On Praise

 “I’ve really done it this time”, the intern thinks as he walks through the door. He’s on the back end of a 36 hour shift, and his attending has called for him. Panicked, he mulls over all his actions throughout the day, “Where could I have messed up? Did I send for those investigations? Is he just in a bad mood today?”. He approaches the desk, and the outlook, is bleak. He prepares himself for the worst, and wonders;

“Why the hell do I even do this?”

I think it would be amiss to pretend that the road to becoming a doctor is straightforward, but of course, it is a rewarding one. No matter where your interests may lie, there is almost certainly some justification for the hardships one may face, but those are long term goals. How does one convince themselves to wake up every morning, to tackle daily obstacles, to be humbled after every mistake? That is what I would like to focus on in this piece.

In 1948, American psychologist B. F. Skinner decided to put a rat in a box. Okay, I’m oversimplifying. Skinner decided to put a rat in a box, with a lever in it, and that lever is what he based the theory of ‘operant conditioning’ on. The rat, be it through accident, boredom, or perhaps morbid curiosity, pressed the lever, and I’d imagine to its surprise, dinner was served! What proceeded to occur after that, is the result of ‘positive reinforcement’. The rat, like a middle aged woman at a slot machine on a hot streak, continued to press the lever at will, knowing that this behaviour would be rewarded with some treats. The rat’s brother in another box however, was not so lucky. The set up was the same, however when curiosity took hold of this rat, it received an electric shock instead. This, of course, discouraged the rat from touching the lever, demonstrating what we call ‘negative reinforcement’ or ‘punishment’. The basic principle is this: ‘positive reinforcement’ rewards a certain behaviour, thus increasing its frequency, whereas ‘negative reinforcement’ punishes that behaviour, reducing its frequency.

With the history lesson out of the way, we can come back to the present, where Skinner’s theory is still widely used, knowingly or unknowingly, but also debated in parenting circles. The ‘correct way’ to raise a child does not exist, but over the years certain parenting practices have gone out of fashion, and for good reason. The use of corporal punishment has been widely condemned in Western countries, with studies showing that children subject to spanking and other forms of physical punishment are significantly more likely to develop attention disorders, anxiety, stunted social skills, and aggressive behaviour. 

This is subject to societal norms of course. In Eastern countries, physical punishment is heavily ingrained into the culture, and it isn’t going away any time soon. One of the schools I attended would routinely ask students to go outside and bring the teacher a stick, only for them to be hit with it. The majority of my peers were subject to physical punishment during their childhood, be it parents or teachers. It was not something to be shocked about, but the norm.

Verbal abuse is also commonplace, perhaps becoming even more prevalent with the condemnation of physical punishment; and is used everywhere, from households, to schools, to workplaces. Just recently, I was involved in an eye screening camp at a rural school, with the goal of identifying refractive errors in students, but the initial wave of nostalgia from being back at school was quickly wiped away when I saw teachers scolding their students for…being unable to read a vision chart? In our society, excellence is expected, and anything less than that is undesirable.

So, what does that mean for the children? Punishment simply shows them what not to do, but a lack of praise and reward results in them not knowing what to do. I believe children subject only to negative reinforcement, and deficient positive reinforcement, grow up starved for praise, terrified to make mistakes, but always looking to please the people around them. I believe that these children will become adults who are fantastic at carrying out orders, but may lack leadership qualities, and the rambunctious ambition one may see in someone who has been adequately praised, brimming with confidence.

And now, finally, how does that relate to us adults? Obviously, the circumstances of ones childhood cannot be changed, but I find it fascinating how the same concepts are applicable to all ages. At work, we are admonished for mistakes, and are rewarded, usually monetarily, for good performance. Not enough praise and too much punishment creates a toxic work environment, with disgruntled workers and suboptimal performance. Too much undue praise, and the workforce becomes lazy, unmotivated, maybe even arrogant. Striking a balance is imperative.

In healthcare, the rewards are perhaps harder to come by. The ladder to the top is arduous, and the short term reward for quality performance is usually self satisfaction, knowing you’ve helped another human being, and keeping impostor syndrome at bay for just a little longer. The proverbial stick is used liberally, but those morsels of carrot are just so incredibly effective.

“This was especially brutal today”, the intern thinks as the scoldings start to fade. He’s withstood the avalanche of insults and colourful language, but the feelings of self-doubt and inadequacy have now come to the forefront of his mind. He begins the long walk back to the door, once again combing through all the events of the day, trying to identify what he could have done differently. Of course, the constant berating and annoyances from the day come to mind first, but his mind settles on a different set of moments. The nod of approval in the OT after closing up a patient, the quick “Good job” from the resident after ordering for the correct investigations, the attending agreeing with his management plan on rounds. He stops at the doorframe, turns to the attending, and with a tired smile, says the same thing he says everyday.

“See you tomorrow, doc.”