The Carrot or the Stick?
There is a good question in orthodontic practice with regard to how much a system of rewards affects the commitment of our employees and of our patients. This was brought to mind by Larry White in last month's Editor's Corner. Dr. White said he had become disillusioned with the system of positive reinforcement through awarding prizes to patients for "behaviors we felt important to successfully complete their treatments". He recounted his experience with behavior modification over a long period of years, and his eventual conclusion that many patients are simply unable to cooperate in proper toothbrushing and in wearing elastics and headgears because they have a low pain threshold. No amount of positive reinforcement, he found, could elicit the desired behavior.
As Dr. White pointed out, theories of behavior modification are based on animal experiments in which it is possible to use measures of positive and negative reinforcement that are not applicable to humans. The decision he came to was that he had to accommodate his treatment to the ability of the patient to cooperate, using such means as soft toothbrushes and palliation for toothbrushing or continuous, lighter forces for tooth movement with appliances that require a minimum of patient compliance.
Many patients are aware that their orthodontist wants to see clean teeth at every visit, so they brush their teeth just before an appointment and seldom in between. Many patients are aware that their orthodontist wants to see a headgear log filled out completely with the requested amount of time, so they fill it out just prior to each visit. We are sometimes fooled into praising them for this behavior. I have had occasion to praise rapid correction of a Class II molar relationship, only to have the patient confess after treatment was completed that he never did wear the headgear. This is not a criticism of headgears, but a demonstration that positive reinforcement can be misdirected at times.
One of the saddest attempts we all make at encouraging cooperation is negative reinforcement. We scold, we make marks on our charts, we have patient/parent conferences, we extend our monthly charges. Sometimes it works--especially the extended charges. But it doesn't create good will. In many cases it doesn't work at all. It would be better if we could identify noncooperators in advance and not accept them for treatment; or upon identifying them early in treatment, we could spare ourselves the negative aspects of negative reinforcement by switching to a treatment plan that did not require much patient cooperation or by dismissing the patient.
What about staff members? Does positive reinforcement in the form of bonuses or negative reinforcement in the form of threats or withholding of raises work?
There seems to be general dissatisfaction with Christmas or year-end bonuses as motivators. Given an adequate salary schedule, if your staff members need additional dollar motivation they may be the wrong people for your practice. However, I can see nothing wrong with a concept of sharing the success of the practice with the people who made it possible. From that point of view, a year-end bonus could be expressed as an increase in salary for the past year--in effect, a backdated raise. This is not necessarily a motivational carrot, but it does tell your staff that they have done well and are appreciated. A merit bonus can be a thank-you for some unusual contribution, but is not a substitute for a retroactive raise.
I have never felt that threats or withholding of raises were appropriate motivators. If after adequate instruction and making sure that the instruction was understood, a staff member is not performing at the expected level for your practice, that person is harming the practice and should be terminated. Moreover, there is evidence that withholding an expected reward does not create motivation; on the contrary, it destroys motivation.
Herzberg had a better concept of the workplace than the behaviorists do. He found that compensation had to be adequate; that less-than-adequate compensation was demotivational, but that more-than-adequate compensation was not additionally motivating; that appreciation for a job well done, chances for advancement, and the challenge of the work were all more important motivators than money. For Herzberg, the job itself was motivational. Many studies have shown that people who expect to receive a reward for their work do not do as well as those who do not expect an extra reward. Herzberg considered the term "punitive management" to be an oxymoron. He dismissed it as "KITA", which he translated as "kick in the pants" management. He said that KITA can produce movement, but not motivation.
Whether you look for patients or employees to do something right and reward them, or look for them to do something wrong and punish them, they are two sides of the same coin. The beauty of a bonus that is given to the entire team for a job well done as a team is that it does not seek to motivate by pitting one employee against another. That is a sure way to demotivate and demoralize the staff.