The task of any medical education program is to support medical students’ successful transition into practicing clinicians who improve the lives of their patients.1 The success of this is heavily dependent on medical educators—namely, the clinicians and other faculty who teach in classroom and clinical environments, many of whom are not salaried or employed by the university, many of whom are not trained as educators, and many of whom discovered their roles as educators only as a secondary career choice.2 Given these barriers, identifying and recruiting motivated and effective educators can be challenging, and there is concern that the drawbacks of teaching increasingly outweigh the benefits. Some researchers have found that almost half of teaching faculty are dissatisfied and are seriously considering leaving their teaching roles.3,4 There are individual, environmental, and systemic factors influencing clinicians’ motivations to teach, and understanding how medical schools can best incentivize teaching and promote teaching excellence is needed.
Motivation refers to the means through which an individual is moved to undertake a task.5 When there is a lack of (or waning) motivation, implementing incentives (i.e., any external offering, tangible or intangible, that is used in an attempt to influence effort) might seem like an obvious solution. However, implementing incentives is not straightforward and can be counterproductive by reducing positive forms of motivation or promoting problematic forms of motivation. For example, introducing financial rewards in attempts to drive up blood donations has backfired and reduced people’s willingness to donate blood.6,7 Incentives can lead people to perform actions “with resentment, resistance and disinterest, or with an attitude of willingness that reflects an inner acceptance of the value or utility of a task.”5 Knowing how to position incentives appropriately to foster productive forms of motivation among our medical educators is, therefore, paramount.4
This paper offers a critical synthesis conducted to explore how, why, and when incentives are positively influential. We highlight key differentiators between fields of study and reveal how researchers have attempted to mitigate negative impacts of incentivization schemes. The medical education literature is considered first to provide context. Subsequently, we highlight gaps in that literature’s portrayal of incentives by illustrating relevant research findings from the fields of psychology, organizational behavior, and behavioral economics. Each contributes relevant empirical data and theoretical understanding that provide additional insight into the medical education context. We then synthesize areas of convergence and divergence within and across these disciplines in an effort to offer practical advice and outline what gaps in understanding remain.
The purpose underlying this effort was to explore a variety of significant contributions to understanding the phenomenon of incentivization rather than to draw conclusions about the consistency/magnitude of any particular observation. As such, we conducted a critical literature review, which is a synthesis guided by a purposeful and iterative approach to understanding the literature within a given field(s). It proceeds through the critical evaluation of publications to identify foundational papers that may be wide reaching and contribute particular insight about different aspects of the topic under investigation.8,9 Its main strength is allowing the researcher to draw on a substantial breadth of literature to develop well-rounded understanding given interest in a phenomenon that is too broad to allow claims of complete systematicity.10
Our process was informed by Grant and Booth (2009)9 and included four steps: search, appraisal, synthesis, and analysis (Figure 1). In the search stage, Google Scholar was used to identify seminal papers and key theoretical concepts related to incentivization that informed search terms that were then applied to a more refined search. While all relevant fields were considered at first, some did not contribute additional knowledge to the lessons gleaned from medical education (e.g., explorations of incentivizing teachers in general education were largely conceptually redundant to explorations involving medical educators), and some fields appeared predominantly to draw from theory and evidence primarily generated in other domains (e.g., exploring coaching in athletic and organizational contexts largely led us back to psychology). Through iterative discussions between both authors as the search process unfolded, the disciplines of psychology, organizational behavior, and behavioral economics were deemed particularly fruitful with respect to deepening our understanding of incentivization as it might pertain to medical education. As a result, additional searches were made through those literatures in a deliberate effort to ensure that those perspectives were represented well. Databases used included CINAHL, Dissertation Abstracts, ERIC, MEDLINE, PsycINFO, EconLit, and Web of Science. Articles were explored in detail if they addressed the following questions: (1) Does the publication explore the interaction between incentives/rewards/barriers and motivation? (2) Does it contribute to deepening understanding of the mechanisms through which incentives can yield certain actions? Most articles were empirical studies, but relevant case studies, book chapters, and editorials were also considered because they could lead to additional insight.
How and why incentives are being used in medical education
A considerable literature, predominantly developed through surveys and interviews, suggests that clinical teachers feel many motivations to teach. Particularly prominent is the ability to demonstrate and refresh one’s medical knowledge,3,11–14 the opportunity to “pay forward” the benefits received from educators,13–18 the opportunity to interact with and help students,3,11,12,15–18 and personal satisfaction derived from feeling challenged or assuming a teaching identity.13,14,16–18 Some who report feeling motivated to teach find it to be the most rewarding of their roles.19Table 1 provides a more comprehensive list.
At the same time, it is clear that some clinicians face many barriers to teaching.17 Clinicians who report being motivated to teach are increasingly dissatisfied with their teaching roles,15 with attrition and burnout being unfortunate outcomes.4,11,14,19,20 Barriers to teaching that are commonly reported include competing priorities,3,11,13,14,17 a lack of perceived skill,7,17,19 poor teaching facilities,3,15,17 and a lack of interest.11,15,19Table 2 provides a more comprehensive list.
The impacts of these barriers are costly given that medical school faculty turnover averages 8% to 10% each year,4 with the 10-year retention rate of assistant professors only 43%,20,21 and turnover costing between $155,000 and $559,000 per clinical faculty member.19 All this, combined with reports that the number of medical students and residents seeking teaching roles is similarly declining, has led to claims that attracting the next generation of faculty and preventing the loss of current faculty must be a dominant priority.4 Little guidance, however, is available to avoid what could be a looming crisis.
The most common incentives for clinical teachers have not stemmed the tide. These include academic appointments, recognition from leadership, faculty development opportunities, awards, money, gifts, continuing medical education credits, and library resources.12,13,17 When clinicians have been asked to rank-order incentives for teaching, personal satisfaction ranks highest, followed by educational opportunities and career advancement, with financial payments and gifts ranking last.12,13 The predominant use of self-report measures in these studies, however, raises concern about the extent to which we have operated from a sufficiently nuanced understanding of the role that incentives play. For example, although financial rewards ranked lowest overall in the study mentioned above, that result depended on the context in which respondents were working: Money was ranked least valued by those who were not paid to teach, but highest by those who were already being paid.12 Further, such rankings may suggest that some people do not teach for financial incentives, but they neglect to address commonly heard concerns of financial disincentives associated with teaching (i.e., money that is given up by not being in clinic). Taken together, this literature and its limitations suggest a more complex reality than simple claims that certain incentives are influential or not.
Given the disconnect between what people perceive to drive their behavior and actual determinants of behavior,22 designing an incentivization scheme based on self-reports is risky. Further, various reports of incentive schemes having counterproductive consequences demand a deeper exploration if we are to better understand the impact of incentives on those who are not required to teach or who could be encouraged to give more effort. To begin, we turned to psychology, a discipline that specializes in understanding such disconnects between expectation and observation.
Psychology’s view on incentives
Psychology researchers have conducted extensive research on the mechanisms by which motivation arises. Four components of motivation are shared among several prominent motivational theories: (1) competence (one’s self-perceived ability to do something well); (2) autonomy or value (the extent to which one wants to complete, or is invested in, the act); (3) attribution (one’s perceived responsibility for the outcome); and (4) sociocognitive elements that involve interactions between an individual and the social context.23 The effectiveness of an incentive for a particular individual, therefore, is dependent on how it builds on or detracts from these four components. A key distinction in this literature, drawn from self-determination theory (SDT), is that between intrinsic motivation, in which a task is performed “because it is inherently interesting or enjoyable”4; and extrinsic motivation, in which a task is performed “because it leads to a separable outcome.”5 To have a separable outcome means that there is some instrumentality to the task, either in the form of a reward that is valued or a punishment to be avoided (e.g., reading a book because it is assigned as homework rather than because the topic is interesting).
A clinician who is intrinsically motivated to teach does so because she enjoys the fun or challenge (i.e., because the reward is embedded within the activity itself). Generally, intrinsic motivation is observable when an individual engages in a particular task even when there is no expectation and despite there being other activities in which the individual could engage.24 According to these models, if every clinician were intrinsically motivated to teach, there would be no issue with staffing medical training programs, thereby begging the question of whether incentives can build intrinsic motivation.
A seminal meta-analysis25 reveals that the provision of incentives is, in most cases, detrimental for those who are intrinsically motivated toward a certain task, sometimes permanently. Cognitive evaluation theorists26 explain that rewards lower an individual’s sense of autonomy and competence, making the task seem less desirable because the reward implies that one would not do it if not rewarded.5 This is particularly the case with task-contingent and performance-contingent rewards (i.e., those given based on completing the task or completing it at a certain level). Non-task-contingent rewards (i.e., those given regardless of whether the task is completed) remove the instrumentality between the task and the rewards (allowing individuals to reclaim autonomy) but can simultaneously remove competence affirmation, eliminating the inherent sense of satisfaction that comes from a task well done.25
Less tangible rewards such as acknowledgment and positive feedback can affirm competence without as much risk to autonomy and have been shown to build motivation for intrinsically motivating tasks,25 but there are important nuances to their delivery. Even positive feedback eventually impacts intrinsic motivation negatively because it can reduce autonomy when it is given routinely and, thus, becomes expected.25 Further, if clinicians know they can either receive positive feedback or a tangible reward, the tangible reward takes on “symbolic cue value” and implies that a degree of competence has been achieved worth rewarding. As a result, in such situations, tangible rewards tend to be more effective.27 If, on the other hand, clinicians do not know they are to be rewarded, then unexpected verbal praise increases intrinsic motivation more than tangible rewards. This distinction offers insight into why the medical education literature suggests that those who are paid to teach rank financial incentives highly, whereas those who are not rank them low.12 Once it is known that a tangible reward is available, the financial incentive takes on greater symbolic cue value as a demonstration that the task is considered important. Although intrinsic motivation might be ideal because it tends to lead to greater creativity and productivity,23 many daily tasks are not inherently interesting, and many medical educators are extrinsically motivated to teach.
Within extrinsic motivation lies a spectrum of instrumental rewards varying in the degree of autonomy perceived over the task.26 At the lower end, one might teach to avoid critique from one’s department head; at the higher end, one might teach because of a belief that teaching is integral to one’s role even if it does not provide implicit satisfaction.5,28 With greater autonomy comes greater engagement, performance, and commitment.28 According to SDT,5 increased feelings of competence and relatedness build more autonomous forms of extrinsic motivation. That is, if clinicians believe they have the relevant skills to succeed, and if teaching provides a sense of belongingness to a group or culture that promotes teaching, they’ll be more likely to integrate the behavior into a sense of self.5,29 Faculty development and teaching academies offer two practical strategies for promoting competence and connections.30 Engagement with such activities can facilitate one’s teacher identity, thereby playing a critical role in building meaningful forms of motivation, which may be especially crucial for those who came to educational roles more through serendipity than design.
In sum, although incentives beyond careful provision of positive feedback are best avoided for intrinsically motivated clinical teachers, they may have a functional role for those who are extrinsically motivated if they support autonomy, competency, and relatedness. Beyond the idealism of a fully intrinsically motivated workforce lies the reality that medical education is reliant on people for which extrinsic motivation is the best one can achieve. In fact, many roles will have some aspects that are intrinsically interesting, whereas others simply need to be done. Further, the many identified barriers to teaching act as particularly powerful disincentives even when one is intrinsically motivated. In such complex situations, SDT research hits its limit with respect to the practical advice it has to offer. We, therefore, turned to the organizational behavior field given its extensive focus on how to incentivize employees in complex workplaces.
Organizational behavior’s view on incentives
Organizational behaviorists have focused on how salary and other incentives influence employee motivation, satisfaction, and productivity.31 Although numerous theories have been applied to workplace settings, they consistently share three interlinked components that are expected to mediate the impact of incentives: (1) factors related to the self determine how much effort one exerts (e.g., achievement orientation, attributional states); (2) factors related to the task include whether it or the goal is desirable, achievable, and worth the effort; and (3) factors related to the environment create conditions that limit or enable one’s motivations. This latter class of factors is a particularly important addition because it acknowledges that motivation does not just live within the individual. That is, incentives play a dual role of raising motivation within individuals and lowering barriers within the environment.
Herzberg’s32 motivation–hygiene theory, for example, identifies two sets of factors that separately influence job satisfaction (i.e., motivators) and dissatisfaction (i.e., hygiene factors). After interviewing employees about when they felt exceptionally good and bad about their jobs, some factors were consistently talked about in terms of feeling good and motivated, and others in terms of feeling bad and unmotivated.32 Motivators arose from intrinsic conditions of the job (e.g., achievement, recognition, responsibility, advancement, growth) and align well with the components of motivation outlined by SDT. Hygiene factors, in contrast, arose from contextual conditions and contributed to dissatisfaction through their absence (e.g., working conditions, interpersonal relations, salary, status, job security).33 Research suggests that both sets of factors operate on separate continua and need to be addressed separately.34–36 Under this model, the incentives discussed above (e.g., teaching academies and faculty development) will have little influence in the context of hygiene factors that promote dissatisfaction (e.g., lack of job security). Additionally, the distinction between motivators and hygiene factors shines new light on the role that money might play: As a negative motivator, money is expected by organizational behaviorists to create dissatisfaction when absent rather than creating satisfaction when present. Perhaps, as a result, it is reasonable to speculate that money lost from clinical practice (creating a strong disincentive for teaching) is more important to consider than money gained from teaching (commonly ranked low on lists of motivating incentives).
To address both motivators and hygiene factors, an adapted version of Maslow’s37 hierarchy of needs theory offers value by suggesting that factors be addressed in order beginning with a clinical teacher’s most fundamental or basic needs and progressing as follows: (1) basic wages, (2) safety in benefits and training, (3) social belongingness, (4) self-esteem, and (5) self-actualization.38 Thus, without adequate wages, job security, and training opportunities, incentives targeting self-esteem and self-actualization may have little influence. Supportive empirical work found that providing financial incentives raised employee productivity by 30%, larger than job enrichment initiatives (9%–17%) and employee participation programs (less than 1%).39 However, although sufficient pay may be important among workers in general, it is difficult to know how these ideas generalize to medical education because clinicians generally enjoy at least “basic wages” even when one gives up clinical time to take on teaching roles. In this sense, the question of financial incentives perhaps becomes less about “how much” and more about “what is fair.”
Equity theory40 posits that the absolute amount of money may not be as important as perceptions of unfairness. Perceiving under- or overpayment given one’s qualifications and effort, in comparison with others, leads to feelings of distress. For example, when two roles within an organization received equal pay despite one role requiring more experience and skill, those in the more senior role were satisfied with the amount of money they were making, but dissatisfied when this amount was compared with those in the junior role.41 That is, motivation may be threatened regardless of financial position when one perceives oneself to be underrewarded or others overrewarded. The perceived “fair” rate of compensation for teaching in medicine is frequently higher than what teachers are actually being paid, suggesting that equity issues may be at play.13 Also, perhaps individuals at institutions who are not paid to teach rank financial incentives low because equity is established when nobody receives teaching honoraria in such environments.12 Employees seek to restore equity by advocating for more fairness, or if unsuccessful, by exerting less effort or abandoning the role completely.42 Whether a rate of pay is considered “fair,” however, likely depends on the reference standard against which it is compared.
It is unclear from the organizational behavior literature whether other incentives are susceptibly influenced by considerations of equitability. For example, a teaching academy might provide a motivator by putting educational roles on a more comparable plane of prestige relative to clinical or research successes, but if only available to an inner circle of educators, the same incentive might be interpreted as a hygiene factor by implying the absence of status and belongingness for teachers who are excluded. While the organizational behavior field broadens consideration of incentives by drawing attention to environmental factors in addition to individual characteristics, it also suggests that financial rewards are much more important in promoting motivation than psychologists have argued or medical teachers have claimed, leaving us with contradictory messages of how to proceed. To begin reconciling these claims, the behavioral economics field provides a more nuanced understanding as to why financial incentives can be simultaneously motivating and demotivating, and introduces us to other forms of motivation beyond the intrinsic–extrinsic spectrum.
Behavioral economists’ view on incentives
Within behavioral economics, motivation crowding theory43 (MCT) combines information from psychology with traditional economics models and provides a particularly useful perspective to aid our understanding of rewards. MCT presupposes that incentives shift an individual’s motivation between intrinsic and extrinsic ends of a continuum43 as described previously, but it also suggests that at each end of the continuum, people are motivated by different sets of principles. If an incentive shifts people toward the extrinsic pole, the incentive “crowds out” intrinsic motivation. In such cases, effort is directly related to the size of incentive, with larger incentives driving greater effort (i.e., people operate in money-market systems).44 Alternatively, if an incentive shifts people toward the intrinsic pole, the incentive “crowds in” intrinsic motivation. In such cases, effort is instead driven by reciprocity or altruism (i.e., people operate in social-market systems).44
The important implication within this orientation is that small- to medium-sized rewards can be the most detrimental to motivation. To illustrate, a seminal study found that larger financial rewards caused individuals to volunteer more hours toward charitable organizations than smaller rewards, but the mere introduction of a reward reduced volunteer time by four hours.45 Only after crossing a particular financial threshold did volunteers commit the same number of hours as without any rewards. As a result, large enough financial incentives can influence effort more than providing no incentives, but small to moderate financial incentives are likely to be harmful.46
It is unfortunately difficult to estimate this threshold value. An amount that seems theoretically large enough can be perceived as too small when put in practice and considered in the context of other relevant factors.46 For example, a $50 honorarium might be small to an anesthesiologist and large to a resident in training, but setting different rates for different groups creates the risk of perceived inequity. Perhaps more importantly, it is critical to remember the risks of lessening quality that come from crowding out intrinsic motivation and having people teach purely to obtain an incentive.
The way out of this dilemma may come from evidence suggesting that the relationships between incentive size and effort do not apply with nonfinancial incentives. For example, large-scale experiments with the Red Cross have found that lottery tickets and gift cards have neutral or positive effects on blood donors regardless of size, while small financial rewards lower willingness to donate blood.6,47 The difference is so powerful that if a nonfinancial incentive is provided with a monetary value associated with it (e.g., “you will receive a $5 chocolate bar”), individuals default to interacting as if it were a financial incentive.44 This suggests that offering a clinician “an honorarium” might have a very different influence relative to offering “a $150 honorarium.”
With respect to factors that seem to operate separately from the intrinsic–extrinsic motivation continuum, image motivation (people’s desire to illustrate to others—and themselves—that they are good people) plays an important role when it comes to prosocial behaviors.43,48,49 Contributing to charities, donating blood, or volunteering to serve as a clinical teacher might not be inherently satisfying, but some appear motivated to perform the tasks because these tasks allow them to feel good about themselves and their public image. This was illustrated by Ariely et al,49 who randomly assigned participants to donate to a charity with their donation amounts being made public or private. They found that larger donations were made in public than in private. If these findings generalize to medical teachers, as seems reasonable given the many prosocial reasons for teaching that clinicians express, then public recognition of efforts may be more impactful than financial incentives. How these findings interact with the observations about perceived equitability and where one lies on the fundamental needs hierarchy, however, remains unclear.
What is clear from this literature is that the positive image associated with particular behaviors is largely derived from the norms and behaviors of others.50,51 Encouraging income tax compliance, becoming vaccinated, and exercising are examples of behaviors people do more of when they appear to be the cultural norm.52 It is logical, then, that the image motivation held by teaching would be partially dependent on the cultural norm of the contexts within which clinicians are situated. That is, image motivation is not likely a factor in a hospital where teaching is not endorsed. Further, in such settings, tangible rewards can unintentionally reinforce the perception that the behavior is difficult or unattractive.48 For example, offering financial incentives to members of a neighborhood when airports or jails are being developed nearby reduces the community’s support for the facility.53 Although the learning environment has been studied substantially from learners’ perspectives, the extent to which the culture of a particular environment changes teachers’ motivations to teach, or whether the influential factors are modifiable in a way that impacts teaching efforts, remains unknown.
In synthesizing the literature reviewed in psychology, organizational behavior, and behavioral economics, we draw three conclusions about the influence that incentives have on the motivations of medical teachers. These are framed below as practical guidelines when considering if and how to implement incentives.
Determine what is driving the individual to act in the first place
First, the influence of an incentive is dependent on how it interacts with the underlying mechanisms deemed important for motivation. Before introducing an incentive to influence effort, it is important to determine what is driving the person to engage in the task in the first place. Do they find it interesting and challenging? Do they assume it to be a core part of their role? Have they been told they need to do it? Do they do it to feel good about themselves? Is everyone else in that context doing it? Such questions will provide a starting point that can help inform what types of incentives might be valued. It is also worth exploring what incentives or disincentives currently support or inhibit these motivations without simply taking claims about what is valued (or not) at face value. For example, if people downplay the importance of money, consider whether they are already being paid, what amount of money would be perceived as “fair,” or whether it might make them look bad if they were to say that money was important. Such considerations will differentiate between a superficial list of motivators and barriers and a nuanced understanding of the likely complex set of factors at play.
Consider the unique interactions between incentives and motivation types
Second, once you have grasped the underlying motivational drives and values, consider whether an incentive is actually needed or could be detrimental. An intrinsically motivated individual might not need any additional incentive, but may require efforts toward removing barriers preventing them from enacting their motivational drives. If an incentive is deemed worth implementing, consider which type will be most effective (e.g., financial or nonfinancial) and how it will be provided (e.g., in private vs. public). This requires careful thought given that, if done incorrectly, the incentive can fail to produce meaningful change or can create sustained problematic forms of motivation that alter the social norms in a manner that further decreases the success of future efforts to encourage the desired behavior.
For image-motivated individuals, financial incentives will work best privately, whereas incentives that recognize the individual’s contributions work best publicly. Normalizing the behavior might change the culture in a way that leads to embracing the behavior. For extrinsically motivated individuals, the incentive should try to build one’s perceived autonomy, competency, and relatedness by, for example, providing skill-building opportunities or enabling connections with others who endorse the behavior. Financial rewards can effectively get people in the door where an individual can then learn to value and appreciate the task itself, but what constitutes “large enough” is important to consider: Such incentives need to be large enough to override any crowding effects and to be considered fair, but not so large that they signal the task as difficult or unpopular. Nonfinancial incentives aren’t as sensitive to size and offer a good alternative particularly if the task is considered prosocial or if different individuals in the same environment have different perceptions of how much is enough, creating logistical problems in offering different-sized rewards for different people. The wide range of things that could qualify as nonfinancial incentives include verbal feedback, engagement with communities of teachers, public recognition, faculty development opportunities, and identity formation support.
Consider barriers that may interfere with incentive effectiveness
Third, the effectiveness of any incentive is dependent on individuals and the contexts within which they work. Implementing the right incentive for the right individual or in the right context is only half the battle as it will have short-term or little impact in a context where there are environmental or contextual barriers. Whether people feel secure in their roles, whether they feel like they are being compensated or acknowledged equitably, or whether more fundamental needs are being met are important considerations that need to be addressed in tandem.
In sum, psychologists, organizational behaviorists, and behavioral economists have provided us with both cautionary tales and success stories that have led to the development of useful recommendations regarding the role of incentives. Despite the insights they have produced, to identify the most valuable and influential incentives that will cultivate sustained and positive forms of motivation among our medical teachers, the field needs greater clarity regarding how, when, and why incentives operate in the variable health professional contexts in which teachers find themselves.
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