differently?  Well I did try more inquiry in a charged family situation and I think things went better.  I don’t have a metric for that, but I can watch for one.  I am also accepting patient’s preferences more quickly when they don’t want to adopt my recommendations.  If I have discussed what is pertinent to their goals and checked in on their motivations, I have done my part. Will this help?  I don’t know.  But it feels better.  Now I just have to avoid assuming that my next patient satisfaction scores have anything to do with this one small change.

Susan Cochella, MD, MPH is an associate professor in the Division of Family Medicine at the University of Utah, School of Medicine.