Authors: Laryssa Patti, MD and Greg Kelly, MBBS
Editor: Michael Gottlieb, MD

A Case

Since moving to the city one year prior, Ahmed had developed an outstanding reputation with his medical team. He was older than most of the other fellows, having started surgical training in Syria before making the switch to emergency medicine in the U.S.. Unsurprisingly, his technical skills were excellent, but it was his calmness, humility, and patience that made him so popular with the department. “We love Ahmed” had become a refrain amongst the nurses when they saw his name on the roster after what had been a few legendarily hectic night shifts, even for this hospital. The delicious food that his wife sometimes brought in for everyone only further boosted his reputation.

Ahmed had moved with his family from a smaller regional hospital after failing his first attempt at the board exams. His mentor there, a friend of the medical director, had personally called to recommend him. “Ahmed’s fantastic, he’s not someone we’re trying to get rid of at all. But as you know, the teaching culture here is not what it could be, and you’ve built a great reputation at your shop. Ahmed is clinically excellent and works really well with our team, but he came from a very different system and English is not his first language. I don’t have any doubts that he can pass, but I don’t know if he will from here. I think exposure to your teaching program is what he needs to get him through.”

The boards were a month away and there were a record four fellows sitting. After participating in the local study group for almost a year, Ahmed had become much more comfortable with case discussions in English. He’d been meeting regularly with local mentors to talk over recent articles and had facilitated a great discussion at the local trauma study day, where he demonstrated his deep experience of gunshot wounds. Recently though, this had all been starting to slip. His grand rounds presentation was, frankly, embarrassing and required his co-presenter to step in and save the day. He’d been rude to a surgical attending who he’d called overnight and several nurses had complained about his recent behavior. Kerry, the medical director, didn’t believe in letting things fester. She saw him walk past her open office door and leapt up from her desk. “Ahmed, do you have a few minutes to talk?” He’d been to her office a few times since he arrived. She loved the way he prepared and drank tea in such a fastidious but elegant way. They’d covered all topics from medicine to Ahmed’s hopes for his homeland and his family. He was someone who she and most of the faculty saw as a potential future colleague who would bring great strength and diversity to the department.This time, as he closed the door and turned back to face her, Kerry saw a completely different expression from Ahmed’s usual one. Worry, fear, even anger flashed across his drawn face. She asked Ahmed to sit down and said “Do you want some tea?” What was going on? 

Background

In 1943, Abraham Maslow published “A Theory of Human Motivation”,¹ in which he described the concept of a hierarchy of needs that motivate human behavior. Maslow’s work arose from the humanistic school of psychology, standing in contrast to the behavioralist school. With reference to education, the behaviorist view was that education was a science that involved transmitting knowledge in the most efficient way. In contrast, the humanists took a more holistic view of people and believed that that an educator’s role was to facilitate the growth of their students, enabling them to self-actualize.²

Maslow posited a hierarchical relationship between physiological needs and increasingly sophisticated needs, eventually ending in self-actualization. In his first paper, he grouped the first four needs (physiologic, safety, love, and esteem) as “deficiency needs” (or “D-needs”) because deprivation in any of these categories will motivate behavior to resolve that deficiency. For example, the individual without reliable housing will be motivated to address that deficiency prior to trying to develop an artistic talent as an expression of self-actualization. Additionally, the longer an individual is lacking in a D-need (for example, the hungrier they are), the more motivated they will be to rectify the deficiency (greater effort to find food). In comparison, self-actualization is not driven by a lack of something, but rather by the individual’s need to become what they can be. Hence, this has been referred to as a “being need” (or “B-need”) and can significantly differ from person to person. According to Maslow’s theory, as the D-needs are progressively satisfied, an individual can address needs farther up the hierarchy until, ultimately, they can focus on achieving self-actualization. The processes of learning may be different from the processes required to complete a task. 

Figure 1. Visual representation of Maslow’s hierarchy of needs. The figure above highlights the various elements of Maslow’s hierarchy of needs (Physiologic Needs, Safety/Security Needs, Love/Belongingness Needs, Esteem Needs, Self-actualization needs).

Figure 2. Dynamic trending of Maslow’s Hierarchy of Needs. The figure outlines the dynamic natures between needs intensity and personal development and how it interfaces with the various elements of Maslow’s Hierarchy. From Wikipedia Commons (Used under a creative commons license, CC-4.0-SA).

Modern takes on this Theory

Later work, including that by Maslow himself,³ de-emphasised the rigid order of needs with the recognition that people do not need to completely satisfy a need before pursuing another, higher order need. Alternatively, he proposed that satisfaction of needs on numerous levels are sought simultaneously. 

Herzberg’s two-factor theory of motivation⁷ arose out of studies of workplace motivation (as opposed to more general motivation theories of Maslow) but there are strong parallels with Maslow’s work. Herzberg’s ‘Hygiene Factors’ align with Maslow’s deficiency needs while the ‘Motivating Factors’ align with Maslow’s being needs. However, Herzberg argued against the idea of needs occurring along a continuum. 

The level that esteem, status, and mating-related motives (e.g., mate acquisition, retention, sex, and parenting) should occupy on the pyramid remains a topic of debate. In 2010, Kenrick and colleagues proposed that mating-related motives should replace self-actualization at the top of the pyramid, adjusting the goals of the pyramid with an emphasis on propagation of humanity.⁸ However, the authors agreed that basic physiologic needs should remain as the base of the pyramid.⁸ 

Seventy-five years after Abraham Maslow’s initial publication, there remains no broadly accepted theory of human motivation. Contemporary authors argue for the continued relevance of Maslow’s work because it is widely recognized, continues to place human motivation at the center of education studies, and “resonate[s] powerfully across disciplines,” whilst acknowledging that Maslow’s hierarchy is not strongly supported by modern science.^9,10 Self-actualization remains an achievable and desirable goal, as our culture continues to revere those who appear authentic, purposeful in their decisions, and certain in their beliefs and principles. 

Other Examples of Where this Theory Might Apply

Since the early 1960s, Maslow’s hierarchy of needs has been incorporated into educational theory. Maslow evaluates the learner holistically, taking into consideration the learner’s physical, emotional, social, and intellectual qualities. It seems apparent that a learner who is unable to address basic physiologic needs would be unable to focus in the classroom. In clinical settings, we must consider whether clinicians have regular access to water, food, bathrooms, temperature control, and an appropriate environment to do their work. How many times have you heard a clinician say that they have not eaten all day because of a busy clinical shift?

A sense of safety may not translate to simply protection from the elements, but rather a sense of security in the clinical setting as well as in the classroom. In the emergency department, this can include the basic protection from violence, ensuring a setting that allows for appropriate patient care with the right tools and sufficient space, and having job stability without fear of being replaced.

Additionally, the classroom should be a place where a student feels like they are a part of the culture and “belong”, as well as a sense that they are esteemed by their classmates and teachers. In the clinical setting, this can translate to a clear role on a patient care team, as well as a cooperative relationship with consultation services and between team members, in which all team members are treated with respect.

In residency programs, the goal should be to train residents who are “self-actualized.” In this context, they should be confident in their ability to perform patient care, be leaders, and advocate for the patient. Self-actualization is unique to the individual, and it is the educator’s role to help the learner along their individual path, rather than molding them in a certain image. The goal should be “to facilitate the student’s discovery and actualization of their nature, vocation, what they are good for, and what they enjoy doing.”²

As educators, if we improve working conditions, this can allow students and residents to focus more on learning and engage them in their quest towards self-actualization.

Limitations of this Theory

Due to the nature in which Maslow’s theories were developed, it is difficult to perform replicable testing or validity evaluations. The definition of “need” may be different between individuals. Maslow’s sample set for biographical analysis was skewed, as it had few women, focused on high-profile individuals, and only took into consideration cultures that were similar to his own. Additionally, more recent data has suggested that people are able to establish meaningful relationships and obtain a sense of belongingness, or even self-actualization despite not achieving some of the more “basic” needs as per Maslow’s definition.¹² 

Returning to the case…

As Ahmed sat down opposite Kerry, he looked up briefly with his tightly-drawn expression and then down at his hands clasped in his lap. 

“Ahmed, I’d like to ask you about a few things that have happened recently. I want to start by saying that we really enjoy having you here and value you highly. It’s not easy to win over some of our nurses but you’ve done it. However, in the last two weeks there have been instances where people have found it difficult to work with you or found your communication unfriendly. I’d like to know your side of the story.” 

Ahmed, who had been staring somewhere past Kerry’s left shoulder, rubbed his face with both hands. Finally looking up, he sighed. “Doctor Kerry, I am really sorry. I know exactly the times that you are talking about. I have already apologized to each of them and I would like to apologize to you, too. I have been really stressed for the last three weeks as I feel like I am living in a nightmare.”

“My wife has been having trouble with her visa since leaving her engineering job and she has to leave in two weeks. We thought she would get a spouse visa, but the immigration office wants our marriage certificate from Syria. She has tried to get her job back, but she needs a visa. Every time we speak to someone from immigration, we are told different answers. I’ve been spending all day waiting on hold. My boards are in less than two weeks and, if I fail again, my visa might also be in trouble.”

Kerry nodded. “Ahmed, I’m sorry. I can understand that must be incredibly stressful. We had a fellow recently with a similar situation. Fortunately, the college has an incredible immigration lawyer who may be able to help us. Let me call her for you.”

Fortunately, the immigration lawyer (Daniela) was free that afternoon. Kerry told Ahmed to take the rest of the day off and sent him straight across the street to see her. He arrived back two hours later and poked his head around the corner of Kerry’s door. 

“Doctor Kerry?” He was smiling. 

“Come in, Ahmed. How was your meeting with Daniela?”

‘Fantastic,” he said. “She said this is a common problem and that there is another visa class that we can change to. We have an appointment tomorrow morning with the visa office. Daniela is amazing. I must get back to my shift but thank you so much, I greatly appreciate it.”

He got up to leave but as he reached Kerry’s door he turned back. “Doctor Kerry, there is something else.”“Yes, Ahmed?” “Daniela said that you told her that you needed her help as you wanted me to join the staff once I passed my boards. She said it’s OK to tell me that.”

“We do Ahmed, if that’s what you want. Is it?”“Doctor Kerry, I would love that. I love my job here. My wife and children love this city, too. We feel accepted and peaceful here. I have many ideas about contributing to your amazing team.”

References

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13. 13.Wahba MA, Bridwell LG. Maslow reconsidered – A review of research on the need of hierarchy theory. Academy of Management Proceedings. 1973;1:514-520.