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• W2036570223 abstract "If everything in life is of equal value, people will choose what they do based solely on personal preference. If you want people to do something that is at odds with their personal preference, you must provide incentives that outweigh the personal satisfaction of just doing whatever they please. That is why we are paid to go to work. Our salary is a regular incentive to get up at 5:45 am and drive to work, instead of lounging late in the morning in a warm bed, and heading out even later to a soft white sand beach. In this issue, Abouleish et al. (1) have provided a fascinating glimpse into how academic anesthesia departments induce their faculty to work harder in the clinical arena. They characterized the construct of clinical incentive plans among 83 responding academic programs. Most (69%) did not pay incentives based on work performed during normal working hours. Ninety percent did not alter total salary by more than 25%. They note that many comments on the survey suggested total departmental productivity did not change with the introduction of an incentive plan. This is not surprising, in that anesthesiologists have little or no control over booking and performing surgeries during their working hours. Now that we know how academic chairs are crafting clinical incentive programs, can we analyze those comparative data to help us all do it better? That remains to be seen. It is interesting that 64% of respondents have had their plans in place less than 5 years, so many of us are on a steep learning curve. This well-timed article may allow us to learn from each other and better serve both our faculty and facility. Furthermore, we may now be able to summarize these data and thus respond more intelligently to our group practice plan managers who insist on productivity-based compensation. While we now know how everyone else is doing it, what more should we know about incentives in general to help gauge whether we are all doing it right? Incentives motivate people to perform in a certain way (more, better, quicker). The key to a working incentive system requires the following: 1) The individual believes that the desired behavior will lead to the desired outcomes (i.e., the incentive is guaranteed to be paid; it is not contingent on profits or anything else outside their control), 2) the individual believes that these outcomes have positive value for him or her (i.e., a noble purpose or a sufficient sum of money), and 3) the individual believes that he or she is able to perform at the desired level (the lack of control over what is booked into one’s room combined with a lack of incentives for daily scheduled work in most plans are a reflection of this reality). It is a basic truth that people always act in their rational self-interest. Therefore, incentives almost always work perfectly to provide the behavior that is rewarded, assuming the incentive is large enough. The only problem is that we often fail to understand what behavior we really want, how to measure what we want (a metric), and how to link the incentive clearly to that metric without introducing new problems. There is a classic article, “The Folly of Rewarding A and Hoping for B,” (2) that details the problems that can occur with poorly designed incentive systems that create perverse results. An example is when an academic department starts to reward clinical billings in an effort to “get everyone to bill more” and all of a sudden finds there are no volunteers for off site cases, the IRB, the preoperative screening clinic, or the medical school Admission’s Committee. Reluctance to get involved in these nonbillable activities is even greater when they require evening or weekend time. The ideal incentive has several characteristics. First, there should be a target of expected performance below which there is no incentive. A number of departments described by Abouleish et al. base their incentives on total dollars or total work. This degrades the differences between those with exceptional productivity and average productivity. If one wants marginal productivity (productivity above that which already exists), then that is what should be rewarded. Second, an unrestricted bonus pool is important. This is easy to do with dollars collected. If one collects more, there are more dollars to include in the incentive. It is much more difficult to do this when financially rewarding the publication of peer-reviewed papers, since one can run out of money with too much success! That is why it is much easier (better?) to create incentives for grants and salary support. Third, the incentive programs should be noncompetitive. Why? Take a pharmaceutical company, for example, that wants to reward superior sales. It could offer to take the top salesperson to Miami Beach for a wonderful sun-filled January 3-day weekend, or it could offer to take every salesperson who sells more than a million dollars of goods. The latter is more likely to yield a greater number of superior salespeople. Why? Imagine Jones has 2 million in sales already, Koogan has 1.9 million, and you have $800,000 with 1 month to go. Do you work hard to hit that million-dollar mark when there is no hope of attaining the coveted reward? Of course not. Furthermore, when Koogan gets a sales lead that might increase sales in Jones’ district, his self-interest is not to help if only the top salesperson is getting rewarded. An ability to recognize team (department, division) success is a natural corollary to this rule. A fourth characteristic of the ideal incentive adds a variable component. A simple target (as in this scenario, 1 million dollars in sales) is not as good as a target with a volume adjustment (the incentive increases for each $100,000 more you sell). Imagine once again that you are a salesman striving to hit the million-dollar mark. Once you get to that, if there is no further incentive to book sales, you might just hold off closing a sale until next year or you might just relax, take some time off, and congratulate yourself on hitting the goal. However, knowing that an extra vacation day in Miami awaits every $100,000 more in sales above $1 million means you continue to strive on your job until December 31st. The article published by Abouleish et al. is enlightening, in that it allows us to compare our clinical incentive programs to those of many other academic programs. It provides a great start to begin the discussion of how to best structure incentives in an academic department, allowing us to see how close we are to the ideal within our specialty. According to this survey, most academic institutions have chosen to reward extra clinical shift work rather than billings overall. The collective wisdom is just that. Most departments have now recognized that since anesthesiologists usually do not make their own assignments, it is pointless to offer an incentive based on something the individual cannot control. (This specifically does not apply to areas like a pain clinic, where relative value units and collections are controllable, based on the types and number of patients the practitioner chooses to see). So, the majority of the larger academic departments are using a system that pays for marginal productivity and that yields the desired result—getting more clinical work out of faculty members who are willing to work more. While this system clearly works, it encourages the faculty to spend more time pursuing dollars rather than academic success. While there may be some marginal improvements to total faculty productivity for working an extra clinical day, some of that extra clinical productivity is simply effort switched away from academics. Only for faculty with a 100% clinical assignment is this incentive system really yielding all the extra productivity you think you are paying for. Thinking otherwise, you will be engaging in the folly of hoping for A while rewarding B. Academic faculty have only so much time and effort to give to their job. If more is spent on clinical tasks, it is probable that less will be spent on other tasks. Eventually, if too much time is spent on purely clinical work, there is little to distinguish the academic clinician from his better paid private practice counterpart, and that may lead to faculty attrition. While Abouleish et al. concentrated on clinical incentive systems, some departments use a much more complex system involving both clinical and academic activities. We would all be well served by a similar study that characterized academic productivity incentive plans. While this is not discussed in detail in the Abouleish et al. article, it is discussed in detail every time two academic chairs have a conversation. Those who have this system attempt to reward the academic productivity that might otherwise be reduced by extra clinical assignments. However, if these academic incentive systems grow too complex, as they often do, they run afoul of the principles that the incentive be clearly related to the pursued activity, that the incentive be clearly understandable to the worker, and that there be only a few rather than many goals. A good review of current literature regarding incentives was presented at the 2004 International Anesthesia Research Society meeting by Kratz et al. (3,4); those findings reflect well my own understanding and experience in these matters. As these nonclinical systems grow in complexity, many nonclinical activities are recognized, and anything more than doing nothing is considered valuable. Frankly, while recognizing the value of many academic activities, rewarding them equally with dollars brings us back to our point in the first paragraph—we are paid to do something other than that which we might otherwise choose. If everything academic is of equal value, we just do what we wish, rather than focusing our efforts on those initiatives that the leadership requires to move a department forward. In a “starter” department, just getting everyone focused on writing abstracts might be appropriate. In a more developing department, moving to only rewarding for papers published might be reasonable. In mature academic departments there is so much rich activity that an administrator might say, “I don’t have just one focus anymore.” That may be true, which is why incentives at that point need to be about personal contracts with measurable activity and deliverables—focusing that individual on incremental effort that the chair thinks will be that faculty member’s most valuable contribution. Recognizing the value the department places on a variety of academic contributions can be done without dollars and accomplished by assigning appropriate academic time to pursue that activity. (Of course, time is money, and a chair might choose to more heavily invest that limited resource in the same manner as cash incentives to promote a particular type of productivity.) If someone is on 10 committees (good), giving 10 lectures (good), and writing 10 abstracts (good), but never finishes one paper (bad), under an incentivize everything scheme, they might do quite well. If the department wants published papers, it has to clearly concentrate its academic incentive plan so that it is clear that reward is reserved only for the effort of planning, executing, and writing up a research project that leads to a peer-reviewed publication. Incentives should be about superior performance as defined by those paying the incentive, or about changing focus or attitude, not about glorifying anything and everything that an academician might choose to do. If everything is incentivized, you really incentivize nothing. You might as well go to the beach." @default.
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• W2036570223 title "Incentivize Everything, Incentivize Nothing" @default.
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• W2036570223 doi "https://doi.org/10.1213/01.ane.0000152011.01993.8c" @default.
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