Data on STMM physicians
Multivariate regressions from survey data indicate that being a surgeon, anesthesiologist or pediatrician predicts STMM participation over practicing other areas of medicine [8]. Being in the oldest of three age groupings (56–73 years) and being married also independently predict participation. The one-time Physicians’ Giving Back Survey indicated that nearly twice as many males as females participate in STMMs. Descriptively, STMM physicians tend to have few or no children in the home at the time of their STMMs, and to have an earned income that is somewhat less that average among their colleagues. Lesser participation among those of higher annual incomes may suggest, among other possibilities, that the increasing opportunity cost of income foregone while away may act as a constraint on participation. This interpretation resonates with findings that arose during physician interviews that unveiled a set of personality traits perceived of repeat participants that begins with unselfishness [9]. Flexibility, referring to the ability to perform effectively in labile or technology-limited circumstances, seems a pre-requisite. The traits profile also included high self-confidence and strong personal ethics, as well as tolerance for arduous and less sanitary conditions. Building on that demographic and personality background, these narratives indicated that the key drivers of motivation, and hence the rewards sought by physicians, include the satisfaction of helping others in difficult circumstances, the appreciation felt from patients and communities, teaching and the physicians’ own learning experiences, and a sense of renewal. Face-to-face experiences with patients and the legacy effect of teaching evoke a desire to repeat.
In contrast, religious affiliation, some elements of religiosity, and the desire to project a favorable image of America were not dominant in the choice to participate. Similarly, the difference in medical philosophy embodied in the two consummate medical degrees available in the United States, MD and DO, did not differentiate participants and non-participants. Half of US physician subjects in the cited narratives identified influences of family or events while growing up as instrumental in pre-disposing them to take part in STMMs, and most of these acknowledged role models in their lives [9].
Most STMMs by US physicians take place in Latin America, not because of pre-existing ethnic or national ties, but rather for reasons related to its proximity. Martiniuk et al. found similar hemispheric ties between the UK and Africa, and Australia and Southeast Asia/Oceania. Canada departs from the pattern with its predominant focus on Africa, perhaps connected to its allegiance to the British monarchy and colonial history [3].
Data on MSF physicians
Comparing the demographic and professional characteristics of STMM and MSF physicians is frustrated by the paucity of such data catalogued by MSF human resources coordinators. For MSF international physicians (those that travel to another country), the male to female ratio is roughly equal, although this data does not demarcate physicians from paramedical personnel [15]. The mean age for all MSF medical personnel was 40.3 years. Seventy-two percent of travelling medical personnel comes from Europe or North America. No data is collected for race, religion, marital status, children at home, or most frequent specialties (personal communications: Fabrice Weissman, Fondation MSF Centre de réflexion sur l’action et les savoirs humanitaires (CRASH) and Pierre Monnier, Fondation MSF Human resources, 2016).
From a collage of personal narratives, Siméant portrays the MSF physician as disengaged from traditional medical practice [13]. This disengagement seems related in part to constrained availability of employment and societal devaluation of the medical profession. Another part of the disengagement, to paraphrase Siméant, is the attraction of the honor of activism and a virile flaunting of one’s courage and noble risk-taking. At the time of MSF’s birth, a similar disengagement from politics ensued, drawing would-be zealots from both the right and left of the political spectrum to cohabitate in the witness of famine and genocide. Humanitarian medical practice would allow one to be more than just a doctor, and one could remain an honorable doctor even if the work was intermittent. The blending of participants from diverse backgrounds inclusive of foreigners and those with Jewish ancestry allowed MSF to flourish from its French foundations, yet as a non-nationalistic movement. From these beginnings, the factors of challenge, risk, and adventure have served the retention of volunteers, creating somewhat of a veritable “risk aristocracy”.
Roderick Wong, a Canadian psychologist, in his text on biobehavioral concepts of motivation, cites the description by Leyton and Locke of MSF personnel in Rwanda during the genocide of 1996 [17, 18]. In that MSF staff seemed to be able to ignore the massive risk about them, the work disconnects them from the minor irritations and “mindlessness of modern life”. Leyton and Locke opine that “self-actualization” à la Maslow’s hierarchy of needs may thereby figure into motivation of MSF staff [19]. As with extreme sports and combat itself, a similar clarity of mind may arise from such adrenaline-laced consciousness and focus.
The backgrounds of physicians from the Siméant interviews included several common threads, beginning with having been in scouting and other forms of early socialization like summer camp, competitive sports, military, and monastic life. Though not failures in education, schooling was not high priority for many. Often, those attracted to humanitarian careers have had difficulty as adult professionals, not with their knowledge or skills, but rather with integrating comfortably into the professional establishment. Professional humanitarian organizations identify and recruit such individuals. Exposure to discrimination, family trauma that led to unexpected responsibility at a young age, and having a hero or social militant figure in the family were repeating themes. Long-term expatriate humanitarian careers are commonly triggered after the death or separation from a significant other. Finally, Siméant calls attention to the advantages of short-term volunteerism since career expatriate humanitarian physicians may find their core skills becoming arcane, and experience psychosocial difficulties with re-entry into their native social structure.
Siméant interviewed mainly volunteers working in conflict settings. In fact, about half of MSF missions now are so-called “mid-term/long-term programs” addressing chronic issues such as the HIV epidemic or high mortality from malnutrition and infectious disease among children in “stable” contexts. Taking this dimension of MSF into consideration, the differences between STMM and MSF volunteers’ motivations and profiles may be less acute, although no data is available (personal communication: Fabrice Weissman, Research Director at MSF Foundation Centre de réflexion sur l’action et les saviors Humanitaires (CRASH)). The terms of these programs generally remain impractical for physicians in domestic practice.
Found within the blog section of the MSF-USA webpages, testimonials bear further insights on a blend of four motivations: 1. escape from a past life or current social situation, 2. adventure and challenges, 3. money (though modest, it can be steady work), and 4. idealism, the hope to be a positive force for humanity [20]. Jobanputra herein contends that all international aid workers demonstrate escapist tendencies, along with adventurism, and concedes that emotional baggage weigh into motivations. Nonetheless, he defends the idealism component as a mechanism of consciously choosing how to influence others. Responders to Jobanputra’s blog post have expressed that the calculation of motivation did not matter provided that results were seen during the project, and that the hard work and setbacks will dispense with the romantic aspects very quickly.
Influence of organizations on physician motivations
NGOs with which US STMM physicians choose to work, if any, are selected based on varying personal criteria, or simply who has invited them. STMM narrative subjects rarely saw in their own motivations the projection of nationalistic influence, and gave no inkling that selection of organizations with which to work had any basis in secondary messages, except, at times, evangelical [9]. Mendoza suggests that the lack of access to medical care and the suffering it provokes is grounded in market failure, and therein lies the impetus for STMM activity as a civil society response [21]. Lasker found nothing in her dual methodology study on STMM-sending organizations to suggest that their objectives include drawing attention to the failures of governing regimes or market mechanisms [22, 23]. The non-medical objectives of organizations that sponsor STMMs, including evangelism, education, fund raising, recruitment, reputation enhancement, research, and nurturing future leadership are non-nationalistic and rooted in the private sector.
MSF has been on display as a case study on organizational motivation in numerous management texts and symposia [17, 24, 25]. The non-medical half of MSF’s core objectives involves the signaling of injustice towards the oppressed and displaced, and as Siméant implies, might be a motivation for physicians [13].