I recently read an article that appeared in the New YorkTimes about what motivates people. It talked about a study of 11,320 cadets entering the military academy at West Point, and followed them over time to see who would make the best soldiers with the greatest longevity. All of these cadets rated how strongly various internal and instrumental (external) motives influenced their decision to attend the academy. On the surface, the differences between intrinsic and instrumental incentives may seem the purview of organizationalbehavior alone, but on reflection, I realize that it plays into everything we (and our patients) do.

Perhaps not surprisingly, those who had the highest internal motivations (e.g., desire to be a leader in the U.S. Army) fared better. I would argue the same applies to medicine. I tell nearly every mentee I meet to follow their passion – a worn out maxim, perhaps, but one which speaks to intrinsicmotivation. If you don’t love what you do, and rather follow a career path because it’s (fill in the blank here – more lucrative, more prestigious, what your parents did, etc.), you may findyourself spending large amounts of time at work being miserable. And miserable people (no offense) tend not to be at the top of their game.

Similarly, the best research often comes from the labs or clinics of those who are truly passionate about the questions they are studying. They truly want to find theanswers. There is something magical about the quest for knowledge that motivates them to pursue their inquiries to the most extreme depths, ultimately leading to significant advantages forsociety.

Our patients, too, have profound intrinsic motivation – to get better, to live cancer free. They want to advance the field of science so that others won’t have to suffer the samefate, which is why I find so many patients jump at the opportunity to participate in clinical trials if given the chance.

What was interesting in the study of West Point cadets was that internal motivation was a strong predictor of success, unless it was also coupled with strong instrumental motivation. Cadets who had both strong intrinsic and instrumental motives did worse on every measure thanthose with strong intrinsic but weak instrumental motives. So what does this mean for us? Clearly, as physicians, we do great work for patients (intrinsic) and we get paid for the same (instrumental). We do research which adds to current knowledge (intrinsic) and we get promoted (instrumental). Does this mean that we will do better if we do not get paid, or never get promoted? Of course not! The article discusses the important distinction between an instrumental consequence of an action versus a motivation. We should certainly reward the behaviors that are desired, but the extrinsic reward should not be what motivates us to behave in the desired way to begin with.

As I thought about this, I pondered the work that has been done with financial incentives being given to patients to motivate them to quit smoking. Shouldn’t they want to quit for intrinsic reasons, like their own health? It would seem to me that instrumental motivation, if considered as such by the participant, is likely only to backfire; those who are most likely to quit long-term are thosewho are intrinsically motivated to do so, and who consider any monetary gain asa reward or consequence, rather than the motivating factor. And so it likely is in life . . . those whosucceed (whether in medicine, research, or whatever else) are likely motivated by a higher internal calling to do so; the accolades that come along as a result are just the well-deserved recognition of their achievement, not the motivation that incited it.


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