Published on January 20, 2025 6:35 PM GMT
Why do highly-paid hospital workers slack off and complain so often? Most would say "because they can" or "they're just lazy" or "it's a tough job, stress release." But I suspect there's a deeper status game at play - one that may illuminate broader patterns of institutional decay.
Consider: I recently observed an ICU Registered Nurse who makes at least ~$236K/year, in a highly rated hospital in San Francisco, demonstrating conspicuous low effort. They:
- Openly bragged to 6 people in the 1 hour of my observation about how minimal of work he was doingActively discouraged others from working hardOptimizing for maximum visibility while achieving peak gravitational slouching abilityConsumed unhealthy food conspicuously.
The conventional view says this is just poor work ethic or a "burned out" employee. But notice - they're not just working little, they're signaling how little they work. This is key.
In most workplaces, appearing hardworking is high status. But here we see the opposite - there's status in showing how little you care. Why?
I suspect it's about demonstrating market power. By conspicuously slacking while keeping their high-paying job, they signal: "I'm so valuable that I can get away with this." It's like a peacock's tail - wasteful display that proves fitness.
The unhealthy food in the hospital setting amplifies this signal: "I'm so secure in my position that I don't even need to maintain appearances."
But there's more. By discouraging others from working hard, they're engaging in a subtle status competition. Each person working hard makes their slack more conspicuous. By convincing others to slack, they maintain their relative status position.
This matches broader patterns. High-status people often signal by breaking rules that bind others. Think of celebrities wearing ripped clothes or tech CEOs in hoodies.
The Status-Wage Paradox
If this model is right, simply raising wages won't help - it might even make it worse by increasing the status value of conspicuous slacking. The more you're paid, the more impressive it is to visibly slack off.
Connection to Known Failure Modes
This pattern connects to several institutional failure modes:
- Moloch Dynamics: The situation resembles a multi-polar trap where individual incentives (status through slacking) create collectively harmful outcomes (degraded care quality).Principal-Agent Problems: Classic monitoring issues where high-skill workers can't be easily evaluated by metrics, leading to perverse behaviors.Coordination Problems: Similar to how academic papers can become about signaling rather than discovery, medical care can become about status display rather than patient outcomes.
What Would Help?
We need to reshape the status landscape through several interventions:
1. Competence Visibility
- Install real-time outcome metric displaysCreate case presentation forumsImplement peer-nominated excellence awardsTrack and display advanced certifications
2. Reformed Mentorship
- Track mentee outcomes long-termCreate mentorship competition dynamicsBuild safeguards against negative mentorship captureImplement dual rating systems (immediate + long-term)
3. Team Alignment
- Create pod structures with shared outcomesLink visible perks to team performanceMake individual slacking hurt team status visiblyInstall public performance metrics
Empirical Testing Possibilities
This model makes several testable predictions:
- Negative behavior should:
- Correlate positively with wage levelSpread more in departments with less measurable outcomesCluster in social networks rather than random distribution
- Increase when audience size increasesTarget peers more than superiors/subordinatesInclude more wasteful signals in more secure positions
- Show better results when status rewards are visibleFail when only adding monetary incentivesSucceed more with team-based metrics than individual ones
Proposed Research Design
To test these predictions:
- Track behavioral markers across wage levels and departmentsMap social networks and attitude spreadImplement A/B tested interventions across similar unitsMeasure both direct outcomes and spillover effects
Control variables would need to include:
- Department typePatient acuityStaff experience levelsShift patternsLocal labor market conditions
Broader Implications for Institutional Design
This case study suggests several general principles:
- Status Engineering: Institutions must actively design their status hierarchies rather than letting them emerge organically.Measurement Systems: What you measure shapes status games - choose metrics that align with institutional goals.Social Architecture: Team structures need to support positive status competitions.
Connection to Other Domains
This pattern might explain similar phenomena in:
- Academia (status through busy-ness)Software development (status through complexity)Government (status through bureaucracy)Corporate management (status through meeting volume)
Questions for Further Research
- How do status games differ between profit and non-profit institutions?What role does job security play in enabling negative status displays?How do professional identity and status games interact?What are the minimal conditions needed for positive status games to dominate?
Action Items for Institutions
For organizations wanting to test these ideas:
- Audit current status markersMap social influence networksDesign pilot interventionsTrack both direct and spillover effectsDocument unexpected adaptations
The key insight: Institutions run on status games. The trick isn't eliminating them, but aligning them with institutional goals. Any solution must make positive behaviors higher status than negative ones.
Remember: I'm not making moral judgments - just examining how status incentives shape behavior. If we want better institutions, we need to understand their real dynamics, not just their formal structures.
I'm particularly interested in hearing from readers who've observed similar patterns in other institutions. What status games have you noticed that others miss? What interventions have you seen work or fail?
[This post builds on ideas from Zvi's "Immoral Mazes" sequence]
P.S. Yes, healthcare workers do crucial work. That's exactly why getting these incentives right matters so much.
P.P.S. Some will say this analysis is too cynical. But if we want to improve systems, we need to understand how they actually work, not how we wish they worked.
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