Last week, my best friend took the recertification exam in anesthesia, the so-called MOCA exam. Like a good doobie, she paid her $2,100, paid her nanny extra so she could study, took a day off in which she missed the funeral of a friend’s husband, and took the test. Wow, she must be the most awesome, most well-read, most skilled, most enthusiastic anesthesiologist ever now! Well, she always was, but the test didn’t make her that way. In fact, there is a large body of evidence that suggests such testing requirements have the potential to reduce the quality of her work.
In 2010, the American Board of Medical Specialties did a survey in which they found that 95 percent of the public rates participation by their physicians in Maintenance of Certification (MOC) as important. Doctors have derided the requirement of MOC as costly, irrelevant, and time-consuming, accusing professional boards of using such requirements as moneymaking ventures. Plus the whole thing doesn’t make sense since doctors originally certified before 2000 or so don’t have to do it at all. The public has said the doctors are whiny and just don’t want to keep up their skills and be accountable. That doctors are, in effect, lazy. Plus they have plenty of money, what do they care about fees? We demand our high-quality health care dammit!
In 1973 three guys named Lepper, Greene, and Nisbett did a study with a bunch of preschoolers. They choose an activity that the kids all liked, drawing in this case, and tested whether kids were more or less interested in drawing when they were given a reward for doing so. It was an if-then scenario: If you do this, you will get that. The kids who got rewarded showed much less interest in drawing two weeks later. They had lost their motivation for drawing. Studies like this were repeated many times in kids and adults, and in 1999 some researchers reanalyzed thirty years of such studies and found that, “When institutions –– families, schools, businesses, and athletic teams, for example — focus on the short-term and opt for controlling people’s behavior, they do considerable long-term damage.”
Daniel Pink, in his book Drive, points out these and many other examples of solid literature suggesting that making people do things makes them less likely to want to. Not only that, but Pink cites plenty of evidence that forcing people to do things reduces the quality of the work. It is true of preschoolers, and it is true of adults. The problem is the difference between External and Internal motivation. My best friend has always kept up her knowledge and skills because of her internal drive to be the best she can be. That drive can be diminished by randomly imposed requirements.
Extrinsic motivators narrow our focus and reduce the breadth and depth of our thinking. If the extrinsic motivator is the most important or prominent motivator, the focus becomes pinpointed to the externally imposed goal. This is certainly true for education. One of the main problems with standardized testing is that students are extrinsically motivated by the imposition of a test. The test becomes the most important motivator for studying. The students’ focus narrows to the regurgitation of facts. Extrinsic motivation is applied over and over in the case of students who do well on such tests. The breadth and depth of knowledge is substantially reduced. Plus, being made to take the tests has the effect of decreasing students’ intrinsic motivation, which is the kind of motivation that results in the best results over time. The same sort of thinking explains why a kid who is interested in music will often lose motivation when external pressures to succeed are placed on him by parents and teachers.
And the same thing happens to doctors. Doctors are no more noble or less human than the rest of us. Being made to do things decreases our intrinsic motivation just a surely as making a kid practice diminishes his desire to make music. The kid will push back. Doctors do too. Maintaining skills and knowing the latest research are important for doctors, just as they are for any profession. We need to adjust the system in such a way that the intrinsic drive to be the best we can be is fostered.
Do you want a physician who loves his work, is internally motivated to read the literature because he is interested in the subject, one who has breadth and depth of thinking? Or do you want a demotivated, narrowly focused test-taking machine?
Shirie Leng, a former nurse, is an anesthesiologist who blogs at medicine for real.
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