Healthcare Systems and Motivation

Erich H. Loewy, MD, FACP

In This Article

What Motivates Physicians?

That self-interest -- conscious or sub-conscious -- plays a role in every person's behavior and, therefore, also in physicians' is beyond doubt. But a larger patient load is hardly a motivating factor for most physicians today. Rather, the main complaint today is a lack of time to devote to the proper care of patients and to their own families, outside interests, etc. Indeed, we in the humanities have steadily decried the fact that physicians seem to immerse themselves in medicine to the exclusion of all else.

Moreover, physicians, like all other people, are motivated by not one but several factors. Their choice of medicine as a profession may be prompted by a variety of things but there are few physicians whose motivation is purely -- or even largely -- material. There is no doubt that if someone is interested in pursuing a particular profession or field that entails a relatively long and expensive preparation, the question of being able to live a comfortable life, to have sufficient time with one's family, and other material conditions most certainly will (and should) play a role. Yet, for example, it is interesting that in the Soviet Union of old there was still a huge number of applicants to medical school despite the expectation of a ridiculously low salary. Since the fall of the Iron Curtain, physicians' salaries there are still inadequate but there are still more applicants than can be accommodated. In many of the former nations allied with the USSR this is still largely the case -- and yet the number of people clamoring to get into medical colleges has not declined.

Physicians are motivated by many things, among which a genuine interest in a particular specialty and being of help to their fellow humans loom large. Many who are motivated to go into underserved areas when they enter find that motivation still undiminished when they leave medical school. Physicians have not taken an oath of poverty, chastity, or obedience but they have taken an oath to "strive to change laws that are contrary to my profession's ethics and will work towards a fairer distribution of health resources." The AMA Code of Medical Ethics contains the following sentence: "A physician shall support access to medical care for all people."

Throughout my rather long professional life -- first in medicine, and now in bioethics -- I have met many physicians who have worked hard and expect a considerably greater than adequate lifestyle, which is not unreasonable when one takes into consideration the fact that physicians, on average, work about 80 hours a week...and many a night. I have met many more who wanted to help their patients and even more who were driven by an urge (not related to money) to excel. These were true "workaholics." I had a colleague elsewhere whose hobby was reconstructing old cars. But he was a cardiac surgeon and was so busy that he finally hired a person to do his hobby for him! On the other hand, I know several who spend 2 or 3 months a year in underdeveloped countries under miserable conditions doing what can be done for their patients. I have known 2 plastic surgeons (they were often accused of being "greedy"), orthopaedic physicians, internists, pediatricians, cardiologists and others who spent 2 or 3 months a year in medically underserved and poverty-stricken countries. And I have known others from all over the world who often paid for their own fare, food, and living quarters. I have also known those who fought for civil rights, for universal health insurance, and for an equitable distribution to all. Of course, I have met physicians who are crassly self-interested, "greedy," if you will. However, there were then -- and I find no reason to suspect otherwise today -- far fewer in medical practice than one finds in other professions.

That people (and physicians are people) wish to have a comfortable living, pay off their debts, help their children through school, and provide for their old age is not a sign of crass self-interest, but one of responsibly providing for one's family and oneself. I do not believe that such a self-interest (defined in monetary terms and going beyond the motivations mentioned) is an important motivator nor is it at the root to the objections to managed care. Physicians' objections are focused, rather, on the constant interference with diagnostic and therapeutic needs; the amount of paperwork which badly cuts down on their ability to take care of patients and, in an academic environment, to teach; and the knowledge that many of their patients will not be able to buy their medications because of their inability to afford ever-rising copayments. Their main worry is that, in our ever-larger MCO-driven market, they are not allowed sufficient time needed to make a decent diagnosis, do not have enough time to get to know their patients, and are restricted in what they are allowed to order: tests, x-rays, consultations, or medications. Worst of all, they, who have pledged not to allow economic circumstances to influence their medical decisions, have often been carefully shielded from the problems of the uninsured or poor patients, who are sent away by some secretary without the physician ever seeing them. Here, at least, physicians united in a like-minded group certainly may be able to do something.

Certainly physicians (and in my view properly) are interested in making a sufficient income to pay their debts, help put their children through school, and provide for their old age. This is not only true of physicians; it is true of all people. Physicians expect, furthermore, to be able to live the way the middle or upper middle class live. That seems to me not only to be expected but prudent. Are there physicians who are as crassly self-interested -- perhaps "greedy" is the more apt expression -- as the example that Altom and Churchill provide? Undoubtedly, but I think the more important question here is why any of us should think the example of "conspicuous consumption" is ever ethically supportable, irrespective of whether it occurs in a physician, a corporate CEO, or an NBA star. Why should we find it more offensive to find an example of "conspicuous consumption" in a physician than in a CEO or an NBA star or an attorney? Especially in the United States today, it should be worrisome wherever it occurs.

Personally, and having looked through the literature on the subject, I find that the income of physicians has steadily declined (a drop of 7% while other professions have risen as much as 7%)[13] and that the income and fringe benefits of nurses have risen steeply from a time when salaries were scandalously low to today, when some nurses make as much as some physicians and, in many cases, receive far better benefits. Further, if we are to compare income fairly we need to take into account the number of hours involved. Nurses work nearly half as many hours as the average physician does, which makes the difference even more pronounced. In addition, when nurses work longer they ordinarily get overtime whereas physicians do not. It takes a physician (depending on the specialty) 12 to 18 years of training beyond graduation from high school, whereas the average nurse need complete only 4 years of training beyond high school and if he or she specializes, an additional 1 to 3. As a result, physicians will start work considerably later in life than nurses. Thus, when all of these factors are taken into account, the pay of many physicians is, in reality, less than that of nurses.


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