By Richard Gunderman, MD, PhD, IU School of Medicine
Physician burnout can often be traced to differences in how physicians and their managers view the practice of medicine. Around 1960, industrial psychologist Douglas McGregor developed two contrasting theories of worker motivation that he called theory X and theory Y. Unfortunately, most physicians are theory Y, but many managers see them through the lens of theory X.
  
Theory X presumes that people prefer not to work. Applied to medicine, this means that most physicians would prefer not to come to work in the morning, see patients, formulate diagnoses, prescribe treatments, perform procedures, or generally exert themselves in any way.  If they could, they would opt to remain at home or on vacation and simply collect their paychecks.

Those who view the medical profession through the lens of theory X naturally suppose that the only way to get physicians to work is to manipulate them. Lacking any intrinsic motivation, physicians will only exert themselves if they are threatened with disincentives such as loss of employment or incentivized through bonuses and the like.

In fact, the problem, as theory X sees it, goes deeper still - only if manipulated will physicians do work of sufficient quantity and quality. Lacking intrinsic motivation to care well for or even see patients, they require managers who rigorously define goals, monitor performance, and enforce standards. Good patient care depends utterly on good management.

According to theory X, in other words, physicians are not to be trusted. Left to their own devices, they would slack off, doing less and less work of lower and lower quality. To prevent this, managers must keep them under regular surveillance and react swiftly and decisively every time they succumb to sloth and sloppiness.

Only managers protect patients and the organizations that care for them from physicians’ worst impulses, theory X holds. As a result, managers must be very hands-on, even to the point of micromanaging their medical staff, because as soon as physicians no longer feel their warm breath on the napes of their necks, performance inevitably declines.

In some situations, theory X tends to take a hard turn toward a surveillance state. Physicians practice day to day, even hour to hour, with a dashboard in front of them. It provides unequivocal real-time updates on throughput and quality metrics, warning them promptly if they fail to keep up the pace or fall below quality thresholds.

From the physicians’ point of view, theory X managers are easy to spot. They talk a lot about systematic approaches to workflow, metrics, and extrinsic punishments and rewards. They describe medical practice in behavioristic terms, focusing entirely on what physicians say and do and neglecting any reference to how physicians think and feel about their work.

Theory Y, by contrast, assumes that physicians bear an intrinsic motivation to work and sincerely enjoy caring for patients. Physicians get up and come to work in the morning not primarily because management compels them but because they want to. Caring for patients is an important life mission for them, and they relish the opportunity to make a difference in their patients’ lives.

Not only do physicians enjoy patient care for its own sake, theory Y suggests, but they do it well out of an intrinsic love of excellence. To be sure, they make mistakes from time to time, but they are trying do to what is best for their patients because they genuinely care for them and find fulfillment in helping them to stay healthy, recover from illnesses and injuries, and to the extent possible, thrive.

A theory Y manager does not feel the need to closely supervise physicians or attempt to manipulate their work through punishments and rewards. Because physicians naturally strive to serve their patients’ best interests, the manager’s primary function is simply to ensure that they have the resources necessary to do so. The manager functions not as a taskmaster but a facilitator.

The theory Y manager understands that physicians have their own styles of practice, and that health care organizations are stronger when they offer a diverse array of practice styles to match the diverse array of patients for whom they are caring. A medical staff made up of identical clones or robots, the dream of a theory X manager, could not provide nearly so personalized an approach to care.

A great deal of burnout in medicine can be traced to theory X management of theory Y medical professionals. Physicians are generally better educated and draw on more experience in patient care than their managers, and when managers adopt an authoritarian approach that treats physicians as fundamentally untrustworthy, the results tend to be poor.

Whenever managers begin to act as though dashboards, PowerPoint presentations, and annual reports are the most real things in their organizations, physicians, who operate with the presumption that patients and patient care must always come first, almost necessarily feel discouraged. To avoid such discord, physicians need to play an active role in educating managers and leading themselves.