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Perspectives |
1 From the Department of Radiology, Indiana University Medical Center, 702 Barnhill Dr, Rm 1053, Indianapolis, IN 46202-5200. Received March 21, 2002; revision requested April 30; revision received May 6; accepted May 24. Address correspondence to R.B.G. (e-mail: rbgunder@iupui.edu).
Index terms: Perspectives • Radiology and radiologists, departmental management • Radiology and radiologists, socioeconomic issues
Lord, grant that I may always desire more than I can accomplish.
Michelangelo
How can radiology leaders effectively motivate the members of their organizations? Consider the following scenario. The clinical productivity of a senior faculty member in the radiology department has steadily declined over several years. The department is losing money because of this faculty member, who costs considerably more in salary and benefits than the collections he generates. Moreover, other more junior members of the section are growing increasingly resentful over the fact that this faculty member is not "pulling his weight." After talking with colleagues, the chairman of the department is weighing three options for handling the situation. Among the alternatives she has identified are the following:
1. The simplest and most direct means of addressing this situation would be to confront the faculty member with the facts and tell him that he must increase his clinical productivity. This demand would be accompanied by threats designed to provoke action through an escalating list of negative consequences that will flow from a failure to turn the situation around. The negative consequences would include more demanding clinical assignments, a reduction in compensation, and, eventually, termination.
2. The second alternative would be to introduce a performance-based compensation system, thereby creating financial incentives for the faculty member to increase his clinical productivity. Instead of using a "stick" to goad him on from behind, this technique relies on a "carrot" to draw him forward from the front. The faculty member’s financial compensation would be tied directly to the amount of work he accomplishes. This would seem to reduce the department’s financial liability, make compensation fairer, and provide a direct incentive for the faculty member to work harder. The benefits of this approach might obtain not only for this particular faculty member but for the section as a whole, as well as for the entire department.
3. The third alternative would be to do nothing. The faculty member has been with the department for decades, once serving a 5-year term as chairman. Moreover, his career included a long period of high productivity as an extramurally funded researcher, and he makes important ongoing contributions to the education of medical students and residents. The chairman contemplates telling other members of the section that the senior faculty member has paid his dues over many years, and that they have no right to complain until they have put in as many years of loyal service. Having tested the waters with one section member, however, the chairman has reason to believe that several junior faculty members might leave the institution if she follows this approach.
How should the chairman approach this situation? Which of the alternatives among which she is trying to choose is the correct one? The purpose of our communication is to address the question of motivation in radiology, an issue that pertains not only to radiology faculty members but to employees such as nurses, technologists, and clerical staff, as well as to learners such as medical students and residents.
Clearly, one of the major factors determining the success of a radiology department is the level of motivation of the people who work in it. If people are highly motivated for the right reasons, a department is likely to flourish. On the other hand, if people are poorly motivated the department is not likely to fare well, no matter how effectively its leadership functions on other fronts. As we discuss the various factors that contribute to and detract from motivation, we will see that none of the alternatives the chairman is currently considering is optimal. To find the best approach will require a new understanding of motivation.
Some of the best-known and most widely respected work on human motivation in the latter half of the 20th century was performed by Frederick Herzberg (1). Originally, Herzberg studied 203 rising accountants and engineers in an attempt to understand what factors contributed to and detracted from their level of professional motivation. Though he substantially expanded on this work over the years (2), he essentially began with two simple questions: (a) Think of a time when you felt especially good about your job. Why did you feel that way? (b) Think of a time when you felt especially bad about your job. Why did you feel that way? From these interviews, he developed a theory that there are two basic dimensions of professional satisfaction: "hygiene" and motivation. Hygiene is used not in its literal sense but as a metaphor for the "healthiness" or "cleanliness" of the work environment. Both hygiene and motivation are important components in a worker’s overall level of job satisfaction, but the two are different in a number of crucial respects. Failure to distinguish appropriately between the two or concentration on one to the neglect of the other spells trouble for leaders, workers, and the whole organization.
HYGIENE
Hygiene factors are related to the environment in which work is performed. As such they represent extrinsic factors pertaining not to the nature of the work itself but to the conditions under which workers are expected to perform their jobs. These factors include company and administrative policies, supervision, salary, interpersonal relations, and working conditions. According to Herzberg (1), hygiene factors do not motivate people to work but instead minimize their level of dissatisfaction. In other words, hygiene factors are not good motivators, but they can become dangerous demotivators if not properly attended to. If leaders fail to keep their organizations "clean" in these respects, their best and hardest-working employees are likely to seek other positions, and replacing those employees will prove to be difficult if not impossible.
Administrative Policies
One sure way to alienate employees is to adopt workplace policies that are perceived as capricious or unfair. The sense of fair play is one of the most powerful human motivators, and it is vital that leaders avoid offending it. In the scenario described earlier, a number of junior faculty members believed that the senior faculty member was getting away with behavior that would never be tolerated from them. The perception that a faculty member was not pulling his weight had produced a serious degree of dissatisfaction within the organization. Nearly as bad as patently unfair administrative policies are unarticulated or unclear policies. This is not to say that radiology departments must clearly specify in detail, in the form of a policy and procedure manual, how every conceivable contingency will be handled. Workers must, however, know where the organization and its leadership stand on key matters and how disputes are likely to be handled.
Above all, workers must believe that matters will always be handled with fairness, respect, and trust. One of the surest ways to drive away faculty is to adopt a critical condescending attitude toward them. An effective chairman is an advocate, not a prosecutor. An effective leader desires to maximize the success of his or her followers and to identify and overcome barriers to their success. Even the proverbial "drill sergeant" has the well-being of the "recruits" in mind. However, leadership styles appropriate for 18-year-old recruits are not appropriate for 35-year-old professionals.
Supervision
One of the most important decisions a leader can make is who to appoint to positions of leadership within the organization. If workers come to believe that their supervisors are undeserving or incompetent, morale will quickly suffer. It can be tempting to promote people who are most likely to agree with the leader and thus cause the least trouble. Similarly, it is natural to assume that good employees will make the best supervisors. In fact, however, both assumptions can be seriously mistaken. Leaders need supervisors who are willing to present alternative points of view, and to disagree when they believe disagreement is called for. Being surrounded by "yes men" only ensures that the leader will become progressively more isolated and ill informed about the organization and the challenges it faces. The best employees are not always the best supervisors either, because they may lack key supervisory abilities, such as the ability to confront people when necessary, the ability to delegate tasks, and the ability to motivate others.
There is a cost to excessive bureaucracy. Without a supervisor, co-workers might be willing to work together to address workplace inefficiencies and improvements on their own. When a supervisor is appointed where previously there was none, the other workers may think they have been stripped of responsibility and lose interest in the process.
Salary
According to Herzberg et al (2), salary is not a motivator, or at least it is not a very good one. In the scenario at the beginning of this article, junior faculty members felt slighted in part because the senior faculty member was being paid as much as or more than they, despite the fact that he was less productive. Again, if people think that inequities exist in the compensation system, the effect on morale can be disastrous. One way to minimize such resentment is to avoid publicizing compensation information, although this does nothing to address the underlying inequity. People will not necessarily work harder if you offer to pay them more, but they will become disenchanted if they believe they are not being paid enough. Attempts to motivate performance through pay are problematic because people soon come to mistake the reward for the goal of enhanced job performance. If such rewards are withdrawn, performance quickly decompensates and workers come to rely on ever higher bonuses to maintain their performance growth.
Interpersonal Relations
Many of the workers in an organization come to work every day partly because their jobs help meet their needs for affiliation or socialization. In the best of all possible worlds, they feel a sense of pride and camaraderie in their work and enjoy being a member of a team. In an effort to increase productivity, a radiology leader might be tempted to reduce break times for hourly employees and eliminate as much free time in the day as possible for faculty members, but such efforts would likely prove to be self-defeating. People, especially highly educated professionals such as physicians, tend to become dissatisfied when they think that someone is trying to micromanage their time. This stems in part from the implicit lack of respect and in part from a reaction to being manipulated. At times, sustaining departmental comity may require that certain individuals be disciplined for inappropriate behavior, but leaders should proceed with humility, patience, and fairness.
Workplace Conditions
If workers see that leadership neglects the workplace, their sense of pride in and commitment to their jobs will suffer. Facilities should be designed to be as warm and friendly as possible and should be kept well ordered and clean at all times. Equipment should be as up to date as possible and well maintained. People should have their own personal space, if possible, and they should be allowed to set it up as they see fit. Leaders must sometimes fight to secure the space and facilities their employees deserve. The importance of such a battle should not be underestimated, because people who work in the organization will be living with it for years and perhaps decades to come.
Often, academic institutions do not fare well in comparison with private hospitals on these terms. For example, private hospitals are more likely than academic centers to provide such amenities as comfortable staff lounges and reserved parking spaces for the physician staff. Reserved parking for physicians may be seen as a form of discrimination against nonphysician employees, yet physicians who come and go at all hours can waste valuable time finding an empty parking space or walking to and from that space. In theory, when everyone is treated fairly, these are not "hygiene" issues, but they can become so if academic physicians believe their counterparts in private practice enjoy such comforts as a matter of course.
MOTIVATION
In contrast to hygiene factors, motivation factors refer to the nature of the work itself. The key question is "What in fact do I do at work?" The best that attention to hygiene factors can accomplish is to achieve average levels of satisfaction and work performance; however, attention to motivation factors can actually result in better work by making work more interesting and enjoyable at an intrinsic level.
According to Herzberg (3), people do a good job because they are interested in what they are doing and are committed to it. No amount of clearly articulated policy, enhanced supervision, increased compensation, or investment in the physical plant can equal the positive effect of workers who believe in what they do. One can reduce dissatisfaction by attending to hygiene factors, but one cannot make people more happy and committed to their work. To achieve that, it is necessary to attend to motivators intrinsic to work, including the nature of the work itself, achievement, recognition, responsibility, and growth.
Work Itself
People need to believe that their work is important and meaningful. If they do not care about what they do, if they view it merely as a means of collecting a paycheck, then they will not perform at their best. One problem with performance-based compensation is the tendency to shift workers’ attention from the intrinsic rewards of the work itself to extrinsic rewards such as salaries and bonuses. As people begin to focus more and more on the system for keeping score, they focus less and less on what they originally set out to do: help provide first-rate health care, teach the next generation of physicians and allied health professionals, and add to our fund of biomedical knowledge. It is important that leaders highlight from time to time the effects of the organization and its workers on the lives of the people—patients and their families—they serve. Anecdotes about how the good work of people in the organization has enriched the lives of others can have a major beneficial effect throughout the organization.
Achievement
Some leaders are cynical. They believe that the people who work in their organization are merely punching a time clock and care very little for the organization and the work it does. Such an attitude can become a self-fulfilling prophecy. A far more accurate and fruitful approach is to assume that people really want to do their jobs well. From this point of view, the leader’s task is to help people find the right positions that make full use of their talents and interests and enable them to keep growing and developing throughout their careers. People want to succeed, and the organization can help them to do so by providing regular feedback on the work they are performing in a way that challenges them to look at things from new points of view and to innovate. Rather than tell a radiologist that he or she must interpret more studies per hour, a good leader will simply provide more feedback on productivity while simultaneously engaging the staff member in discussions on how the organization can operate more efficiently. A focus on productivity can prove highly counterproductive, however, if it ever leads to a neglect of quality. People may become rapidly disenchanted if they believe that quality is being sacrificed for the sake an enhanced bottom line.
Recognition
The most important source of job satisfaction and motivation is internal, yet every person defines and appraises what he or she does in part through how others see it; recognition is an important component in addressing this need. Praise can be worth far more than dollars, particularly when dealing with people who approach their work from the perspective of a professional, such as a physician or nurse. This is not to say that people will be happy being underpaid as long as you heap praise on them—there is no question that compensation is an important component of hygiene that must be attended to in order to avoid dissatisfaction. Yet praise ultimately means more, because it speaks directly to the person as a professional and what their work means to themselves, their colleagues, and the people their organization serves. A good leader looks for opportunities to recognize workers for a job well done. Beware, though, such well-intentioned efforts as employee-of-the-month programs: These programs quickly lose their motivational value as the award is simply passed around the organization month by month. A well-crafted note of praise is worth far more.
For many, recognition may come from the respect and trust shown by referring physicians who seek out a particular physician for the expertise and the rapport they enjoy with that person. In an academic department, every faculty member should be able to find some niche where he or she is the local expert. Younger faculty members may benefit from advice and encouragement in developing good relationships with clinical colleagues.
Responsibility
There are two concepts in the field of organization behavior that bear definition (2). Ownership is a state of belief in and commitment to the task. This is most likely to occur when employees are participants in the decision-making process and believe that what they are doing is important. Empowerment describes the concept of delegating to an employee or an associate authority over the work process, such as the responsibility for fixing obvious inefficiencies without seeking support from superiors.
Herzberg emphasizes giving employees ownership of their work. The way not to do this is what he calls "horizontal loading," an approach that actually reduces workers’ contributions rather than helps them grow by means of their job (3). Examples of horizontal loading include increases in meaningless production targets, addition of another meaningless task to the work the person already performs, rotation of assignments between different meaningless positions, and removal of responsibilities so that a person can concentrate efforts on less-challenging aspects of an already meaningless job. "Vertical loading," in contrast, involves removing some controls while accountability is retained, giving a person responsibility for a natural unit of work such as a section or work area, making performance reports directly available to the worker, introducing new and more challenging assignments, and enabling individuals to develop expertise. The way to enhance motivation is to make the job—and, ultimately, the mission it represents—an important part of the person.
Growth
People need to feel challenged by the work they perform—challenged in ways that help them grow as a professional and as a person. Medicine provides a marvelous opportunity to develop some of the most important human virtues, such as courage, honesty, compassion, intelligence, and wisdom. It is vital that situations in which such virtues are drawn on not be managed out of the organization. For example, in the name of increasing patient throughput, some radiology departments have reduced to the greatest possible extent the interaction between radiologists and the people they serve, such as patients and referring physicians. In the short term, more radiologic images may be interpreted, but in the long term staff may find their work lives less challenging and less fulfilling. One dependable way to enhance opportunities for personal and professional growth is education, and all organizations should make substantial investments in the ongoing education of their workers.
APPLICATION
How should the chairman respond to the problem of the poorly productive faculty member of the opening scenario? The goad technique of forcing the individual to increase productivity is unlikely to succeed for several reasons. First, the use of force is only temporarily effective, and the individual being forced quickly develops a tolerance for the level of stimulus being applied. To remain effective, the aversive stimulus must be applied again and again, and the level of stimulation must be gradually increased to produce the same effect. A second problem centers on the self-identity of the individual being prodded. Particularly for individuals with high self-esteem, castigation is hurtful and quickly becomes counterproductive as the individual looks for ways to deflect the criticism or even to retaliate. Finally, to treat a colleague in such a fashion is, in a deep sense, to treat that person as though he or she were a mere production line worker who can "turn up" or "turn down" the rate of production at will. If, for example, the problem seems to be that the faculty member spends too little time in the reading room, a better approach would be to say, "I notice you are spending less time in the reading room these days. Is there a reason for that? Is there anything we can do to make it a more comfortable and efficient environment?"
The idea of implementing a performance-based compensation system is also fraught with potential difficulties. First, as already noted, this approach tends to redirect workers’ attention to the rewards they are receiving for working quickly and away from the quality of their work. Second, the "carrot" suffers from many of the same habituation problems as the "stick"—to achieve the same effect, larger and larger rewards are necessary. People soon come to depend on extra financial rewards for their performance, and if those rewards are ever withdrawn they experience that withdrawal as a punishment. Third, if Herzberg (3) is correct, financial rewards simply will not work unless the individual believes he or she is underpaid. One could, of course, simply pay radiologists piecemeal, on a per-case basis, but then professionalism itself is endangered. A radiologist being paid for every image interpreted may be less willing to provide excellent consultative service and may face important conflicts of interests in the area of self-referral.
Despite the difficulties of these two approaches, the alternative of doing nothing may be even worse. Doing nothing is all too easy, because the chairman is spared the unpleasant necessity of confronting a senior colleague and because little or no effort is needed. Perceived inequities must be addressed. The point of departure for the chairman should be to determine whether such perceptions are, in fact, warranted. Sometimes, simply talking with the parties involved reveals misperceptions that can easily be corrected. When problems turn out to be real, steps should be taken to resolve them. For example, the senior faculty member might be invited to participate in a team to evaluate productivity throughout the organization and make recommendations for improvements. Placement of a problematic individual on a team charged with finding solutions sometimes produces dramatic results. In other cases, career counseling may be called for, but such efforts should always focus first on developing opportunities to enrich the work itself.
In this case, when the chairman investigated the matter further she discovered that the faculty member in question was in fact not doing less work than his colleagues. The apparent productivity deficit was composed of two misleading factors. First, the faculty member was doing more low relative-value-unit work (eg, interpreting conventional radiographs and performing fluoroscopy) than his junior colleagues, and this made his productivity appear to be lower. In fact, after intermittently observing the section’s workflow for a week, the chairman determined that the senior faculty member was actually logging more hours of work than the others. Second, the senior faculty member had assumed the lion’s share of medical student and resident teaching for the section, which simply did not show up in the section’s clinically based productivity data. Both student and resident evaluations showed that the senior faculty member was by far the most highly regarded educator in the section. In both cases, the senior faculty member had assumed low relative-value-unit responsibilities virtually by default. When these factors were pointed out to the more junior section members, perceptions of inequity vanished.
What if our ending had not been so happy? What if the individual truly was performing below reasonable expectations? Few if any truly indolent people ever reach such levels of achievement, and it was unlikely that the senior faculty member was simply lazy. Perhaps the individual was depressed or undergoing a personal or family crisis distracting him from his work. Perhaps he desired to switch to part-time but was too proud to ask. Such issues could be elucidated through a concerned and compassionate dialogue.
Management theory could suggest many other causes and solutions beyond what we have presented. It was the venerable Adam Smith (4) who introduced the concept of division and specialization of labor. In a nutshell, everyone wins when each is given the opportunity to do what he or she does best. Perhaps the individual in our example was inappropriately assigned. Departments can sometimes be inflexible in tailoring work assignments to a particular individual’s interests and skill sets. An older radiologist may enjoy interpreting conventional radiographs and performing fluoroscopy but feel anxious when working with body magnetic resonance (MR) imaging, and his or her productivity might suffer if forced to perform MR. On the other hand, he or she might have a keen interest in MR imaging and resent being exiled to the "barium kitchen." Good administrators should take an inventory of their human resources by learning the special skills of each and what each most enjoys. Armed with this knowledge, the administrator should attempt, insofar as is possible, to maximize the time each employee spends in his or her area of interest and expertise.
CONCLUSION
Satisfied physicians, nurses, technologists, clerical staff, and administrators are key to providing care that produces a high level of satisfaction for patients, families, and referring physicians. To achieve these objectives, radiology leaders must attend carefully to both hygiene and motivation factors and carefully differentiate between the two. On the hygiene front, if people believe that they work in an unfair or unfriendly place or that their salaries are so low that they are being taken advantage of, such issues should be addressed immediately and effectively. On the other hand, no amount of attention to hygiene factors will motivate people to do a better job. The best one can hope for by attending to those factors is to reduce dissatisfaction to its lowest possible level.
Herzberg’s theory is not the only one to address these issues, but it bears the distinction of having been empirically validated within a professional population (1–3). If Herzberg is correct, radiology leaders seeking to motivate others should look not for ways to prod or entice workers but should endeavor to enrich the nature of work itself. As any truly successful person will attest, it is the intrinsic features of work itself that inspire the highest levels of excellence.
REFERENCES
This article has been cited by other articles:
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  K. Horst and R. B. Gunderman There Is More to Life than Lifestyle Radiology, March 1, 2006; 238(3): 767 - 771. [Full Text] [PDF]
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R. B. Gunderman Understanding and Enhancing Work Performance Radiology, June 1, 2003; 227(3): 623 - 626. [Full Text] [PDF]
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