In our last post, we introduced the concept of self-determination theory, (“SDT” for short), and contrasted it with the concept of goals-directed motivation as represented by physical or psychological rewards and punishments. Pay-for-performance programs in healthcare are an example of the latter, while the former is largely unknown and unused in conventional healthcare circles. We also established that SDT is based upon the idea that there are many things that people do not for the promise of external reward, but because of some sort of intrinsic, human desire for autonomy, competence and relatedness. It therefore behooves us to ask and understand what that’s all about. (See author note below.)
According to SDT autonomy and competence are critical to the mental processes of behavior internalization and integration,
“…through which a person comes to self-regulate and sustain behaviors conducive to health and well being. Thus, treatment environments that afford autonomy and support confidence are likely to enhance health outcomes. Equally important to internalization in the SDT view is a sense of relatedness. People are more likely to adopt values and behaviors promoted by those to whom they feel connected and trust.”
The labels given to these desires are self descriptive. “Autonomy” means that, other things equal, individuals would prefer to make his/her own decisions. Decisions arrived at independently are given more credibility, valued more highly and more likely to result in supportive action by the individuals involved when compared to decisions made as a result of outside pressure. “Competence” means that people are more likely to change or instigate new actions and behaviors if they feel confident in their ability to do so properly. (“Relatedness” was explained in the quote above.) Furthermore, SDT asserts that these attributes are most important when it comes to tasks that involve thought, skill, complexity and are inherently interesting. Things like flying airplanes, arguing cases in front of the Supreme Court, inventing things, fighting a battle, playing the piano, stalking game and, yes, practicing medicine. They are relatively less important when it come to boring, tedious or repetitive tasks such as digging ditches, working on an assembly line or selling stamps and weighing packages at the post office.
All of this is eminently believable on some level. Few of us like having someone looking over our shoulders when we’re the ones who have to get the job done and are most in a position to know what’s going on. Decisions and actions are going to be more tentative and less decisive when we don’t feel competent. And of course people tend to relate better to peer groups, since they are the people whose needs and solutions will probably be most closely related to our own situation. But we shouldn’t establishing important healthcare policies based upon what sounds good, no matter how plausible it might be. After all, that wouldn’t be “evidence-based”. So what is the evidence for the relevance and effectiveness of interventions based upon SDT, and how does it compare with the corresponding evidence of the utility and benefits of pay-for-performance?
There is now quite a bit of experimental evidence regarding these questions, and it covers a wide range of disciplines and real-world applications, ranging from education and healthcare to child-rearing, relationships and sports. For the purposes of our discussion in healthcare there are just two questions that are particularly important:
- Is there any reason to believe that using P4P as a management tool might be ineffective, or even harmful as a means of influencing the behavior of patients and healthcare providers?
- Is there any evidence that SDT can be used to positively and effectively influence the behavior of patients and healthcare providers?
Experimental Evidence Involving P4P and SDT
By now some of our more skeptical readers might think that they smell a rat. “Why,” they might ask, “should anyone think that P4P might actually be harmful as a motivation technique? After all, it works very well in many situations. People and animals who are offered rewards clearly alter their activity in response, and even produce larger quantities of the desired goods, services and/or behaviors under many circumstances. As we’ve seen here, P4P did not appear to have any beneficial impact when used to try to improve quality of care in Britain, and appears to have been equally ineffective in the United States. But why the sudden implication that it might actually be harmful? Isn’t that taking things a bit too far?”
Not according to the proponents of self-determination theory. P4P is all about extrinsic motivation. SDT contends that the rewards and punishments that characterize extrinsic motivation are inherently poor motivators:
“In SDT, external regulation is considered controlling, and externally regulated behaviors are predicted to be contingency dependent in that they show poor maintenance and transfer once contingencies are withdrawn.”
In other words, the use of P4P is a type of coercion whose benefits are only realized as long as the reward is in place. Still worse, forcing someone to do something (even if you’re being “forced” by the prospect of garnering additional food, love or money), tends to destroy feelings of autonomy, competence and relatedness. Especially if, for example, the external incentive comes from a government administrator telling you that you’re incompetent to manage your patients, and will be punished unless you adhere to his non-specific and sometimes inappropriate guidelines of care.
Tough guy administrators who pooh-pooh psychology and all of this namby-pamby “feelings stuff” are likely to scoff at the idea that rewarding people for performance is going to do any harm. Trashing P4P is a big deal given its ubiquity as a management tool; one would hope that the SDT advocates would have the data to back it up. As it turns out, they do. The evidence comes in many forms and under a wide range of conditions, and can be found in both children and adults. Each of these bullet points has experiments (most often multiple experiments) and statistically significant data behind it:
- If you ask people to do something that is inherently interesting – such as solving a puzzle – they will do so voluntarily and of their own accord. However if you pay them for doing the exact same activity, they lose interest in it and will no longer choose to do it if and when you stop paying them.
- In women, blood donation is, without a doubt, intrinsically motivated. In one experiment, offering to pay subjects to donate blood reduced the number of women volunteers by 50%. (Interestingly enough, the number of men volunteering was unchanged.) Offering to donate the payment to the subject’s charity of choice completely reversed this “crowding out” affect.
- “For activities that children find inherently interesting, using rewards has a paradoxical effect. Receiving expected rewards for doing an activity that one likes and enjoys leads to a decrement in intrinsic motivation (i.e., spontaneous engagement in the activity decreases when reward contingencies are absent). This undermining effect occurs regardless of whether rewards are made contingent on simply engaging in the task, completing it, or reaching a performance standard.” The same effect is found in studies utilizing adults as well.
- “A meta-analysis of 128 studies examined the effects of extrinsic rewards on intrinsic motivation. As predicted, engagement-contingent, completion-contingent, and performance-contingent rewards significantly undermined free-choice intrinsic motivation (d = –0.40, –0.36, and –0.28, respectively), as did all rewards, all tangible rewards, and all expected rewards. Engagement-contingent and completion-contingent rewards also significantly undermined self-reported interest (d = –0.15, and –0.17), as did all tangible rewards and all expected rewards. Positive feedback enhanced both free-choice behavior (d = 0.33) and self-reported interest (d = 0.31). Tangible rewards tended to be more detrimental for children than college students…”
- “Thirteen studies have investigated the differential effects of rewards on interesting versus boring tasks. When the results were aggregated meta-analytically, it was shown that the negative impact of rewards was limited to interesting activities (d = -0.68, p < .001). For uninteresting tasks, rewards were found to have a slight positive effect on motivation, though this effect did not reach statistical significance (d = 0.18, p = ns).”
- Recent research in Japan seems to show that there is a specific and demonstrable neural basis for the undermining effect of monetary reward on intrinsic motivation that can be seen by use of functional magnetic resonance imaging.
So there is plenty of reason to believe that P4P is not only not very effective when it comes to motivating patients and healthcare providers, but may actually be detrimental when it comes to getting people to “do the right thing” independently and of their own accord.
But what about the reverse? Is there any evidence that interventions designed to foster a sense autonomy, competence and/or relatedness can actually do any good? Yes, there is:
- “One thousand and six adult smokers were recruited into a randomized cessation induction trial. Community care participants received cessation pamphlets and information on local treatment programs. Intervention participants received the same materials and were asked to meet four times with counselors over six months to discuss their health in a manner intended to support autonomy and perceived competence. The primary outcome was 24-month prolonged abstinence from tobacco. The secondary outcome was 7-day point prevalence tobacco abstinence at 24 months post-intervention. Smokers in the intervention were more likely to attain both tobacco abstinence outcomes and these effects were partially mediated by change in both autonomous self-regulation and perceived competence from baseline to six months.”
- Patients’ perceived autonomy support and competence were significantly associated with improved glucose control, medication compliance and quality of life in diabetics. Similar results have been seen with respect to maintaining weight loss. Randomized controlled trials testing the efficacy of SDT-based interventions have shown positive results with respect to tobacco dependence, weight loss, physical activity and dental hygiene.
- Perceived autonomy, perceived autonomy support and competence with respect to tobacco cessation counseling by physicians were strongly correlated to more time being spent by physicians in counseling patients about tobacco use.
- There is considerable evidence that higher levels of perceived autonomy and competence (as well as autonomy and competence support) is associated with a generally greater sense of well-being – especially when compared to controlling interventions such as P4P. In other words, people tend to be happier and less resentful when intrinsically (as opposed to extrinsically), motivated.
It’s unfortunate that there have not been more numerous and ambitious studies with respect to using SDT interventions in healthcare – particularly with respect motivating physicians to do the things that we would like them to do. Given the amount and strength of the evidence surrounding the respective advantages and disadvantages of SDT and P4P, it is astonishing that our healthcare system’s political and bureaucratic leaders have given so little time, money and attention to the former and so much to the latter. The stakes in healthcare are so high that is frankly a form of managerial and healthcare policy malpractice.
Again, with a little reflection none of these findings should be particularly surprising. Take the case of SDT and intrinsic motivation. The vast majority of physicians and other healthcare providers entered medicine because they found it interesting and wanted to help patients to the best of their ability. Most of them have spent literally decades of their lives and hundreds of thousands of dollars preparing to make medical decisions autonomously and competently. Probably the majority of them are perfectionists. They value the esteem and opinions of their colleagues, and abhor the idea of practicing in a way that would lead to poor results, bad outcomes or perceived incompetence. They find it satisfying when they are able to have a positive impact, and intensely frustrating when subjected to outside control by people who aren’t in their shoes, don’t have all of the fact and frequently don’t even know the first thing about practicing medicine. Who in their right mind could possibly blame them? And why on earth would anyone imagine that the vast majority of them weren’t doing their level best to provide the best quality care than their time and level of skill and education would allow?
Now take the case of P4P and extrinsic motivation. It doesn’t exactly take a PH.D. in human psychology to imagine that various types of threats and coercion (as we’re seeing applied with the use of mandatory clinical guidelines and laws mandating the use of poorly built and even defective electronic medical record systems), are practically guaranteed to create anger, resentment, frustration and an urge to ditch medicine for a less stressful, less manipulated career. Maybe this wouldn’t matter if these people were easily replaced with fresh cannon fodder, but they’re not. Our nation’s reserve of medical experience and expertise is relatively small, certainly hard-won and extremely valuable. Skilled, competent healthcare providers are not something that we can simply and easily import from China, India or anywhere else. They’re a precious resource in terms of both utility and scarcity – certainly too valuable to squander through something as stupid as misguided and ineffective healthcare management policies.
A great deal is now known about how one might apply SDT to the management of both patients and providers in the healthcare setting. We haven’t time to go into it in this post, but many of the most effective techniques are subtle and unassuming. Things like:
- Making sure that everyone understands the rationale behind what you’re trying to accomplish and, just as importantly, ensuring that the rationale is a good one;
- Communicating the rationale and proposed interventions in an autonomy-supportive (e.g., “could”, “may”, “if you like”), as opposed to a controlling, manner (“must”, should”, have to”);
- Providing choices and alternatives for accomplishing the mission at hand; and
- Perhaps most importantly, simply refraining from the use of coercive or seductive contingencies.
This last one may be the most difficult task of all for healthcare administrators the world over. It means unlearning techniques they’ve been using, with dismal results, for decades. But that’s really the bottom line, isn’t it? When it comes to our healthcare system do we want our leaders and administrators to be powerful, decisive and controlling? Or do we want good results? Based upon the theory and scientific evidence behind SDT we can choose one or the other, but not both.
*Author note: There has been an enormous amount written about SDT and we’ll make no attempt to provide a complete overview, history, explanation or set of references here. Instead, we’ll approach this topic in the spirit of learning enough about it to judge whether it seems plausible, is supported by real-world scientific evidence, and – most importantly – has any plausible implications for how both patients and providers in the world of healthcare could, should or ought to be motivated to “do the right thing”. For a complete introduction to SDT, see the dedicated SDT website here.