Opinion
VIEWPOINT
James L. Madara, MD Chief Executive Officer, American Medical Association, Chicago, Illinois; and Feinberg School of Medicine, Northwestern University, Chicago, Illinois. Jon Burkhart Chief of Staff and Vice President, Executive Offices, American Medical Association, Chicago, Illinois.
Corresponding Author: James L. Madara, MD, American Medical Association, 330 N Wabash Ave, Ste 39300, Chicago, IL 60611-5885 (james .madara@ama-assn .org).
Professionalism, Self-regulation, and Motivation How Did Health Care Get This So Wrong? physician professional organizations and medical societies have no binding authority that governs profesDwight D. Eisenhower sional conduct. Yet such entities have historically been highly influential in shaping the policies and convenWhat is the role of professional organizations and tions that define medical practice. Not surprisingly, prosocieties in the medical profession’s long-standing tra- moting professionalism is central to the mission of most dition of self-regulation, and what actions and influ- medical societies, and the ability to imbue professionences might enhance the ability of the medical profes- alism is a central metric of success. In medicine, as in many disciplines, professionalsion to operate effectively and responsibly? Such questions seem natural given the rapidly changing ism is in part characterized by the extent to which memhealth care system with the emergence of a plethora bers of the profession are motivated by intrinsic values of new payment and delivery models—all hoping to that uniquely define the profession, rather than by exachieve the Institute for Healthcare Improvement’s ternal incentives, such as financial rewards. Objective eviTriple Aim initiative for better health, better health dence of professionalism, so defined, does exist for phycare, and lower cost. It is critical that the medical pro- sicians. However, this does not suggest that among the fession demonstrate its ability to respond to these approximately 850 000 active physicians practicing in changing environments in ways that both acknowl- the United States there are no outliers to these measuredge and advance society’s interest in having an opti- able elements of professionalism. For example, in a study among surgeons, an extrinmal physician workforce. It is equally critical to understand factors that underpin the noblest traits in sic incentive (financial reward) was compared with an inphysicians then deploy this knowledge in shaping trinsic incentive (rapid feedback of comparative data that would allow surgeons to improve practice if they so delivery systems that emerge. Self-regulation is a central tenet of professions, has choose; no financial incentive) to see which would most been long-standing, and has seen multiple professions markedly enhance quality of care.3 The intrinsic incenthrough vast environmental change. Indeed, the pro- tive (an indicator of internalized professionalism) was fessions of medicine, divinity, and law have been more powerful than the extrinsic financial incentive. Another recent study of physician practices in multiple markets revealed that physicians view as favorable incentives Professionalism resulting in excellence conditions that provide more timely, acof patient care is the prime directive. curate, information sharing that allows improvement in patient care.4 In conself-regulating since the Medieval period. Three funda- trast, a driver of physician dissatisfaction is being chained mental elements broadly define self-regulation: to an overly complex dashboard of clinical measures— (1) agreed upon standards by which individuals may particularly if the information feedback is untimely or the enter the profession and by which they then practice, measures are seemingly unrelated to the quality of care, (2) responsibility for teaching these professionals how given the specific practice type.5 to exercise those standards on a day-to-day basis, and How might the need for ongoing professionalism in (3) enforcing those standards and deciding when and medicine be instilled in this current rapidly changing enhow those who violate them will be disciplined.1 Such vironment? Responsiveness and adaptability on the part self-regulatory status, granted by the government and of professional organizations can help increase their inthe judiciary, is provided based on the unique and com- fluence and help strengthen their role in medicine’s selfplex body of knowledge and skill required. For physi- regulatory structure by demonstrating their ongoing relcians, there exists the expanded element of “a set of evance to physicians. Professional organizations can also moral values that guide as well as constrain the physi- set an example for the profession by embracing changes cian’s behavior [including] altruism, integrity, caring, that reflect new priorities and attitudes toward health and community focus….”2 care delivery and the health of the population. The conPhysician self-regulation consists of a complex web cept of professionalism must expand beyond a physiof interactions between many professional organiza- cian’s individual behavior and embrace the goals and vitions, although the actual authority of each organiza- sions that are propelling the nation’s health care system tion varies greatly. Unlike the Liaison Committee on forward to achieve the Triple Aim. Medical Education, the Accreditation Council for GraduA key role that physician organizations can play is ate Medical Education, and state medical boards, most biasing toward professionalism by understanding and Motivation is the art of getting people to do what you want them to do, because they want to do it.
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(Reprinted) JAMA May 12, 2015 Volume 313, Number 18
Copyright 2015 American Medical Association. All rights reserved.
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Opinion Viewpoint
then getting the incentives (motivating factors) right. This starts with understanding the core values of the population in question (viz, physicians). Physicians appear motivated intrinsically to provide the best care for their patients. When tools are applied that assist this aspiration (timely data feedback, measures that truly matter), motivation occurs. The current incentive system for physicians, however, largely relies on external motivators (financial rewards and penalties), and thereby creates misalignment. Bènabou and Tirole6 summarize this conundrum well: “A central tenet of economics is that individuals respond to incentives. For psychologists and sociologists, in contrast, rewards and punishments are often counterproductive, because they undermine ‘intrinsic motivation.’” Physicians have a high degree of intrinsic motivation to engage their patients, use tools that work effectively for clinical care, and improve patient care using real-time measures of meaningful data highly relevant to their patient population. However, physicians often find themselves embedded in systems that diminish time with patients (due to administrative demands on time—often of trivial nature), provide tools that are far from optimized for clinical care (such as the current state of most electronic health records), and rely on extensive sets of measures, many of which fail to relate to either practice type on one hand or an actual outcome on the other. Not only do such environments fail to leverage powerful intrinsic incentives and motivators embedded in most physicians, but imposed rewards and punishments are added that, as Bènabou and Tirole suggest, “are often counterproductive.” Like other professional organizations, those of physicians have been self-regulating successfully in changing environments over more than a century. Professionalism resulting in excellence of patient care is the prime directive. However, during this current period of rapid evolution of the health care environment, at rates of change never before encountered, physician self-regulation needs ARTICLE INFORMATION Conflict of Interest Disclosures: Both authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. REFERENCES 1. Bertkau A, Halpern J, Yadla S. The privileges and demands of professional self-regulation. Virtual Mentor. 2005;7(4). doi:10.1001/virtualmentor.2005 .7.4.fred1-0504.
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to extend to and nimbly influence the environments that are the consequence of the emerged trends. This has likely happened over the last centuries but the rate of change currently requires more. First, it requires active and ongoing quantitative and qualitative studies of environmental influences that promote the professionalism naturally embedded in physicians in these evolving environments; studies that identify physician concerns about the current practice environment (performed by RAND and supported by and in collaboration with the American Medical Association).4,5 Second, it requires applying what is learned toward structuring new delivery system environments that naturally leverage the motivators intrinsic in physicians. That is the current challenge. In the past decade, enhancing physician practice has developed into an environment of rewards and punishments, poorly functioning tools for efficient delivery of relevant information at the point of care, a sense that more clinical measures means better care (even when the evidence base for the measure was weak or the benefit to the particular patient uncertain), and the untimely return of data related to meaningful clinical measures, inhibiting practice improvement. Potentially even worse, these inhibitory features may act to quench professionalism by actively countering the intrinsic motivators of physicians. Having recently developed an improved understanding of the motivators of physicians, physician organizations need to use their self-regulatory influences to better craft environments that leverage these intrinsic motivators derivative of professionalism (ie, harmonizing the tsunami of unaligned administrative forms and work so that more time can be spent with patients). The work may be difficult, but the goal is simple: by structuring practice environments with the intrinsic incentives and motivators of professionalism, have physicians help accomplish the Triple Aim by relying on the simple fact that this is actually what they want to do.
2. Reinhardt UE. Foreward. In: DeAngelis CD, ed. Patient Care and Professionalism. Oxford, UK: Oxford University Press; 2014. 3. Kolstad JT. Information and quality when motivation is intrinsic. http://www.nber.org/papers /w18804.pdf. Accessed April 8, 2015. 4. Friedberg MW, Chen PG, White C, et al. Effects of health care payment models on physician practice in the United States. http://www.rand.org /pubs/research_reports/RR869.html. Accessed April 8, 2015.
5. Friedberg MW, Chen PG, Van Busum KR, et al. Factors affecting physician professional satisfaction and their implications for patient care, health systems, and health policy. http://www.rand.org /pubs/research_reports/RR439.html. Accessed April 8, 2015. 6. Bènabou R, Tirole J. Intrinsic and extrinsic motivation. http://www.princeton.edu/~rbenabou /papers/RES2003.pdf. Accessed April 8, 2015.
JAMA May 12, 2015 Volume 313, Number 18 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of North Dakota User on 06/10/2015
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VIEWPOINT
James L. Madara, MD Chief Executive Officer, American Medical Association, Chicago, Illinois; and Feinberg School of Medicine, Northwestern University, Chicago, Illinois. Jon Burkhart Chief of Staff and Vice President, Executive Offices, American Medical Association, Chicago, Illinois.
Corresponding Author: James L. Madara, MD, American Medical Association, 330 N Wabash Ave, Ste 39300, Chicago, IL 60611-5885 (james .madara@ama-assn .org).
Professionalism, Self-regulation, and Motivation How Did Health Care Get This So Wrong? physician professional organizations and medical societies have no binding authority that governs profesDwight D. Eisenhower sional conduct. Yet such entities have historically been highly influential in shaping the policies and convenWhat is the role of professional organizations and tions that define medical practice. Not surprisingly, prosocieties in the medical profession’s long-standing tra- moting professionalism is central to the mission of most dition of self-regulation, and what actions and influ- medical societies, and the ability to imbue professionences might enhance the ability of the medical profes- alism is a central metric of success. In medicine, as in many disciplines, professionalsion to operate effectively and responsibly? Such questions seem natural given the rapidly changing ism is in part characterized by the extent to which memhealth care system with the emergence of a plethora bers of the profession are motivated by intrinsic values of new payment and delivery models—all hoping to that uniquely define the profession, rather than by exachieve the Institute for Healthcare Improvement’s ternal incentives, such as financial rewards. Objective eviTriple Aim initiative for better health, better health dence of professionalism, so defined, does exist for phycare, and lower cost. It is critical that the medical pro- sicians. However, this does not suggest that among the fession demonstrate its ability to respond to these approximately 850 000 active physicians practicing in changing environments in ways that both acknowl- the United States there are no outliers to these measuredge and advance society’s interest in having an opti- able elements of professionalism. For example, in a study among surgeons, an extrinmal physician workforce. It is equally critical to understand factors that underpin the noblest traits in sic incentive (financial reward) was compared with an inphysicians then deploy this knowledge in shaping trinsic incentive (rapid feedback of comparative data that would allow surgeons to improve practice if they so delivery systems that emerge. Self-regulation is a central tenet of professions, has choose; no financial incentive) to see which would most been long-standing, and has seen multiple professions markedly enhance quality of care.3 The intrinsic incenthrough vast environmental change. Indeed, the pro- tive (an indicator of internalized professionalism) was fessions of medicine, divinity, and law have been more powerful than the extrinsic financial incentive. Another recent study of physician practices in multiple markets revealed that physicians view as favorable incentives Professionalism resulting in excellence conditions that provide more timely, acof patient care is the prime directive. curate, information sharing that allows improvement in patient care.4 In conself-regulating since the Medieval period. Three funda- trast, a driver of physician dissatisfaction is being chained mental elements broadly define self-regulation: to an overly complex dashboard of clinical measures— (1) agreed upon standards by which individuals may particularly if the information feedback is untimely or the enter the profession and by which they then practice, measures are seemingly unrelated to the quality of care, (2) responsibility for teaching these professionals how given the specific practice type.5 to exercise those standards on a day-to-day basis, and How might the need for ongoing professionalism in (3) enforcing those standards and deciding when and medicine be instilled in this current rapidly changing enhow those who violate them will be disciplined.1 Such vironment? Responsiveness and adaptability on the part self-regulatory status, granted by the government and of professional organizations can help increase their inthe judiciary, is provided based on the unique and com- fluence and help strengthen their role in medicine’s selfplex body of knowledge and skill required. For physi- regulatory structure by demonstrating their ongoing relcians, there exists the expanded element of “a set of evance to physicians. Professional organizations can also moral values that guide as well as constrain the physi- set an example for the profession by embracing changes cian’s behavior [including] altruism, integrity, caring, that reflect new priorities and attitudes toward health and community focus….”2 care delivery and the health of the population. The conPhysician self-regulation consists of a complex web cept of professionalism must expand beyond a physiof interactions between many professional organiza- cian’s individual behavior and embrace the goals and vitions, although the actual authority of each organiza- sions that are propelling the nation’s health care system tion varies greatly. Unlike the Liaison Committee on forward to achieve the Triple Aim. Medical Education, the Accreditation Council for GraduA key role that physician organizations can play is ate Medical Education, and state medical boards, most biasing toward professionalism by understanding and Motivation is the art of getting people to do what you want them to do, because they want to do it.
jama.com
(Reprinted) JAMA May 12, 2015 Volume 313, Number 18
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of North Dakota User on 06/10/2015
1793
Opinion Viewpoint
then getting the incentives (motivating factors) right. This starts with understanding the core values of the population in question (viz, physicians). Physicians appear motivated intrinsically to provide the best care for their patients. When tools are applied that assist this aspiration (timely data feedback, measures that truly matter), motivation occurs. The current incentive system for physicians, however, largely relies on external motivators (financial rewards and penalties), and thereby creates misalignment. Bènabou and Tirole6 summarize this conundrum well: “A central tenet of economics is that individuals respond to incentives. For psychologists and sociologists, in contrast, rewards and punishments are often counterproductive, because they undermine ‘intrinsic motivation.’” Physicians have a high degree of intrinsic motivation to engage their patients, use tools that work effectively for clinical care, and improve patient care using real-time measures of meaningful data highly relevant to their patient population. However, physicians often find themselves embedded in systems that diminish time with patients (due to administrative demands on time—often of trivial nature), provide tools that are far from optimized for clinical care (such as the current state of most electronic health records), and rely on extensive sets of measures, many of which fail to relate to either practice type on one hand or an actual outcome on the other. Not only do such environments fail to leverage powerful intrinsic incentives and motivators embedded in most physicians, but imposed rewards and punishments are added that, as Bènabou and Tirole suggest, “are often counterproductive.” Like other professional organizations, those of physicians have been self-regulating successfully in changing environments over more than a century. Professionalism resulting in excellence of patient care is the prime directive. However, during this current period of rapid evolution of the health care environment, at rates of change never before encountered, physician self-regulation needs ARTICLE INFORMATION Conflict of Interest Disclosures: Both authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. REFERENCES 1. Bertkau A, Halpern J, Yadla S. The privileges and demands of professional self-regulation. Virtual Mentor. 2005;7(4). doi:10.1001/virtualmentor.2005 .7.4.fred1-0504.
1794
to extend to and nimbly influence the environments that are the consequence of the emerged trends. This has likely happened over the last centuries but the rate of change currently requires more. First, it requires active and ongoing quantitative and qualitative studies of environmental influences that promote the professionalism naturally embedded in physicians in these evolving environments; studies that identify physician concerns about the current practice environment (performed by RAND and supported by and in collaboration with the American Medical Association).4,5 Second, it requires applying what is learned toward structuring new delivery system environments that naturally leverage the motivators intrinsic in physicians. That is the current challenge. In the past decade, enhancing physician practice has developed into an environment of rewards and punishments, poorly functioning tools for efficient delivery of relevant information at the point of care, a sense that more clinical measures means better care (even when the evidence base for the measure was weak or the benefit to the particular patient uncertain), and the untimely return of data related to meaningful clinical measures, inhibiting practice improvement. Potentially even worse, these inhibitory features may act to quench professionalism by actively countering the intrinsic motivators of physicians. Having recently developed an improved understanding of the motivators of physicians, physician organizations need to use their self-regulatory influences to better craft environments that leverage these intrinsic motivators derivative of professionalism (ie, harmonizing the tsunami of unaligned administrative forms and work so that more time can be spent with patients). The work may be difficult, but the goal is simple: by structuring practice environments with the intrinsic incentives and motivators of professionalism, have physicians help accomplish the Triple Aim by relying on the simple fact that this is actually what they want to do.
2. Reinhardt UE. Foreward. In: DeAngelis CD, ed. Patient Care and Professionalism. Oxford, UK: Oxford University Press; 2014. 3. Kolstad JT. Information and quality when motivation is intrinsic. http://www.nber.org/papers /w18804.pdf. Accessed April 8, 2015. 4. Friedberg MW, Chen PG, White C, et al. Effects of health care payment models on physician practice in the United States. http://www.rand.org /pubs/research_reports/RR869.html. Accessed April 8, 2015.
5. Friedberg MW, Chen PG, Van Busum KR, et al. Factors affecting physician professional satisfaction and their implications for patient care, health systems, and health policy. http://www.rand.org /pubs/research_reports/RR439.html. Accessed April 8, 2015. 6. Bènabou R, Tirole J. Intrinsic and extrinsic motivation. http://www.princeton.edu/~rbenabou /papers/RES2003.pdf. Accessed April 8, 2015.
JAMA May 12, 2015 Volume 313, Number 18 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of North Dakota User on 06/10/2015
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