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Take the Power Back: Using Need Crafting to Improve Physician Well-Being

TIMOTHY D. RILEY, MD
GREGORY GULDNER, MD, MS, FACEP

FPM. 2026;33(4):14-19.

Author disclosures: no relevant financial relationships.

This content conforms to AAFP criteria for CME.

This simple technique, based on self-determination theory, can help physicians meet their need for autonomy, belonging, and competence even in challenging circumstances.

Primary care physicians face multiple challenges in daily practice, including unrealistic patient expectations, regulatory requirements, insurance red tape, and inefficient practice environments. All of these factors increase the risk of stress and burnout, even for the most resilient physicians.1–3 Given the evidence supporting system-level interventions as the most effective approach to alleviate physician distress,4 national leaders have advocated for prioritizing system change.5 But system change is slow, leaving many physicians exhausted, cynical, emotionally withdrawn, and seeking reductions in clinical effort.6,7 Ironically, physician disengagement may impede progress on system-level changes, given physicians' critical role in these efforts.8

KEY POINTS

  • In response to the many challenges of daily practice, physicians cannot simply wait for top-down system change, which can be slow.
  • Instead, individual physicians can use “need crafting” methods to meet their own basic psychological needs.
  • Techniques include reframing, self-advocacy, creating choices, creating personal connections, and playing to strengths.

In this context, how can individual physicians effectively navigate challenging circumstances while contributing to system change and protecting their own well-being? One possible path forward is an emerging concept within self-determination theory called “need crafting.” Rather than simply waiting on organizations or leaders to provide an environment that meets their needs (a top-down approach), individuals can proactively adjust their behaviors, thoughts, and interactions to meet their own needs (a bottom-up approach).

SELF-DETERMINATION THEORY AND THE THREE BASIC PSYCHOLOGICAL NEEDS

A leading theory of human motivation and well-being, self-determination theory posits that we all have an inherent drive to flourish.9 To do so, three basic psychological needs must be satisfied:9–11

  • Autonomy, the sense of agency and control over our actions and decisions (not necessarily independence or freedom, but volitional endorsement and congruence with our interests and values),
  • Belonging (or relatedness), the need for connection — feeling understood and valued by others,
  • Competence, the feeling of growth, mastery, and effectiveness in our pursuits.

When these needs are met, the result is improved well-being, productivity, and effectiveness.12–15 When these needs are thwarted, stress, burnout, decreased productivity, and ineffectiveness may ensue.12 Abundant research supports this theory and shows that environments meeting the basic psychological needs of the workforce reliably lead to these benefits.14,16 Yet frontline physicians frequently face environments that thwart their basic psychological needs.17

Table 1 lays out a case example of how a primary care physician's basic psychological needs may be thwarted during a typical workday. Too often this creates habits that diminish physicians' perceived ability to change their circumstances,18–20 making it more difficult to flourish in the clinical workspace.

TABLE 1. CASE EXAMPLE: NEED THWARTING

Scenario Relation to need thwarting
Dr. Thwarted arrives at her clinic and is greeted by several stressors: a blank disability form (for a patient she saw six weeks ago) in her paper inbox, multiple messages in her electronic inbox from patients asking about new symptoms, and a complex patient (for whom she had requested a 30-minute follow up) scheduled in a 15-minute time slot. Already feeling overwhelmed, she manages a curt greeting for the nursing staff and launches into her day. Autonomy thwarted:

  • No perceived choice regarding forms and messages to be addressed.

  • No endorsement of circumstances (e.g., appointment length) she did not choose.

Belonging thwarted:

  • No meaningful connection with staff.

Competence thwarted:

  • Failed attempt to ensure appropriate appointment length.
For her first patient of the day, she only has 15 minutes, but the patient has many complex needs and Dr. Thwarted wants to be comprehensive in her care. She manages to address most items on the patient's list and her own agenda in 30 minutes, a testament to her skill and efficiency. Still, several issues go unaddressed, and the longer visit puts her behind to start the day. Autonomy thwarted:

  • No perceived choice regarding the need to address multiple problems at short visit.

  • Incongruence between value of comprehensive care and available time.

Belonging thwarted:

  • Overly full agenda leads to lack of meaningful connection with patient.

Competence thwarted:

  • Unable to attain goal of comprehensive care despite addressing multiple issues.
She manages to finish her morning with enough time to eat lunch while working on her inbox before the afternoon session starts. She answers her patients' messages as best as she can but feels frustrated that they expect her to diagnose and treat them without an in-person history and exam. Autonomy thwarted:

  • No perceived choice regarding addressing patients' inbox questions.

  • Incongruence between value of effective care and asynchronous care expectations.

Belonging thwarted:

  • Inbox interactions with patients lack meaningful interpersonal connection.

Competence thwarted:

  • Unable to effectively manage patients' problems via messaging.
After a busy afternoon, she again sees the blank disability form. Knowing she will not have time to address it tomorrow, she completes it as quickly as possible, hoping the details she provides meet the patient's needs and do not require revisions. The nursing staff check in before leaving for the day. She leaves an hour later, just as the evening cleaning staff arrive. She drives home hungry, having missed dinner with her partner and children. Autonomy thwarted:

  • No perceived choice regarding timing or circumstances of form completion.

Belonging thwarted:

  • Unavailable for meaningful connection with colleagues.

  • Missed opportunity to interact with family over meal.

Competence thwarted:

  • Risk of ineffective form completion leading to rework.

Dr. Riley is professor and associate vice chair for wellness in the Department of Family and Community Medicine, Penn State Health.

Dr. Guldner is vice president of academic affairs for graduate medical education at HCA Healthcare and clinical professor of emergency medicine at the University of California Riverside School of Medicine.

The views expressed in this publication represent those of the author(s) and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.

Disclaimer: This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare affiliated entity.

Send comments to fpmedit@aafp.org, or add your comments to the article online.

Author disclosures: no relevant financial relationships.

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