Measuring the Attending Job

This lesson comes from Clayton Christensen’s How Will You Measure Your Life.

Christensen references Frederick Herzberg’s “motivation-hygiene theory” of satisfaction. The argument is that there are two different types of job factors: hygiene and motivation.

Motivation factors stem from the intrinsic character of the work itself: challenge, recognition, personal responsibility, meaningful impact, involvement in decision-making, feeling valued.

Hygiene factors stem from extrinsic factors of how the work is done:

Hygiene factors are things like status, compensation, job security, work conditions, company policies, and supervisory practices. You need to get it right. But all you can aspire to is that employees will not be mad at each other and the company because of compensation.

The crux is that these categories are independent. Motivation factors drive job satisfaction, but the absence of hygiene factors causes dissatisfaction.

As in, hygiene doesn’t really make you happy, but it can definitely make you unhappy.

If you instantly improve the hygiene factors of your job, you’re not going to suddenly love it. At best, you just won’t hate it anymore. The opposite of job dissatisfaction isn’t job satisfaction, but rather an absence of job dissatisfaction.

Most discussion of the physician job market, particularly on social media, is exclusively focused on hygiene factors.

But I think this actually belies a sadder trend: many doctors now assume a low motivation environment, so hygiene seems like the only differentiating factor. Perhaps it should be no surprise that we are riding a wave of mass quitting in the workforce. In my field of radiology, a 2020 study showed that 41% of radiologists had changed jobs in the past 4 years.

The theory of motivation suggests you need to ask yourself a different set of questions than most of us are used to asking. Is this work meaningful to me? Is this job going to give me a chance to develop? Am I going to learn new things? Will I have an opportunity for recognition and achievement? Am I going to be given responsibility? These are the things that will truly motivate you. Once you get this right, the more measurable aspects of your job will fade in importance.

The Wikipedia article I linked to above breaks down the two-factor theory into four combinations:

1. High Hygiene + High Motivation: The ideal situation where employees are highly motivated and have few complaints.

2. High Hygiene + Low Motivation: Employees have few complaints but are not highly motivated. The job is viewed as a paycheck.

3. Low Hygiene + High Motivation: Employees are motivated but have a lot of complaints. A situation where the job is exciting and challenging but salaries and work conditions are not up to par.

4. Low Hygiene + Low Motivation: This is the worst situation where employees are not motivated and have many complaints.

Despite the fact that physicians are generally well-compensated compared to most other professions, I would argue that the ideal combination is rare. Most job conversation seems to fall on combinations 2-4.

See if these look familiar when rephrased:

• High Hygiene + Low Motivation: Employed position in a relatively physician-friendly corporatized job market. Pay/work balance is good but lack of autonomy and control makes it a clock-punching endeavor.
• Low Hygiene + High Motivation: Employed position in an understaffed or relatively resource-depleted environment. Many academic centers fall into this category, where more and more is being asked of physicians who believe in the academic mission, and the reward for being motivated and hard-working is more unpaid work and extra administrative responsibility. Thanks to budgetary gerrymandering, everyone is somehow always losing money. The institution doesn’t love you back, and this explains the revolving door in so many academic departments.
• Low Hygiene + Low Motivation: Underpaid and underappreciated is a truly toxic combination. This is what happens, for example, in the private equity death spiral. It’s also what happens when large systems would rather replace physicians with midlevel providers when competitive physician salaries are deemed too expensive for the bottom line. A job where you’re not just a cog–a warm body capable of producing RVUs–but also one that isn’t even valued.

In real life, both of these characteristics fall on spectrums as opposed to a binary high/low. And, I suspect individuals also fall on a continuum for how much motivation is necessary to feel professionally fulfilled.

It may not be possible to find a high/high job in every market, but it is important to consider both factors in the job-hunting process.

If you’re looking to build a true career and not just find a job, then you can’t ignore motivation. The beauty of being a physician is that the job itself often carries some high-motivation characteristics merely through the act of patient care.

But low hygiene–particularly bad work conditions, culture, and supervisory practices–can make what should be a good job unredeemable. Think hard about how different hygiene factors affect your degree of dissatisfaction and avoid accordingly.