Monday, June 18, 2012

What if we didn't care? (What really motivates healthcare workers?)

During my medical school application interview, I was asked why I wanted to be a doctor.  I gave the answer that I thought was expected of me: Because I want to help people.

I don't know what the interview committee thought about that answer.  Did they mentally roll their eyes as they listened to that rote response for the umpteenth time?  How can this 18-year-old kid know anything about caring for sick people?

If they wondered that, then they were right.  In retrospect, I had very little idea what I was in for, what a life in medicine would involve.  It's been a happy coincidence that I've found this career very fulfilling.  And I hope I channel that satisfaction into a genuine caring for the wellbeing of my patients.

But what if I didn't genuinely care about my patients?  Could I fake it?  Would it matter?

At many conferences and meetings, I've heard speakers remind us that "we all got into this job to care for people".  But, is it true?  I've never heard anyone publicly question it.  Imagine the horrified response if someone did take exception to that dogma!

I have no doubt that the majority of healthcare workers truly do care for their patients and clients.  

Wow - that sentence came out almost without me thinking about it.  It's so appalling to even suggest that healthcare workers might not actually care ("care" is written right into health care, for goodness sake!), that I reflexively wanted to avoid insulting anyone by even having suggested it.  But, after I read the words, I realized that I don't know how to judge if someone truly cares for a patient's wellbeing.

Let's say caring means a genuine concern about another person's welfare.  That's a state of mind.  We could measure "caring" by asking a person about their feelings or attitudes.  If they answered honestly, we could decide whether they were concerned about a patient's welfare.  But, if they thought they were expected to answer in a certain way, they might not be frank.

Perhaps their actions could be a surrogate measure.  If we observed them to be friendly, solicitous and gentle then we could conclude that they genuinely cared.  But, could they fake that?  And if they faked it, would it matter?  As long as the patient perceived the person as being caring, what difference would it make?

I think it is important to recognize how healthcare workers truly feel because it speaks to their real motivation to carry out their duties in a way that patients and clients want.  If we delude ourselves that everyone in healthcare is motivated solely by genuine caring for their patients' wellbeing, then we may be missing opportunities to unleash workers' potential.  And more importantly, we may be missing opportunities to let workers find joy in their relationships with their patients and clients.

My own motivation includes a mixture of (not an exhaustive list, and in no particular order...) financial reward, technical mastery, peer approval, and caring for others.

I don't know what my cutoff for remuneration would be before I decided to find another job.  I know I wouldn't sweat over a tough surgery or be on weekend call for free, but I get enough satisfaction from the job that I would likely do it for less than I get paid now.  (You didn't hear that from me.)  I suspect there is little direct relationship between remuneration and caring, as evidenced by some of the fabulous volunteers I know in our community.

For me, as with most surgeons, technical mastery is a tremendous motivator.  Last month, I was called on to repair an injury a patient had suffered during a previous emergent and difficult operation.  If I could fix it endoscopically, she would be spared an additional operation and weeks of recovery.  I cared about sparing her that additional burden, but I was also intrigued by the puzzle before me.  What instruments would I need?  What staff should be in the OR?  I visualized the procedure to decide how to arrange my instruments for easy access in the order I would need them.  When the challenging procedure went well and I was able to accomplish my goal, I felt tremendous satisfaction.  And, by another happy coincidence, accomplishing my goal meant that my patient would have a faster recovery.

Peer approval is a powerful force among physicians.  If, after I successfully complete a challenging operation or clinch an obscure diagnosis, one of my partners says simply "Good job", it's deeply rewarding.  When we've discovered variation in clinical practice among our group, there's been a desire to conform to the majority's behaviour.  If the majority are already performing according to best practice, then the task of standardizing behaviour is made easier by the outliers' desire to conform.

(Imagine what a crafty, yet well-intentioned, administrator could do with this information.  Just as one example, they could create easy access to performance metrics and encourage comparison between individual physicians and departments.)

Everyone will have their individual formula that motivates them to behave in a caring way.  (Note that "behaving in a caring way" is different from "caring", which presumes a state of mind.)  If we unquestioningly accept that all healthcare providers are primarily motivated by "caring", then we may be missing the chance to address all the other sources of motivation that could bring more joy to their work and greater satisfaction and better outcomes for their patients.

And, greater joy in work will lead to true caring.  As a friend recently told me, "You can act your way to a new way of thinking".

Or more plainly, "Fake it 'til you make it!"


  1. Any doctor or nurse for that matter doing his/her best and doing what he/she thinks is best for the patient is what I call 'caring'! Thanks for the post, it made me think.

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