July 14, 2023
Dear Interested Readers,
Intrinsic and Extrinsic Motivation as Factors in The Joy of Practice
When I am walking or exercising, I enjoy listening to a variety of podcasts. Since I spend around two hours a day walking or riding an indoor or outdoor bicycle or doing Pilates, I listen to a lot of podcasts. Most of the podcasts I enjoy have a political or philosophical orientation. I have recently added Sean Illing’s podcast from Vox which is entitled “The Grey Area” to the list of podcasts that I hear weekly.
About three weeks ago, I listened to Illing’s conversation with David Samson who is an evolutionary anthropologist at the University of Toronto. Samson has recently published Our Tribal Future: How to Channel Our Foundational Human Instincts into a Force for Good. There is an excellent short interview with Dr. Samson in the Toronto Star where he disciusses his book. You can listen to the podcast by clicking here and selecting the June 22 podcast. If you prefer to read their conversation, the transcript is available by clicking here. The review of Samson’s book by the publisher hit on several areas of interest to me:
Our Tribal Future explores a central paradox of our species: how altruism, community, kindness, and genocide are all driven by the same core adaptation. Evolutionary anthropologist David R. Samson engages with cutting-edge science and philosophy, as well as his own field research with small-scale societies and wild chimpanzees, to explain the science, ethics, and history of tribalism in compelling and accessible terms.
One interesting point that Dr. Samson makes in his book and in both the interview with the Toronto Star and on Illing’s podcast is that until about 300,000 years ago humans were unable to form groups larger than one hundred and fifty individuals which is “Dunbar’s number.” 300,000 years ago and even now it is hard for Homo Sapiens to manage relationships with more than one hundred and fifty people. That number limits our most significant relationships to close relatives and a small circle of good friends and trusted associates. Innately, we have trouble developing trust with people we don’t know well, and if we have difficulty knowing more than one hundred and fifty people well enough to trust them, our possibilities for collaboration are limited. The breakthrough that made large tribes possible was the development of symbols. Samson says:
… And that’s [Dunbar’s number] limited to the maximum number of individuals who can register in a mental ledger book of reciprocity. That was it until around 300,000 years ago, when human ancestors developed a capacity for symbolism that could send complex signals into the environment — a cheat on knowing who to trust and who not to trust among strangers that scaled up trust to small-tribe size.
If you are confused, think about Red Sox caps, Yankees’ T-shirts, MAGA hats, American flag lapel pins, Crucifixes, Stars of David, white lab coats, and the caduceus. Obviously, it’s possible to be a member of more than one tribe as defined by symbols. The symbol tells us something about people we would not otherwise know. For example, I am a little leary of close proximity to someone wearing a Yankees’ t-shirt or a MAGA hat. Their symbols give me a sense that they are “other.”
As you may have guessed, I have been enjoying Dr. Samson’s book since listening to his conversation with Sean Illing. Beyond the importance of symbols, there are many connections that he makes in the book that are applicable to the future of healthcare, our current political divisions, and the future of the planet in an era of global warming. What he writes that is hard for me to fully accept is in the second part of the book’s title, How to Channel Our Foundational Human Instincts into a Force for Good. I am not sure that enough people will learn the lessons that he is offering to make a difference, but I admire his enthusiasm for the healing power for humankind if we could develop a better understanding of how our concerns about “others” who are not in one of our personal intersecting tribes developed.
I am especially skeptical about using an enhanced understanding of tribe to mend deep bipartisan divides over issues in healthcare or global warming. Samson may also be a little too enthusiastic about ever having policymakers and politicians understand how their own primeval tribal instincts prejudice their feeling about the ideas of “others” not in their tribe, but I have always enjoyed conjectures about the “origins” of things. In Chapter Six, Samson focuses on the benefits of our tribal instincts to overcome isolation and improve happiness. His discussion of what makes us happy and how we need contacts or a community is enlightening. It is an unfortunate fact that in our post-modern world replete with electronic devices that capture our attention we have more focus on “self” than community.
Samson is not the only writer to push this idea. Johann Hari has written about our lack of community in his book, Lost Connections. Our current Surgeon General, Dr. Vivek Murthy has recently warned us of his concerns about our epidemic of isolation, and he has written a book on the same topic, “Together: The Healing Power of Human Connection in a Sometimes Lonely World.” It seems that Samson, Murthy, and Hari all agree that we need to find a way back to a real sense of community. I think that is true for healthcare and its providers as well. Have we lost our sense that we are a community of concerned professionals working toward some shared goals?
As I was doing my morning survey of the “Opinion” offerings in The New York Times entitled “If Loneliness Is an Epidemic, How Do We Treat It?” The article was written by Eleanor Cummins and It is a quick read that clearly identifies a role that clinicians can play in combating loneliness which most certainly can be the origin of many medical conditions or cause exacerbations of chronic diseases. It seems to me that loneliness is a real concern for many and perhaps should be considered part of our social determinants of health. They write:
A report on loneliness in America published by Harvard University’s Graduate School of Education two years ago has a similar starting point. Doctors “should be asking patients if they are lonely as part of annual physicals,” the authors wrote.
From there, doctors can help patients single out components of chronic loneliness and line up appropriate treatment.
As Samson continued his discussion of community and our need for each other he ventured into a review of intrinsic and extrinsic factors that favor or block professional satisfaction and associated personal happiness. The discussion was not specific to healthcare or our problem with burnout, but it did get me thinking about my own experiences in healthcare. I tried to remember what gave me a sense of satisfaction and what frustrated me.
Samson used playing the guitar as an example of an activity that could be impacted by internal and external factors. That example resonated with me as I thought about my youngest son. He always has a guitar nearby. He can’t get enough of it. He is constantly trying new “tunings.” New melodies come to him as easily as a conversation comes to most of us. The guitar gives him relaxation when he is tense, and I imagine he turns to it if life feels frustrating.
After describing all the joy and satisfaction that can come for some people from playing a guitar, Samson then asks to us imagine that we need work and have gotten a job playing guitar in a busy restaurant. The boss is demanding. He has no appreciation for our talent and wants us to play songs that don’t interest us and that don’t really challenge our capabilities. We put up with him because we need to work to pay our rent, but the hourly pay is minimal. There is a lot of noise in the restaurant and little evidence that anyone cares about what we are offering. We feel alone in a crowd. It’s not true that all extrinsic factors are negative. One night you are “discovered” by a record producer who recognizes your talent. The analogy delivers a clear picture. Extrinsic circumstances can crush a person even if they are doing something that they love, and occasionally recognition or relief can come from an unexpected external source.
Samson’s analogy brings to mind the enthusiastic physician or nurse fresh out of training and looking forward to a rewarding life of compassionately providing care and solving complex clinical problems. Perhaps you have been in practice long enough to remember that once there were better days, but now it is hard to remember when you last found joy in your professional pursuits. You are employed, and your employer has productivity expectations of you but does not supply you with the clinical support necessary to meet those expectations. Your pay is “market” but that term makes you feel like an hourly employee in a menial task and not someone who spent four years in college, four years in medical school, and four years in postgraduate training to become a competent professional. The person managing you hasn’t made the commitment of time or experienced the sacrifice that was required to develop your professional expertise. He/she has four years of college and an MBA which impressed him/her with the need to tightly manage you to maximize “shareholder” value. If you practice in a non-profit environment, you are tired of hearing “No margin, no mission.” Your medical director demands that you follow algorithms that describe best practices and limit waste when in fact you value clinical autonomy especially when there is a great deal of uncertainty about what the diagnosis really is. All of the joy that you once dreamed of or even once experienced seems to be a distant memory. Occasionally, a patient or a patient’s family recognizes the efforts that you have made against resistance to give them what they need, and for a brief moment, you experience something that you once hoped would be a frequent occurrence. Perhaps, I am being a little melodramatic so I decided to ask my Chatbot buddy what she thought were the intrinsic and extrinsic factors that impacted the professional satisfaction of physicians.
Please explain intrinsic and extrinsic factors that impact the professional satisfaction of physicians.
ChatGPT
The professional satisfaction of physicians is influenced by a combination of intrinsic and extrinsic factors. These factors can have a significant impact on their overall job satisfaction and well-being. Here’s an explanation of intrinsic and extrinsic factors and how they affect physicians:
Intrinsic Factors: Intrinsic factors are related to the internal aspects of the work itself and the individual’s personal experience.
- Autonomy: Physicians often value autonomy in their work. Having the freedom to make clinical decisions, choose treatment plans, and exercise professional judgment can contribute to their satisfaction.
- Meaningful Work: The intrinsic value of providing care to patients and making a positive impact on their health and well-being is a significant driver of professional satisfaction for physicians. The sense of purpose and fulfillment derived from helping others can be deeply rewarding.
- Pofessional Growth and Development: Physicians value opportunities for continuous learning and professional growth. Access to educational resources, research opportunities, and career advancement can enhance their job satisfaction.
- Work-Life Balance: Achieving a balance between personal life and professional responsibilities is important for physician satisfaction. Adequate time for personal pursuits, leisure activities, and time with family can contribute to overall well-being.
Extrinsic Factors: Extrinsic factors are external to the individual and are often influenced by the work environment, compensation, and organizational factors.
- Compensation and Benefits: Competitive and fair compensation is an important extrinsic factor for physician satisfaction. Adequate financial rewards, benefits packages, and incentives can positively impact job satisfaction.
- Workload and Work Hours: The workload and working hours can significantly affect physician satisfaction. Long and demanding work hours, excessive administrative burdens, and high patient volumes without appropriate support can lead to burnout and decreased job satisfaction.
- Supportive Work Environment: A positive work environment that fosters collaboration, communication, and mutual respect can enhance physician satisfaction. Having supportive colleagues, effective teamwork, and administrative support can contribute to job satisfaction.
- Administrative Efficiency: Administrative tasks, bureaucratic burdens, and paperwork can detract from the time spent on patient care and contribute to frustration and dissatisfaction among physicians. Streamlining administrative processes and reducing paperwork can improve job satisfaction.
- Recognition and Appreciation: Feeling valued and recognized for their contributions is important for physician satisfaction. Feedback, acknowledgment, and appreciation from colleagues, patients, and the organization can positively impact their professional well-being.
It’s important to note that the impact of intrinsic and extrinsic factors on physician satisfaction can vary among individuals. Different physicians may have varying priorities and preferences. Understanding and addressing both intrinsic and extrinsic factors are crucial for promoting physician well-being and ensuring a satisfying and sustainable medical career.
It seems that my Bot friend and I see things similarly. Dr. Samson would consider healthcare professionals to be members of a tribe. The question is can we be an effective tribe? Perhaps, the most organized part of our tribe is the AMA which does not give me much confidence that our tribe will be able to change direction and move back toward predominantly positive intrinsic motivations that neutralize the external factors that harm so many professionals and the patients they try to serve. The history of the AMA suggests that as a tribe it has often been rather self-protective, and has often put the business interests of the profession above the best interests of the public and the patients it must serve. In a recent New Yorker article entitled Inside The American Medical Association’s Fight Over Single-Payer Health Care: A long-standing battle highlights a profession’s political transformation,” In this article, which I quoted before, Dr. Clifford Mark highlighted the history of the AMA from a movement that began in the 1840s with the lofty objectives of rooting out quackery and improving the quality of physicians and medical education to a political lobby with immense power that since the 1930s has sought to optimize profits for its members by opposing expanding medical education and blocking efforts to establish universal access to care.
Dr. Samson is hopeful that we can understand the origin of our tribal relationships and learn how to effectively employ the benefits these instincts might offer as we seek to craft a better future. He warns us that we also need to understand that the same instincts can lead to dualistic thinking and other liabilities like genocide. These instincts have mostly enhanced the success of our species for the last 300,000 years and could be better employed for our benefit now if we understood them better. I hope that he is right.
Everything Seems to Be Floating Away
The header for today’s post is a dreary picture. Low-hanging clouds and a little fog lie against the hills across the lake. If you look closely you can see that the mooring ball to which my Sunfish is attached is almost entirely submerged. That’s because the level of the lake is up about two feet. The picture was taken after we had nearly six inches of additional rain over the previous 24 hours. Perhaps you have seen scenes from the floods in Vermont that resulted from the same storm. The scene was very similar to the aftermath of Hurricane Irene in 2011. It is a reality that storms are experienced differently in Vermont than in New Hampshire.
If you have ever driven up Interstate 89 and crossed the Connecticut River at Lebanon or Hanover you may have noticed that the topography changes, and you are entering a different world. There are mountains and maples in both states, but the geographical history of the west side of the Connecticut River is different than the east side. The east side came from Africa and the west side was once the coast of North America. A tectonic collision more than 400 million years ago stuck a piece of Africa onto North America. New Hampshire has lakes that are a good buffer for heavy rain. Vermont has steep mountains and deep valleys that are quite beautiful but don’t buffer big storms as effectively as the broader valleys and lakes of New Hampshire. Interesting.
Tuesday was a day of reprieve and recovery. My fishing boat along with its two small motors was underwater at my dock, but the sun was out. The rain has returned off and on and the weatherman on Channel Nine says that it will be one drenching after another until sometime in August at the earliest. The Governor of Vermont is telling Vermonters that there is more grief coming their way. Summer is my favorite time, most of the time. This summer is beginning in a very unusual way. The good news is that the drought they were talking about last summer is definitely over. My heart goes out to the people across the South and Southwest who are getting fried. I would rather be wet than fried.
My poet/songwriting son now lives in a little town between Portland and Brunswick, Maine. That area was also drenched and he wrote a little bit of an essay and song about the weather.
Notes: It has been a damp summer and everyone around here is sick and tired of it. I’m pretty annoyed with it myself after a much-anticipated camping trip was mercilessly washed out over the weekend. It’s easy to let it get you down when it just keeps on coming. But I want to cultivate a better attitude. Rain is a life giver, and my surroundings attest to it. It is green and lush here. Inconvenience be damned. If it keeps coming, I want to try to be out in it more. I want to embrace it for what it is and to show it my gratitude for life as we know it here on dry land.
No One Likes the Rain
It seems that no one likes the rain
Always running from it any way we can
Ain’t it a shame?
‘Cause it’s a long lost part of us
Ain’t it strange?
Hiding from the mother of us all
I hope that your weekend goes well and that wherever you are you will be neither too hot nor too wet and will be enjoying beautiful summer weather.
Be well.
Gene
