The dangers of performance measurement (h/t @danielpink)T


Category : Medical Rants

I just finished reading Drive for the 3rd time.  The messages from this book are ones that the wonks should embrace, but that they will ignore, because the messages do not fit the conventional wisdom.  I wrote about this book 7 months ago – What @danielpink teaches us about medicine

This rant will be partially repetitive, but I cannot overestimate the importance of this book.

The key to understanding motivation comes from distinguishing between extrinsic and intrinsic motivation.  The paradox of motivation occurs when we try to add extrinsic motivation to existing intrinsic motivation.  We get expertise when we have such intrinsic motivation that we will work diligently enough to achieve expertise.  Human beings (and even primates) enjoy hard work and solving problems.  Outpatient medicine has intrinsic interest and therefore induces intrinsic motivation. 

Physicians obviously want reasonable autonomy in developing a relationship, diagnostic plan and treatment plan for each patient.  I believe the entire field of performance measurement, physician report cards, and perhaps even quality improvement can decrease intrinsic motivation and job satisfaction.

When you hear internists and family physicians complain about their jobs, the problem is consistently related to autonomy.  What do they hate?  They hate prior authorization, second guessing their orders, subspecialty organizations saying they are doing a poor job.

Daniel Pink also talk about how performance measurement changes the focus, and often in an adverse way.  Performance measurement might induce us to be more disease focused than patient focused.

Obviously physicians should strive to provide the best possible care for patients and that includes appropriate treatment for the diseases in question.  However, excellent physicians will balance treatments and risks.  While theoretically performance measures may do that, in practice even a two dimensional measure reverts to one dimension. 

While the current demise of primary care has many causes, I submit that the performance measurement movement only accelerates the demise. 

The sad observation comes from understanding that all these rules, measures and contortions stem from a misplaced belief.  I quote from Daniel Pink's book:

… Remember: When children didn't expect a reward, receiving one had little impact on their intrinsic motivation.  Only contingent rewards – if you do this, then you'll get that – had the negative effect.  Why?  "if-then" rewards require people to forfeit some of their autonomy.  Like the gentlemen driving carriages for money instead of fun, they're no longer fully controlling their lives.  And that can spring a hole in the bottom of their motivational bucket, draining an activity of its enjoyment.

The entire field of performance measurement and its kin debase professionalism, physician satisfaction and likely worsen care.  The idea is based upon a faulty premise, but one that is very difficulty to have experts abandon.  CARROTS and STICKS do not work for this kind of work.  The reward should remain in the work itself.  But that only happens when the bean counters understand that the act of counting beans is detrimental.

Comments (4)

Daniel Pink popularized the intrinsic motivation paradigm, for sure. But the research that showed all what he claims was conducted in the 60ies and 70ies. If you want a lot more and in-depth literature on the topic of motivation, I can highly recommend reading "No Contest" and "Punished by Rewards" from Alfie Kohn. He comes from pedagogy, but his exhaustive summary of contemporary motivation research is mind-blowing.

How does Pink handle the problem of monetary compensation? "The reward should remain in the work itself"– that does not make sense because, after all, we don't work for free.  If internist got paid more, wouldn't some of the job disatisfaction go away– you spend more time with a patient, and wouldn't mind the pre-auths and paperwork because you have the time to do a good job anyway?

@ErnieG: People are not the "homo oeconomicus" the economic scientists always assumed he is. Most humans are interested in fair payment, which pays their bills and values their level of education and experience. I have met very few doctors unsatisfied with their payment (in absolute terms), they were mostly unsatisfied with having to do so much stupid paperwork and organizational tasks and not being adequately or at all paid for it.

great point DB….  but how bad does it have to get before doctors stop complaining and actually act?  or how bad does care have to get before patients demand better?
that would be an interesting question to answer…..   I agree with lupo.  you either pay (PCPs in particular) better or you do away with worthless mundane unfunded paperwork and mandates.  
i think either would accomplish the goal.  again…. how bad does it have to gt before PCPs rebel instead of just complaining?

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