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Perspectives |
1 From the Education Division, Department of Radiology, Indiana University Medical Center, 702 Barnhill Dr, Rm 1053, Indianapolis, IN 46202-5200. Received October 8, 2002; accepted October 14. Address correspondence to the author (e-mail: rbgunder@iupui.edu).
Index terms: Economics, medical • Radiology and radiologists • Radiology and radiologists, departmental management • Radiology and radiologists, socioeconomic issues
An unemployed existence is a worse negation of life than death itself. Because to live means to have something definite to do—a mission to fulfill—and in the measure in which we avoid setting our life to something, we make it empty.
José Ortega y Gasset (1)
Our radiology departments typically spend millions of dollars building and renovating facilities and purchasing new equipment but relatively little time or effort in developing a better understanding of the people who work in them. This practice overlooks a vital truth: Organizations do nothing. It is not the organization but rather the people who work in it who make things happen. Departments of radiology much more closely resemble systems of government than machines, and they can be only as good as the people they employ. When something important needs to get done, the operative question is not, "What button do I push?" but "With whom do I need to speak?" To understand adequately the nature of radiology departments and why they do what they do, it is necessary to understand the people who work in them. To improve organizational performance, we must understand what makes people tick.
Radiologists need to consider basic questions in human motivation. Are good workers born or made? Why do some people work harder and better than others? Can we predict which job applicants are likely to prove to be the best workers? Are there steps managers and leaders can take to enhance the motivation of the people they work with? What are the most effective motivators? Which is more effective, "carrots" such as salary raises and public praise, or "sticks" such as the threat of termination and reductions in compensation? Can we improve workers’ performance by placing them under tighter control, or is it better to increase their own sense of autonomy and empowerment? Perhaps most important of all, what can each of us do to improve our own motivation? Radiology neglects such questions at its peril.
If the people who work in radiology organizations, particularly the leaders of the organizations, do not understand the people they work with, their performance will suffer. They will experience difficulty recruiting and retaining employees, a prescription for disaster in a time when key personnel such as radiologists, nurses, and technologists are in increasingly short supply. The performance of workers will suffer, and a decrease in the quality of worker performance not only compromises financial performance but may even endanger lives. Finally, workers’ morale and commitment to the success of the organization will suffer, because their needs and aspirations are not being attended to. In each case, failure to understand human motivation hamstrings the organization (2). I will provide an overview of three of the most important 20th-century theories of worker motivation. By examining their own organizations in light of these theories, radiologists can define and implement more effective motivational practices.
X or Y?
One theory that highlights the frequently stark contrast between different approaches to worker motivation is that of Douglas McGregor (3). McGregor argues that two fundamentally divergent approaches to leadership flow from two fundamentally different views of human nature, one negative and one positive. The negative one he refers to as theory X, and the positive one, theory Y. Leaders who favor authoritarian approaches and prefer to work in organizations with a high degree of centralized control tend to make the following theory X assumptions about human nature:
1. The average person dislikes work and attempts to do as little of it as possible.
2. People will work only if they are prodded into doing it through control, coercion, and threats of punishment. Otherwise, they can be expected to show little concern with the achievement of the objectives of the organization.
3. People have little or no ambition and wish to bear as little responsibility as possible. What they do want is security.
It is no surprise that leaders operating on the basis of theory X tend to be highly directive, telling workers what to do and involving them very little if at all in the decision-making process. When a worker asks, "Why do you want me to do that?" the answer is likely to be either, "Because I told you so" or "Because if you don’t, I will punish you." Theory X leaders are not interested in enhancing worker satisfaction and loyalty or helping workers achieve their ambitions, because they assume that they have none. They view the people who work in their organizations more or less as tools: useful as long as they can be made to do what is needed, but eminently expendable as soon as it becomes clear that they are not bending to the will of their superior. If a theory X radiology organization is to succeed in mission-critical tasks such as recruitment and retention, its leaders must either dangle very large carrots, such as exceptionally high rates of compensation, or brandish very big sticks.
Theory Y offers a strong contrast to theory X in that it incorporates the following much more positive assumptions about human nature:
1. Work is as natural to people as play or rest, and, depending on the conditions, people may find their work a source of satisfaction and therefore want to perform it for its own sake.
2. External control and threats are not the only way to get workers to do what the organization needs. When people are committed, they will exercise self-direction and self-control.
3. People can be committed to organizational objectives that contribute to their own self-actualization, at least when they see their own achievement and that of the organization as intimately intertwined.
4. People not only accept but also actively seek responsibility. If people avoid responsibility, display little ambition, and seem concerned only with security, it is generally because their work experience has taught them to do so and not because they were born that way.
5. The capacity to exercise imagination and creativity in the pursuit of the objectives of the organization is widely, not narrowly, distributed.
6. In many organizations, the intellectual capabilities of the average person are only partly engaged.
In contrast to the authoritarian theory X leader, the theory Y leader attempts to create work conditions that match the needs and aspirations of workers with those of the organization. For example, most physicians regard themselves as high achievers, and during their education grew accustomed to receiving recognition for their first-rate performances. Realizing this, a theory Y leader would look for areas of the organization in which each radiologist could make an important contribution for which he or she could earn recognition. A radiologist with a background in computer programming might be given the responsibility and training to help implement a new radiology information system. Another radiologist with strong organizational skills might be asked to design and implement a new faculty orientation and development program intended to help faculty members reach their full potential by acquainting them with institutional resources helpful in their work. An overarching objective would be to involve radiologists in decisions about how their work is targeted, organized, and evaluated, with such decisions always being framed in terms of the larger strategic objectives of the department.
In broad terms, theory X represents a rather cynical view of human nature. It fosters the development of organizations that health professionals, who place a high premium on their own autonomy and self-direction, are likely to find stifling. Theory Y, in contrast, holds that the most effective way to run an organization is to respect and trust the people you work with, and, above all, to work with them. How can leaders and prospective employees tell whether the working environment of an organization more closely follows theory X or theory Y? Ask some simple questions. Do members of the department refer to their leaders by their first names? Do they get together on a regular basis to discuss departmental operations and strategy? Are they working together on projects? Do most members of the organization have special responsibilities in patient care, research, or teaching missions? Do they refer to their work in terms of what they have been told to do or in terms of their own initiative and participation in teams? Do they seem professionally challenged and fulfilled? Theory Y, not theory X, provides the better model for most radiology departments.
Learned Needs
David McClelland postulates that people have three fundamentally different sets of needs, which predominate to different degrees in different individuals (4). He emphasizes that these needs are not inborn but rather developed over time, depending on what sort of environment a person has been exposed to. While everyone has all three sets of needs to one degree or another, the set of needs that predominates in a particular individual can be expected to have a big effect on how he or she approaches work. The following are the three sets of needs:
1. Need for achievement. This is the need everyone has to perform well relative to standards, to feel a sense of accomplishment in what one does, to help resolve problems, and to excel professionally.
2. Need for power. This is the need to influence or control how others behave and to exercise authority over them.
3. Need for affiliation. This is the need to be associated with others, to form and develop warm and friendly relationships with one’s coworkers, and to avoid conflicts.
Of the three sets of needs McClelland describes, the one that has received by far the most attention is the need for achievement. It should come as no surprise to physicians to learn that most of their colleagues feel a relatively high need for achievement. Understanding and tending to this need are a matter of particular importance for leaders in radiology. People with a high need for achievement tend to prefer situations in which they can take personal responsibility for solving problems. If they work in situations in which they have little or no control over what happens, and therefore experience success and failure as though they were arising from chance, such people are likely to become disaffected and lose motivation. Another characteristic of such people is a tendency to set moderately high goals for themselves. They actually want to find projects that require them to exercise their full capabilities. If their position does not provide them with such challenges, they are likely to become bored and disengaged. Finally, such individuals want and need clear feedback on their performance. Their motivation will decline if there are no systems in place to help them assess whether they are achieving their objectives.
A second area of concern is the need for power. This need should be carefully attended to, particularly when selecting leaders and supervisors within the organization. It is important not to equate the need for power with a desire to control other people or simply to be in charge. In its positive sense, the need for power reflects a sincere commitment to the success of the organization and not merely a subterfuge whereby people use the organization as a means to their own self-advancement. People who seek power in the positive sense do so because they recognize that their influence over others can help the organization fulfill its mission. Such people want to have a positive effect on the organization and the people they work with. If the need for power is not attended to in an organization and people see that they have no meaningful influence over its destiny, their need for power will go unfulfilled and they will look elsewhere for opportunities to play a more important role.
The third need, for affiliation, manifests as a desire to be identified with a group and to be well liked by its members. People with a high need for affiliation may place a higher premium on the quality of relationships they enjoy than on their own accomplishments and may prefer developing friendships to augmenting their own power. Such individuals may perform poorly as leaders. They want to be on good terms with everybody. As a result, they are unable to make tough decisions for the good of the organization for fear that they might offend some person or group of people. Discipline, enforcement of rules, and termination of employees are examples of situations that people with a high need for affiliation are likely to find troubling from an emotional point of view. As a result, many such people may find leadership positions frustrating, because they are regularly called upon to engage in activities that they instinctively avoid.
The relationship between the need for achievement and the need for power deserves special attention, particularly with regard to the selection of leaders. People with a high need to achieve, though often the most successful people in a department, may not always provide the best leadership, and radiology leaders should think twice about automatically appointing the best clinical radiologist, researcher, or educator to a position of authority. The success of the organization hinges on responsibility and control at the level of the group, not that of the individual, and this wider diffusion of responsibility and control may not suit some high achievers. In many situations, the more effective leader would be an individual with a high need for control, who naturally thinks in terms of the group and takes responsibility for what happens within it.
Expectancy
Victor Vroom, in a book by Vroom and Jago (5), agrees that needs are extremely important in motivating human behavior but believes that simply understanding what people need is not enough. To gain a complete picture of motivation, we must understand the factors that influence the process of making decisions about how needs will be satisfied. Vroom argues that the following three conditions are those in which this decision making process takes place:
1. People must believe that making an effort will make their desired level of performance more likely. If they believe that they are unlikely to achieve the desired level of performance no matter how hard they try, they are unlikely to make an effort.
2. People must see how achieving that level of performance will help them achieve some concrete goal or award.
3. They must value that goal or outcome.
Vroom adds to the other motivational theories the insight that people often view daily tasks not as ends in themselves but as means to other ends. In other words, goals and achievements are not necessarily directly connected with one another, but they may be separated by a number of intermediate links. He defines expectancy as an individual’s assessment of the probability that his or her efforts will lead to a desired level of performance, while he defines instrumentality as the probability that that desired level of performance will lead to the desired outcomes. Hence, there are at least two levels of outcome: levels of performance and levels of reward. The first level of outcome, the effort to perform, includes such parameters as quantity or quality of work produced, attendance, and creativity. By contrast, second-order outcomes include earning the esteem of co-workers, the praise of supervisors, the ability to structure the work environment, and promotions. If people believe that their first-order outcomes do not contribute substantially to the achievement of their second-order outcomes, they are likely to perform at a lower level.
To expectancy and instrumentality Vroom adds a third factor, valence (5). Valence describes the value that a person attaches to a particular outcome. For example, one individual might be relatively unconcerned about salary, in which case compensation would have a low valence, while for another person salary might be the most important outcome in their work, in which case compensation would have a high valence. Thus, a person could be absolutely certain that making a bigger effort would improve the quality of his or her work (expectancy = 1.0) and that improved quality would increase his or her compensation (instrumentality = 1.0), yet care very little about achieving a raise (valence = 0.1). Because the three factors are multiplicative, a lower value assigned to any one of the three factors leads to a low overall level of motivation. Leaders need to attend to all three factors if they are to help develop a work environment that fosters a high level of motivation.
The key for leaders is to determine what second-order outcomes really motivate their employees. If the thing that motivates a group of radiologists most is their compensation package, then an effective leader must find ways to enable them to augment their incomes by producing a greater quantity or quality of work. Conversely, if the thing that motivates a group of radiologists most is the desire to make a substantial contribution to the care of patients, then leaders must find ways to enable the radiologists to see directly the fruits of their patient care efforts. Alternatively, some radiologists may place an especially high premium on expanding the envelope of radiologic knowledge through research. Others may prize most highly the opportunity to educate the next generation of radiologists. Still others may find opportunities to make administrative contributions of greatest personal value. The key for radiologists is to understand the people they are working with.
As McClelland indicates, however, these aspirations are probably not set in stone and may be subject to environmental influence (4). Hence, leaders should attend not only to what workers expect today but also to the expectations prospective employees bring with them and to how everyone’s expectations are shaped in the future. These considerations will vary depending on the nature of the organization itself. For example, in an academic department, it might be unwise to position compensation as the top second-order outcome for fear that other academic missions such as research and education would soon be regarded as sources of inefficiency. In such a situation, the academic organization would either need to sustain lower-revenue–generating missions such as teaching at the risk of losing workers to higher paying clinical practices or abandon such missions for the sake of generating even greater clinical revenues. In a practice situation specifically adapted to maximize income, in contrast, such considerations would not apply, and members could focus their full attention on eliminating inefficiencies and maximizing throughput.
A final consideration flows from the fact that all persons in an organization do not necessarily share the same preferences regarding the rewards of work. The assumption that everyone is the same can prove disastrous. This is particularly true if new programs that appeal to the motivations of only a small number of people are applied across the board, as though everyone looked at work in that same way. For example, if an academic department decides to reorganize itself to maximize clinical revenues and that reorganization makes it increasingly difficult for faculty members who love to teach to find the time necessary to do so, then the educational mission of the department is likely to suffer and educationally motivated faculty members may choose to leave. The consequences of such decisions may take some time to fully emerge. Years might elapse before it became apparent that such a change in organizational philosophy was stimulating more residents to choose careers in private practice and contributing to a shortage of academic radiologists. Therefore, leaders need to attempt to anticipate the long-term effects of their policies by adopting a longer term strategic perspective.
Conclusion
There is no single universally accepted theory of human motivation. Moreover, the three theories presented here barely scratch the surface of what is known. People and organizations are highly complex entities, and any effort to reduce their motivations to a handful of factors is bound to produce some gaps and distortions. Yet this is no excuse for neglecting the subject. Leaders in radiology need to be scientifically knowledgeable and technically savvy, but they must also be people-wise. The most important ingredient in the recipe for success is people. Leaders must carefully evaluate who works in the organization, what working conditions the organization provides, and how these two factors interact with motivational factors to enhance or undermine the mission of the organization. Do people have the ability to do what they need to do? Does the organization provide the resources people need to get the job done right? How well do motivational factors mesh with abilities and resources to make the organization a success? By understanding what makes people tick, leaders can do a better job of making their organizations hum.
REFERENCES
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  P. Karamoskos and R. Gunderman Knowledge Work, Motivation, and Why Karl Marx Would Be Happy [letter] * Dr Gunderman responds: Radiology, March 1, 2004; 230(3): 888 - 888. [Full Text] [PDF]
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