In podiatry, we all see the same pattern: two patients with essentially the same diagnosis, the same procedure, the same follow‑up plan.  Then they have very different outcomes. One heals smoothly and gets back to walking the dog, working, and playing golf. The other drifts in and out of care, “forgets” the boot, misses dressing changes, and eventually ends up with complications we were trying to prevent. It’s easy to blame noncompliance or “difficult patients,” but that doesn’t actually help us change anything. Over time in practice, I’ve found it’s more useful to ask a different question: what’s really driving their behavior?

That’s where the Motivation–Opportunity–Ability (MOA) model becomes useful. The MOA model has its roots in work on employee performance and human behavior.  This emerged in organizational psychology in the late twentieth century.  Blumberg and Pringle wrote about this in their 1982 article appeared the Academy of Management Review.  The article stressed discussed a three‑factor model consisting of “capacity, willingness, opportunity”.  This later evolved into the AMO/MOA family of frameworks. (AMO is Ability–Motivation–Opportunity model)

It’s a simple way to think about why people do—or don’t do—the things we ask them to do. In my world as a podiatrist, it applies just as much to patients as it does to staff, and even to my own. The model says that for someone to take meaningful action, three pieces have to line up: motivation, opportunity, and ability. When all three are present, things tend to move in the right direction. When one is missing, we get the familiar mix of apathy, frustration, and stalled progress that one would see in any business.

Motivation is the “why.” It’s the internal drive or external pressure that makes a patient actually want to follow instructions (despite when they just nod politely in the exam room). A motivated patient isn’t just trying to “heal the wound”; they want to walk at their granddaughter’s graduation, or keep their job, and even avoid the hospital. Sometimes it’s positive, when it provides more freedom, less pain. Sometimes it’s negative, avoiding surgery or amputation. Both can work if they’re specific and personal. When motivation is missing, you can feel it in the room. The dressing change instructions land, but there’s no spark behind the eyes. The patient hears you, but they don’t really see the point, and nothing changes when they walk out the door.

Opportunity is the piece we, as physicians, tend to underestimate. We assume that if people know better, they’ll do better. But I’ve had plenty of patients who desperately wanted to heal and still couldn’t follow the plan (I often say, if I only took care of people who listened to me, I would be very lonely). Opportunity is all the external conditions that either support or sabotage what we’re asking from the patient.  Things like their time, transportation, money, having home support, changing work demands or the physical environment. Think of the patient who wants to offload but stands all day at work, the person who can’t get a ride to follow‑ups and walks a mile to the office, or the patient whose dressing supplies are too expensive or not covered.

It is important to understand that they’re not ignoring you, they’re boxed in. On the practice side, opportunity shows up as staff levels, scheduling realities, EHR workflows, and whether we give our team the space and tools to do what we’re asking them to do. When motivation is there, but opportunity is missing, everyone ends up frustrated. The patient feels like they’re failing. The team feels like they’re spinning their wheels.

Ability is the third leg of the stool. This is where skills, understanding, and experience live. Patients need to know not just what to do, but how to do it.  How will they behave when care is in their own hands, or in their own home, even with their own limitations. Problems arise like issues with  dexterity, balance, memory, and health literacy. If you’ve ever had a patient who “keeps doing it wrong” despite seeming engaged, you’ve probably run into an ability problem. They nod in the office, but when they’re back in their bathroom at 10 p.m., nothing you said translates into action. Our staff face the same issue when we throw new workflows, documentation demands, and clinical expectations at them. They may want to do a good job, and have the time to do it, but they simply haven’t built the skills yet.

What makes the MOA model actually practical is how these three factors combine. When motivation, opportunity, and ability are all present, you see what we call success.  The wound that steadily improves, the post‑op patient who follows restrictions, the team that runs clinic smoothly. When motivation and ability are present but opportunity is missing, you see frustration.  It is the patients who wanted to do the right thing, but can’t because of work, finances, transport, or home realities. When opportunity and ability are present but motivation is absent, you see apathy.  People have plenty of capacity, just no real interest in performing the task. When motivation and opportunity are there but ability is missing, you see a skills gap.  This is the patient or staff member who cares, has time and tools, but still can’t execute consistently.

In day‑to‑day practice, I’ve found that this model works best as a quiet mental checklist. When a case isn’t going the way it should, I ask myself, is this primarily a motivation problem, an opportunity problem, or an ability problem? For the non‑healing diabetic ulcer patient who keeps loading the foot, maybe we haven’t connected the plan to something they actually care about, so motivation is weak. Maybe they can’t realistically stay off work and don’t have access to a scooter or boot that fits their reality, which means opportunity is lacking. Maybe they literally don’t know how to get from bed to bathroom without loading the wound, which is an ability issue. Once you see which leg of the stool is wobbly, the intervention changes. Instead of repeating the same instructions louder, you adjust the plan: reframe the “why,” remove a barrier, or teach the skill in a more hands‑on way.

At the end of the day, we’re not just treating skin, bone, and biomechanics, we’re treating human behavior.  This is in real life, often with messy circumstances. The MOA framework doesn’t fix that complexity, but it gives you a cleaner way to navigate it. If you build it into how you think about patients, staff, and even your own habits, you’ll find it easier to understand why good plans fail and what you can tweak to get people moving in the direction you both want.