How are the five elements of the “SCARF model” — status, certainty, autonomy, relatedness, fairness — affecting physicians’ responses to what is happening in the health system across Canada? How can physician leaders create conditions that keep threat and reward responses balanced?
Conversations with physicians during my travels across Canada, combined with daily health-related news, reports, and studies, show me first hand that many doctors have disengaged and can no longer be motivated to contribute to the much-needed health system reform. Although conversations between physicians and other stakeholders continue to be productive in a few pockets, in more cases, conflict has become overt, triggering incivility within and outside the profession.
Based on well-known survival-related brain reactions, the SCARF — status, certainty, autonomy, relatedness, fairness — model1,2 offers, in part, an explanation for the increasing disengagement and change fatigue that can contribute to burnout. The model captures the common factors that can activate a reward or threat response in social situations, leading to positive or negative influences on an individual’s motivation. It draws our attention to the basic psychosocial aspects of human nature. Motivation that drives social behaviour is governed by an overarching, mainly subconscious, mechanism of avoiding danger and maximizing reward, using the same brain networks as our ancestors did to survive. A perceived threat to one’s status activates similar brain networks as danger to one’s life, and a perceived increase in fairness activates the same reward circuitry as receiving a monetary reward. Top
Status is about one’s importance relative to others. Over the ages, physicians have earned the trust and respect of society, and medicine remains one of the most respected professions.3 However, the status of physicians is changing as knowledge, once exclusive to the profession, becomes shared with many through the Internet and other media. The increasing — reasonable and unreasonable — expectations of the public challenge the physician’s expertise and decision-making and trigger a threat response. Real or perceived attacks by some politicians further undermine the status of the profession. The increasing demands of performance reviews and outcome measures add to that status threat.
Status perception improves with public acknowledgement, particularly of efforts leading to improvements. Improvements often go unnoticed in Canada. For example, Canadians are unaware how much heart attack prevention and survival rates have increased in the last 50 years4, and they know even less about the many small, altruistic acts physicians perform for their communities. How can we as a society celebrate these improvements? Physician leaders, within their own groups and within their communities, can recognize and celebrate what doctors are contributing to our society. The perception of status can also be improved when physician leaders identify and draw on areas of expertise of physicians who then become engaged in health system change and receive recognition for their contributions. Top
Physicians have come to a point where they need to renegotiate their professional role, and the status that comes with it, as part of the social contract around stewardship.5 It is up to physicians to choose whether they see that renegotiation as a danger or an opportunity.
Certainty deals with the ability to predict the future. The brain continuously looks for patterns and, if recognized, tries to predict the future based on which it can make decisions. Unfortunately, we live in a world that is volatile, uncertain, complex, and ambiguous. In it, physicians need to develop resilience and agility, including the capability to act both as disease experts for each patient and as stewards of the health care system. Top
Involving physicians in organizational strategies and planning or systemic redesign can help them regain certainty. How can physician leaders influence governments at all levels to engage doctors in the redesign of the various components of our health system, thereby decreasing the danger triggers around uncertainty? How can they influence their own colleagues to become engaged in the reform of the health care system? As the system will not change without physicians, they have to become engaged in innovation at all levels.
If physician knowledge and expertise are to be recognized, all physicians must take the initiative to reach out and engage on an interpersonal level and/or take a leadership role in an institution or community. Following several of the CSPL white paper’s6 recommendations might also reduce the uncertainty threat for physicians, including becoming active champions for and partners in physician engagement and leadership development toward transforming the Canadian health system.
Autonomy provides a sense of control over events, a feeling of having choices. A reduction in autonomy, or the perception thereof, can generate a strong danger response; however, it does not have to be like that. Top
For many years, physicians, because of their unique contractual relationship with the system, have reveled in their special status, which in many cases allows them to be independent business people and grants them significant freedom compared with other health care professionals. When reform happens, it inevitably alters the context in which physicians practise.
Physicians appear to have two choices: either become part of the process of reform in a manner that allows them to negotiate what the future system will look like or remain independent of it and accept whatever society negotiates for them. Taking the latter path is dangerous: in negotiation, if one side is not at the table, the other side will dictate the rules. Thus, physicians must challenge their own sense of independence and accept that how their time is allocated, how their work is defined, and how care is delivered will not be independently determined, but agreed on collectively. Top
Autonomy is part of stewardship, which is embedded in the social contract between society and physicians. Society provides physicians with autonomy, trust, self-regulation, monopoly, status, and rewards. In turn, physicians provide compassion, availability, and accountability, working for the public good with altruistic service.5 If either society or physicians vary the terms in the contract, there is a corresponding, unavoidable variance by the other party. Top
Is physicians’ sense of change in autonomy affecting the way they see the social contract? Every time a patient is seen, an opportunity can be created to reshape the health care system. Physicians can do this by shifting the social contract equation in a positive direction to improve the relationship, not only with that patient, but also with society in general. Ultimately, this will create a positive patient experience, happiness, and system success. Physicians can do this only through the individual choices each doctor makes, every time they interact with a patient. It is up to physicians to renegotiate their role within a social contract and, in so doing, renew or redefine the autonomy of their profession.
Relatedness is a sense of safety with others and knowing that others are “alike” enough to be part of a social group. That relatedness is threatened from inside and outside the profession. On the inside, incivility is occurring, as described by Kaufman in this issue.7 Opportunities for conversation among peers have also been diminished: attendance at medical staff meetings has been dwindling in many parts of the country; emails are the preferred mode of communication rather than a phone call or face-to-face conversation; and doctors’ lounges are virtually extinct. Top
How can physicians relate more frequently and in meaningful ways with each other, converse in person, have a cup of coffee together or a meal? How can physicians and physician leaders help each other as mentors or coaches or by creating support groups?8 Working toward each other’s wellness and developing the skills to offer that support will contribute to less fatigue and, hopefully, reduce progression to burnout. Top
From the outside, physicians are pressured to work in multidisciplinary teams. By creating projects requiring collaboration, physician leaders can help all physicians develop skills to engage others, be part of team building, and create a sense of belonging. Feelings of belonging and trust building can only occur in an environment of psychological safety.9
Fairness is a perception of equitable exchanges between people. Unfair exchanges generate a strong response in the part of the brain that deals with intense emotions, such as disgust.10 Recent national events around tax unfairness and breaches of agreement in some provinces have increased the fairness threat among many physicians. Because the scope of involvement of doctors in areas affecting patient care and their own practice is much broader today than in the past, the boundaries of where and when physicians speak out about real and perceived threats to fairness have increased. Top
Physicians need to increase their level of involvement, starting with conversations on the purpose of our health care system and where physicians’ responsibilities start and stop. Without clear definition of roles and responsibilities, fair judgement on accountability is impossible, which, in turn, makes it difficult to build trust within the system.11 This vagueness can add to the sense of unfairness, which can be attenuated by clarity about the responsibilities of all stakeholders. Top
In conclusion, as physicians have a unique position and responsibility in the delivery of our universal health care, efficient and effective reform cannot happen without their active participation. Physician leaders are well positioned to be “interface professionals,” who bridge the disciplines of medicine, administration, management, and leadership to fulfill the systemic fiduciary responsibilities to Canadians. Paying attention to the domains of SCARF might help physicians find balance between psychosocial reward and danger responses while redefining and renegotiating their professional roles within the social contract of the Canadian health care system. Top
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7.Kaufman M. Five fundamentals of civility for physicians. Can J Physician Leadersh 2017;4(2) 41-46
8.Snell A, Eagle C, Van Aerde J. Embedding physician leadership development within health organizations. Leadersh Health Serv 2014;27:330-42.
9.Hirsch W. Five questions about psychological safety, answered. Science for Work 2017; Oct. Available: https://tinyurl.com/yae2ykrt (accessed 15 Oct. 2017).
10.Tabibnia G, Lieberman M. Fairness and cooperation are rewarding: evidence from social cognitive neuroscience. Ann N Y Acad Sci 2007;118:90-101.
11.Van Aerde J. Embedding trust in the Canadian health care system. Can J Physician Leadersh 2016;3(2): 37-8.
Johny Van Aerde, MD, MA, PhD, FRCPC, is editor-in-chief of the Canadian Journal of Physician Leadership and past president of the Canadian Society of Physician Leaders.
Correspondence to: firstname.lastname@example.org