Editor’s Corner: What’s Your Type?

Aristoteles Giagounidis, MD
Head of the Department of Oncology, Haematology, and Palliative Care, Marien Hospital, Düsseldorf, Germany

Each of us remembers moments in our education that have shaped us into who we are. Books we read, lessons we hear, and encounters we have often make a deep and lasting impact.

As a teenager, I was impressed by German neurologist Hoimar von Ditfurth’s explanation of the universe and the theory of evolution in Im Anfang war der Wasserstoff (It All Began With Hydrogen). The Color Atlas of Physiology, coauthored by Agamemnon Despopoulos, MD, from the University of New Mexico, was a great read in medical school. (Sadly, Agamemnon and his wife went missing when trying to cross the Atlantic in their sailboat in 1979.)

The lessons of Werner Correll, PhD, former Director of Psychology at the University of Giessen, Germany, were also most interesting – and I still find them helpful today.1 They have, for example, taught me a lot about why some people easily accept current recommendations about wearing masks to help prevent the spread of the coronavirus, while others are obstinate in opposing any well-intended advice. Dr. Correll’s research also may help explain why the leaders of some countries have done better than others when it comes to facing the ongoing pandemic.

Dr. Correll studied behavioral and motivational psychology in the 1960s and ‘70s and claimed that, at any given point in time, people are intrinsically and primarily driven by one of five basic motivations:

  • Type 1: Social recognition
  • Type 2: Security
  • Type 3: Emotional rewards (“love”)
  • Type 4: Rules
  • Type 5: Success

No one single motivation is “better” or “more desirable” than another, and the balance between motivations may change over time, but our primary motivation influences how we behave at work, respond to stress, or interact with our families. I find myself thinking about his psychological assessments when seeing patients, interviewing new staff, interacting with students, and – in today’s climate – explaining to people why they should wear a mask.

Dr. Correll shows that your main motivation will be reflected in your personal preferences and behavior. A person who is mainly motivated by social recognition (Type 1), for instance, can be recognized by his or her apparel, choice of vacation destination, choice of car, etc. Imagine, for example, a man who wants to become President of the U.S., is rich enough to do so, and is mainly motivated by the quest of social recognition. This hypothetical man would probably have a personal plane and tall buildings boasting his name in large letters, his wife would look like a Victoria’s Secret model, and he would constantly brag about his intelligence and his television ratings. Other people like him would drive a fancy sports car and show it off as much as possible, or they might always use the latest smartphone, wear an eccentric watch, and spend vacations going heli-skiing, shark riding, or playing golf at the most exclusive international destinations.

In academic medicine, someone with Type 1 primary motivation would love giving talks and go to great lengths to be the top recruiter on a clinical trial. Long discussions about authorship are guaranteed (unless the person is first author). If a Type 1 becomes your patient, however, watch out. Skipping a pill here or there makes no difference to a Type 1. They may have just undergone R-CHOP but will still plan a short trip to the Bahamas on days 3 to 7 after chemotherapy.

If you want to motivate your Type 1 patient to do something (like wear a mask), Dr. Correll advises us to find a positive and famous role model who wears a mask and tell them that “even the greatest comply with medical advice.” When discussing options for patients with BRCA mutations and breast cancer, you might refer to Angelina Jolie’s preventive mastectomy.

You will not have to do this at all with a Type 2, who is motivated by the quest of security. They will check everything several times. There is no bragging, no Rolex, and no Porsche involved. Type 2 doctors make sure they don’t miss the slightest detail. They round at the hospital three times a day and call patients at home to ask if they have taken their medication as prescribed and if there were any adverse events. They hate publicity and never stand in the front row when a photograph is taken.

You don’t need to worry about Type 2 patients not taking their prophylactic antibiotics or antifungals – they would never omit a single dose. And they always wear masks. You recognize these patients because they bring a relative to the appointment to make sure no detail is missed, and they tend to let the other person speak. Their apparel is appropriate, but there isn’t the slightest eccentricity involved. Motivating these patients to do something involves telling them it’s the safest option.

In contrast, a Type 3 person is rewarded by being loved by or caring for others. We have plenty of these types working in medicine: They work overtime when needed and are happy to swap on-call shifts or organize events for the department. They are family-oriented, belong to religious organizations and clubs, and are very active socially. They choose their car according to the needs of the family. Type 3 patients may ask to rebook an appointment because they need to care for someone else first. Dr. Correll tells us that stressing how their actions will affect others is the best way to motivate these patients.

A Type 4 person follows their own set of rules and tends to be as fastidious as Hercule Poirot. They seek order above all else. A doctor friend of mine is a Type 4: He always starts his ward round at precisely 7:30 a.m. – never late, but never early, either. His beard is always cut to the same length. He becomes furious if the resident can’t recite the blood counts of every patient. On the day before a vacation, he always wear the same tie with the words “bye-bye” printed on it.

As a patient, they will show you diagrams charting their CBCs and page-long lists of their blood pressure or glucose levels. They never arrive late to an appointment. They are meticulous in taking their pills. Taking one-quarter of a tablet will not bother them, and the instruction to take a pill 2 hours before or 4 hours after food and never with a bivalent ion will almost certainly be precisely followed. It’s not a good idea to change the treatment for a Type 4 patient without an obvious reason, though. Every alteration needs a reason and must be scientifically supported. The best motivation for such a patient is a scientific manuscript detailing the outcomes of each patient subgroup with a corresponding p value.

A Type 5 person is mainly motivated by results. Their standard question is, “What’s in it for me?” When it comes to medical decisions, they are pretty relaxed, look for opportunities (“Is there a clinical trial?”), and generally behave sensibly. As patients, they are factual, constructive, and understand the limits of medical treatment. They are well-dressed and drive a nice car but are rarely showy. They will follow your treatment advice – as long as they think it benefits them.

What struck me most in this universe of motivational analytics is the tremendous difference in the distribution of primary motivators that exists between countries. In Germany, about 14% of people would be considered Type 1, 36% Type 2, 13% Type 3, and 35% Type 4. Type 5 people are nearly nonexistent, at less than 2%.1 In England, though, Type 5 is 22% of the population!2 Greece has plenty of Type 3 people, and 70% of Japan’s population is Type 4.

The makeup of intrinsic motivations affects public health, too. With nearly 40% of Germans striving for security and 35% following rules, it’s no wonder everyone started wearing masks when the COVID-19 pandemic began. Things were different in the U.S.

To increase the number of people wearing a mask, telling your constituents that doing so will save the lives of others will only work with Type 3 people who value emotional rewards. The narrative must be adapted for Type 2s, who would respond better to hearing that wearing a mask will keep them safe, as will staying at home and washing their hands. Type 4 people will usually respond to orders issued by the government or clear scientific evidence, but Types 1 and 5 are more difficult to motivate on a national level. Type 1 people might respond to, “We are the greatest country and will show the world how fast we can tackle the pandemic,” but Type 5 people will need to understand that what benefits the majority will eventually benefit the individual, too.

So, which major motivation group do you belong to?

References

  1. Correll W. Menschen durchschauen und richtig behandeln. München, Mvg Verlag, 2005.
  2. Correll W. Personal communication.