Part 3 - Why It Is So Hard To Change — BROWN EMERGENCY MEDICINE BLOG

Despite education and awareness around institutionalized bias (aka “-isms”) they persist because of punitive processes and invisible reinforcers."

The barriers of turning knowledge into change:

When we think of basic behavior patterning we think of classical vs. operant conditioning [1]. In 1904 Ivan Pavlov won the Nobel prize in Physiology [2] for his experiments of classical conditioning. In his experiments, he trained a reflex behavior, salivating to food in dogs to salivating to a bell (instead of to food), thereby re-routing a reflex behavior through conditioning. Operant conditioning is a term coined in 1937 by B.F. Skinner to describe conditioning voluntary behavior change based on punishment or reward (consequences) [3].

Figure 1. Example of classical versus operant conditioning [verywell]

Often institutions turn to classical or operant conditioning because of its simplicity. However, our behavior patterns are complex and have layers of nuance due to our own internal motivators. Creating health equity and remediating institutionalized “-isms” is more complex than attempting to implement operant behavior change. Often institutions fail because they rely too heavily on punishment and reward. To institutionalize change we have to start from a place of understanding that punishment and external reward will not get us to where we want to go, in fact it is preventing us from moving forward at all. “Punishment undermines moral development by leading people to ask, “What do they want me to do, and what happens to me if I don’t do it” and actively discouraging them from asking, “What kind of person do I want to be?” (Alfie Kohn) [4]

In an attempt to avoid punishment as a motivator, institutions will try external rewards; yet, punishment and rewards inevitably lead to the same outcome: short term modifications at the expense of lasting value-based change. By external rewards, we are talking about things that someone can give or withhold from us, such as praise or money. This is in contrast to internal rewards, which are our intrinsic motivators and which we give to ourselves. As Alfie Kohn illustrates in his book Punished By Reward, “manipulating people with incentives appears to work in the short run but it is a strategy that ultimately fails and even does lasting harm.” [5]

What does accountability look like without punishment? This question is so common and highlights our misunderstanding of both accountability and justice.

“Accountability is the corollary to grief for those of us who are responsible for harm, and it is as essential as a grieving process is in restoring us to our best selves” (Danielle Sered)[6].

Holding ourselves and each other accountable is the solution; it is a part of restorative justice and a part of creating equitable futures. You do not need punishment for accountability to exist, in fact, punishment often prevents accountability.

“When we’re being accountable to ourselves, we’re acting in a way that honors our values. We’re acting with integrity by taking responsibility for who we are in the world and for living in alignment with our values. I’m responsible to myself, but I’m also responsible to those who are around me for the consequences of my choices” (Mariame Kaba) [6].

Change seems hard because our traditional use of operant conditioning doesn’t come from intrinsic motivators and it doesn’t include accountability. For us to change as individuals and institutions we must advance our approach to change!

Author: Shay Strauss, MD, is a third-year emergency medicine resident at Brown Emergency Medicine Residency.

Faculty Reviewer: Taneisha Wilson, MD is an attending physician and educator at Brown Emergency Medicine.