“If you take more vacation than the amount accrued in your account, then the imbalance will be deducted from your compensation,” our office manager said. He was explaining how a vacation policy intended for people who work 40 hours a week would now apply to surgeons who did not have a 40-hour workweek. It was a policy change designed to keep employees from taking more than their allotted time off. But that is not what I heard.

Over the two decades of my career, I have always taken less vacation than I was allowed. I did this because I am a professional who feels a responsibility to my patients and partners. But in an instant, that manager changed my attitude. For years, my wife and I dreamed of an extended European vacation with our children before they left for college. But it had never seemed possible to get that much time away from work. Now, with one sentence, my manager made what had felt impossible possible. If I wanted to take a month off to travel with my family, I could, as long as I was willing to pay the price in a missed week or two of salary. In an instant, I no longer saw myself as a professional. For the first time, I saw my work as transactional. I was exchanging my time for money. I needed to do a cost-benefit analysis to decide if the time away was more valuable to me than the salary I would forfeit.

This shift in my relationship with the system that employed me reminded me of a study I read about daycares in Israel. At the time, it had sounded like a disturbing warning.

Daycares in Haifa, Israel signed contracts with parents in which the parents agreed to pick up their progeny at the appointed hour of 4 p.m.⁠ Tardy pickups were rare, but they meant that a teacher had to stay late to monitor the children. A group of researchers offered to help with the problem by instituting a fine for parents who arrived more than 10 minutes late. The penalty was modest but not trivial, and researchers felt it would be adequate to affect parental behavior. And it did, just not in the way the daycare intended.

The study ran for 20 weeks, and the first four weeks used to collect baseline data. At the beginning of the fifth week, researchers randomly selected 7 of the eleven daycare centers to introduce the fine. Did the fine solve the late pickup problem? No, it did the opposite. The number of parents who arrived late to pick up their charges increased in the daycare centers that introduced the fine. Why should that be?

Researchers speculate that the introduction of a fine changed the relationship between the parents and the center. Before the fine, parents had wanted to be good citizens of the daycare community and recognized that they had a responsibility to collect their charges at the appointed hour. Both the parents and the daycare understood that there would be extenuating circumstances that might keep a parent from arriving on time, but both groups expected these events to be the exception and not the rule. When the daycare implemented a fine for late pickup, the daycare altered that relationship. Parents now viewed keeping your child after hours as a service they were buying. Before, parents had felt an obligation to arrive on time. Now, parents did a cost-benefit analysis and decided whether staying at work longer was more valuable than the cost of the fine. If so, they paid a fee for the service and collected their children late. The fine eliminated the parents’ desire to be good citizens and replaced it with a fee-for-service model.

And, the story does not end there. The part I find most concerning is this: after 16 weeks, the daycares removed the fine for late pickups, but the late pickup rate did not return to its pre-fine level. Instead, the ratio of late pickups remained elevated. The fine had changed the fundamental relationship between parents and daycare so profoundly that the removal of the penalty did not remove the parents’ new transactional mindset. The daycares’ attempt to use an incentive to fix its problem had made the situation worse — and there was no going back.

I think this study has severe implications for the health care profession. In the past, we as a group have done our work out of a sense of professionalism. In other words, how I conduct myself as a surgeon is based on how I think a professional should act, regardless of the existence of a “rule book.” However, with the rise of corporate health care and increasingly strict contracts for medical professionals, we are losing that sense of professionalism. The simple fact of the matter is that the organizations we work for have, in the past, extracted a great deal of uncompensated work from us. We worked late, nights, and weekends because patients needed us. We did community outreach for free because that is what responsible clinicians do. We invested time and effort into trying to improve the quality of care in our institutions. And we did that without a contract spelling out a system of incentives and fines for doing so. We did it because we are professionals, and that is what professionals do. 

But not anymore. As in the daycare in Israel, once an incentive (or penalty) succeeds in changing the relationship between a company and the people who interact with that company, removing those failed incentives may not reverse the change in attitude. The current use of incentives with medical professionals risks changing how those professionals see themselves and their role in health care. We risk taking the professionalism out of patient care and turning all medical professionals into simple employees. If such a change occurs, it will be detrimental to patients, hospitals, clinics, and the health care profession itself. And, if my fear is realized, removing the ill-conceived incentives and fines may not reverse the damage. Once the genie is out of the

bottle, it may be impossible to put him back in. It may be impossible to return the professionalism to the profession.

How have incentives worked or not worked with respect to your medical practice? Share your thoughts and experiences in the comments!

Charles Black was born and raised among the cornfields of rural Iowa, but moved to the Colorado mountains as soon as he got the chance. He is a general surgeon, writer, photographer, outdoorsman, trail runner, and fires-side philosopher. His musing on medicine and life in general can be found here and you can view his photography here. Dr. Black was a 2019-2020 Doximity Op-Med Fellow and is currently a 2020–2021 Doximity Op-Med Fellow.