In a recent op-ed in The New York Times, David Brooks argues that we are seeing a level of agreement on how to deal with SARS-CoV2 that has not been seen since 9/11. He sites various data, but I am reminded of David Hackett Fischer’s analysis of the perpetual tension between liberty and freedom in American history. Briefly stated, he compares the Latin notion of liberty as a license granted by government, while freedom is a Nordic right obtained by membership in the group. Thus, loosening of quarantine efforts is seen by some as a liberty while others are complaining of loss of liberty to do whatever they want. While Brooks is right, the overwhelming majority of us agree with current efforts to contain the pandemic, it is a mistake to dismiss the protestors as a fringe group. Over time, the consensus will erode, as it always does.
Another way of stating this is that we are always balancing the needs of the community versus the needs of the individual. Given the new awareness of the needs of the community, is this a time to develop a new concordat in medical care organizations? And if so, what might that look like? Interesting insights can be obtained from an article by Herrera and associates detailing how the Central Florida Division of AdventHealth has been responding to the pandemic challenge. As it happened, they had been developing a new model for physician engagement across the system by transitioning the unit medical director position from its old role of monitoring behavior to what they call the Transformational Medical Director. This new role focuses on four areas: waste reduction, innovation, standardization, and experience. When the pandemic struck they were able to assemble teams of these medical directors to address the new challenges in an effective, multidisciplinary way. The article has considerable detail and I recommend it to those who want to pursue it further.
For my purposes here, though, I want to counter with a perspective published by Hartzband and Groopman in The New England Journal of Medicine on 1 May 2020. They begin by summarizing the state of things at the start of the year.
“The unintended consequence of the radical alterations in the healthcare system that were supposed to make physicians more efficient and productive, and thus more satisfied, have made them profoundly alienated and disillusioned. The problem has become even more urgent with the realization that it’s costing the health care system approximately $4.6 billion a year.”
They conclude the root cause is a misalignment between caregivers’ values and the reconfigured health care system. Their analysis is based on organizational psychology research which classified motivation as extrinsic or intrinsic.
“One might imagine that intrinsic and extrinsic motivators would have additive or even synergistic effects. But Gagne and Deci showed that tangible extrinsic motivators, such as monetary rewards, can paradoxically undermine intrinsic motivation. Such unexpected effects occur particularly among professionals, who undertake complex tasks requiring cognitive flexibility, creativity, and problem solving…In a misguided attempt to improve the medical system, health care reformers put into place various positive and negative extrinsic motivators, without realizing that they would actually erode and destroy intrinsic motivation, eventually leading to “amotivation”—in other words, burnout…Gagne and Deci posit there are three pillars that support professionals’ intrinsic motivation and psychological well-being: autonomy, competence, and relatedness. All three have been stripped away as a direct result of the restructuring of the health care system.”
I find myself remembering conversations with lay people involved with restructuring our organizations and realize I was instinctively fighting many of them because I felt the threat, though I lacked the concepts and the data. As we continue to confront the pandemic and the pressure it puts on all or our organizations to respond effectively, we will certainly see the effects of “amotivation.” But can we see this as a time to fix some structural issues if we have the wit to do so?
There are two basic approaches. The first, which I would prefer, is to find ways to fully integrate clinical concerns into the life of the organization as outlined by the Herrera and colleagues. The other would be to create a structure where the professionals were free to operate in the clinical world as they saw fit with only the senior leadership interacting with the business concerns. This structure has been widely used but is likely doomed to failure as the business concerns mount. We have frequent headlines about the financial strains our hospitals are experiencing with the pandemic added to existing problems. The urge to tell the professionals what to do with a goal of making money is too great. While it is a truism that “no money, no mission,” it is equally true “no mission, no money.”
Is it possible the strain of dealing with the pandemic will help us break out of the destructive rut we have been in for the past 20 years or so? Let us turn to Hartzband and Groopman again.
“With the Covid-19 pandemic, medicine is at a crisis point. Health care professionals are responding with an astounding display of selflessness…Indeed, the whole medical system, including hospital administrators and insurers, among others, has rallied to support the caregivers. But will these positive changes be sustained? Tectonic shifts are at work as hospitals and clinics suffer grave financial losses and the workforce is diminished by illness and exhaustion. As the current crisis ultimately abates, we need to remember the lesson that the system can be reset. It is time to evaluate what has worked, and what hasn’t in health care reform. We must not return to the status quo.”
12 May 2020
 Brooks D. Why the Trump Ploy Stopped Working. 30 April 2020. Accessed 1 May 2020 at https://www.nytimes.com/2020/04/30/opinion/coronavirus-unity.html.
 Hackett Fischer D. Liberty and Freedom: A Visual History of America’s Founding Ideas. (Oxford: Oxford University Press, 2005.
 Herrera V, Finkler N, Vincent J. Innovation and Transformation in the Response to COVID-19: Seven Areas Where Physicians Need to Lead. NEJM Catalyst, April 2020. Published online 16 April 2020. doi: 10.1056/CAT.20.0087. Downloaded 22 April 2020 from https://catalyst.nejm.org.
 Hartzband P, Groopman J. Physician Burnout, Interrupted. doi: 10.1056/NEJMp2003149. Published online 1 May 2020 at https://nejm.org.
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