Motivational patterns of administrators, physicians, and chiefs-of-service in a variably structured health maintenance organization

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Content MOTIVATIONAL PATTERNS OF ADMINISTRATORS, PHYSICIANS,
AND CHIEFS-OF-SERVICE IN A VARIABLY STRUCTURED
HEALTH MAINTENANCE ORGANIZATION
by
Honore Lynn Newman
A Dissertation Presented to the
FACULTY OF THE GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PHILOSOPHY
(Business Administration)
December 1991
Copyright 1991 Honore Lynn Newman
UMI Number: DP23468
All rights reserved
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UNIVERSITY OF SOUTHERN CALIFORNIA
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This dissertation, written by
under the direction of h..&r....... Dissertation
Committee, and approved by all its members,
has been presented to and accepted by The
Graduate School, in partial fulfillment of re
quirements for the degree of
Lorn
N SSZ
DOCTOR OF PHILOSOPHY
Dean of Graduate Studies
Date October^3A 1991
DISSERTATION COMMITTEE
ACKNOWLEDGEMENTS
I am deeply grateful to those who have supported me throughout the
pursuit of the Ph.D degree. Without these faculty, family and friends, the
completion of the doctoral program would have been a more difficult and less
rewarding experience.
My sincere thanks go to the faculty and members of my thesis
committee for their ongoing encouragement and scholarly guidance. I want
to thank in particular the following scholars because their special insights
have influenced my approach to this field of study: to Fred Maserik and Ian
Mitroff, for their blending of multiple perspectives and wholistic views; to
Mary Ann Von Glinow and Tom Cummings for their steady support and
tough-minded perspectives at critical times; to Morgan McCall for his drive to
make research relevant and practice responsible; to John Davis, who has been
an empowering teacher and mentor; to Dennis Hosevar for his statistical
expertise and timely critiques of my dissertation work in progress; to Jim
O’Toole for his respect of doctoral education and inspiration to write; and to
John Miner, for his views of organizations from both sociological and
psychodynamic perspectives, and especially for his willingness to consult with
me from another coast.
I am grateful for the generous assistance of Irwin Goldstein, A1 Bolden
and Dick Barnaby in providing the research site for this work; special thanks
ii
as well to the many administrators and physicians who participated in the
study.
My personal appreciations are first and foremost to my mother, for
choosing a difficult journey and providing me with much inspiration through
the example of her own life. Most importantly, she has helped me to see that
the next generation should always achieve more.
Thanks and much affection go also to my very closest friends--Jean,
Darryl, Vicki, Joyce, Barbara and David-for encouraging me to break
through self-imposed limits and to trust in my own process. They have been
there when I’ ve needed them.
Finally, this is for Michael. I want to leave a legacy to you of love,
achievement and success.
iii
TABLE OF CONTENTS
PAGE
ACKNOWLEDGEMENTS....................................................................................... ii
LIST OF T A B L E S......................................................................................................... vi
ABSTRACT................................................................................................................... viii
CHAPTER 1 INTRODUCTION AND REVIEW OF THE LITERATURE . . 1
Purpose of the S tu d y.............................................................................1
Characteristics of Professionals.........................................................4
Professional vs. Bureaucratic Orientation .....................................7
Role Motivation Theories .................................................................13
Characteristics of Professional Organizations ................. 21
Oliver Organization Description Questionnaire .........................26
Physician E xecutives.......................................................................... 30
Research H ypotheses.......................................................................... 37
CHAPTER 2 PROCEDURE AND METHODOLOGY........................................40
Procedure ............................................................................................ 40
S a m p le ................................................................................................... 41
Administrators ........................................................................41
Physicians..................................................................................44
Chiefs-of-Service..................................................................... 48
M ethodology......................................................................................... 55
Instruments............................................................................... 55
Demographic Data Form .................................................... 55
Oliver Organization Description
Questionnaire (OODQ) ......................... 56
Miner Sentence Completion Scale Form H ....................57
Miner Sentence Completion Scale Form P ...................... 58
Satisfaction With W o r k ......................................................... 59
Role Ambiguity and Role C onflict..................................... 60
Data A n a ly sis.......................................................................... 61
iv
PAGE
CHAPTER 3 R ESU LTS.............................................................................................. 66
Hypothesis 1 ..........................................................................................66
Hypothesis 2 ......................................................................................... 68
Hypothesis 3 ..........................................................................................70
Hypothesis 4 ......................................................................................... 72
Hypothesis 5 ..........................................................................................74
Hypothesis 6 ......................................................................................... 79
Hypothesis 7 ..........................................................................................80
Hypothesis 8 ......................................................................................... 83
CHAPTER 4 DISCUSSION, IMPLICATIONS, CONCLUSION ....................89
O verview.................................................................................................89
D iscussion.............................................................................................. 92
Administrators ........................................................................ 92
The Medical System-Practicing Physicians and
Chiefs-of-Service......................................................... 96
Chiefs-of-Service . ...............................................................102
Implications for HMO Management ...........................................106
Implications for Future Research ................................................112
Conclusions..........................................................................................114
REFERENCES ........................................................................................................... 117
A PPEN D IC ES..............................................................................................................128
V
LIST OF TABLES
TABLE
1 Organization Scores and Classification in
Oliver Sample of Organizations (1982)
2 Subsample Means from the Oliver Sample of
Organizations (1982)
3 Frequencies of Demographic Variables
Reported in Percentages for Administrator
Group
4 Frequencies of Demographic Variables
Reported in Percentages for the Physician
Group
5 Frequencies of Demographic Variables
Reported in Percentages for the Chief-of-
Service Group
6 Comparison of Group Means for the
Administrator Group on the OODQ
7 Comparison of Hierarchic to Professional
Motivation for the Administrator Group
8 Pearson Product-Moment Correlations
Between Hierarchic and Professional
Motivation and Satisfaction with Work, Role
Conflict and Role Ambiguity for the
Administrator Group
9 Comparison of Group Means for the
Physician and Chief-of-Service Groups on the
OODQ
10 Comparison of Hierarchic to Professional
Motivation for the Physician and Chief-of-
Service Groups
PAGE
28
29
42
45
49
67
69
71
73
75
vi
TABLE PAGE
11 T-tests Between Physician and Chief-of-
Service Groups on Hierarchic and
Professional Motivation
77
12 Significant T-tests Between Physician and
Chief-of-Service Groups on Subscales for
Hierarchic and Professional Motivation
78
13 Pearson Product-Moment Correlations
Between Professional Motivation and
Satisfaction with Work, Role Conflict, and
Role Ambiguity for Combined Physician and
Chief-of-Service Group
81
14 T-tests Between Chiefs-of-Service with and
without Elevated Professional Motivation on
Variables of Satisfaction With Work, Role
Conflict, and Role Ambiguity
82
15 T-tests between Chief-of-Service Choice and
No-Choice Groups with H and P Motivation,
Satisfaction with Work, Role Conflict and
Role Ambiguity
84
16 Comparison of Chief-of-Service Choice and
No-Choice Groups with Desire to Remain in
a Medical Management Role in the Future
using Chi-Square Test
86
17 Comparison of Chief-of-Service Choice and
No-Choice Groups with Age using the Chi-
Square Test
87
vii
ABSTRACT
This study examined the motivational patterns of administrators,
physicians and chiefs-of-service within a large, complexly structured Health
Maintenance Organization (HMO) in the Western United States. The
structural characteristics of the medical care setting were investigated and
found to vary between the administrative and medical delivery structures of
the HMO. It was hypothesized that those subjects with motivational patterns
which matched the structural characteristics of their respective system would
report greater satisfaction with work and less role stress than those subjects
with motivational characteristics which differed from the system type in which
they worked. John Miner’s hierarchic and professional role motivation
theories were used to explore these hypotheses.
Within the administrative system, a mixed, semi-hierarchic and
professional motivation pattern was found most prevalently amongst
administrative subjects, matching the system type identified by the
administrative subject group. This matched motivation pattern was not found
to correlate in the expected direction with satisfaction with work and role
stress. Professional motivation for this group was found to correlate positively
with satisfaction with work.
Within the medical system, partial support for the predicted motivation
pattern was found: a mixed, hierarchic and professional motivation pattern
viii
was found to be most elevated and predominant for both physician and
chief-of-service groups. Where one predominated, it was more often the
professional than the hierarchic. The chief-of-service group was also expected
to be higher on both hierarchic and professional motivation than their
practicing physician counterparts. Results indicated no difference between
the groups on professional motivation, but the chiefs-of-service were found to
be significantly more hierarchically motivated than the practicing physicians.
The chiefs-of-service who were identified as being more professionally
motivated were also found to be significantly more satisfied with their work.
A focal aspect of the study related to the chief-of-service subject
group-both by way of comparison of motivational dynamics with the lay
administrators and practicing physicians, and with respect to the chiefs
motivational dynamic upon entering medical management. Those chiefs who
indicated that they had made a deliberate choice to enter medical
management were contrasted with those who described their entry as being
influenced more heavily by other factors.
The choice to enter medical management was not found to be related
to higher levels of hierarchic or professional motivation or to satisfaction with
work. A "choice"to enter medical management was found to be signifcantly
related to chief-of-service desire to remain in medical management in the
future. This was an important finding given that only 41% of the
ix
chiefs-of-service in this sample perceived their entry into their management
role to have been through a deliberate choice on their part. There was also
some indication that those chiefs-of-service under 40 years of age are making
a choice to enter management more often than those in the over 40 year old
group in this HMO practice setting.
Another important and possibly related finding from the study was
with regard to the professional identity of the chief-of-service. The
chiefs-of-service perceived their professional identity to be most strongly that
of the practicing physician, rather than an administrator or manager. This
was in contrast to the general perception reported by the physician group,
which viewed the chief-of-service as primarily an administrator.
The implications of the findings are discussed, as they relate to
management of the medical group practice system and to research in such
settings. The findings suggest that it is because of the HMO structural
deviations from more classic bureaucratic and professional systems that some
of the research hypotheses were not supported. It is noted that our research
today needs to be carried out by institutional setting to be valid, as medicine
has become inextricably tied to the characteristics of the complex
organizations in which patient care is taking place.
CHAPTER ONE
Introduction and Review of the Literature
Purpose of the Study
Today we are witnessing a major occupational transition as the last of
the autonomous professions, medicine, becomes a group enterprise. The
solo fee-for-service practice of medicine has given way to a virtual medical
industrial complex (Reiman, 1980; Wohl, 1984). In the past decade
alternative health care delivery systems have emerged as prepayment
requirements have changed, employers have sought less expensive health
care, the supply of physicians has grown, and consumer attitudes have
shifted. How to manage managed care is now a critically important issue as
the field of medicine and health care delivery become organizationally based
on a broad scale. Both the technical and institutional nature of medical
work has become increasingly complex and differentiated. Research
therefore needs to be carried out by institutional setting to be valid (Light
and Levine, 1989).
Currently, more than half of all physicians work in some kind of
group practice, and most common of these is the health maintenance
1
organization (HMO). An HMO is an organization that integrates the
delivery and financing of health care services. HMO’s have been leaders
amongst the alternative health care providers in containing costs. In the
past five years, the number of patients enrolled in HMO’s has doubled to
32 million (Gibbs, 1989). It is within the HMO setting that this study will be
focused.
The physician working within an HMO is a professional and a
salaried employee, serving the interests of the patient and the organization.
As a result, questions concerning the impact of corporatization on physician
professionalism and satisfaction are increasingly raised today. Some believe
the traditional emphasis on autonomy and independence makes American
physicians ill-prepared to enter the organizational structures of the modern
industrial world (Rueschemeyer, 1986). Others contend that an increased
sense of autonomy and lessened role stress actually result from a more
bureaucratic and formalized institutional setting (Engel, 1969; Podsakoff
et al., 1986).
Though the trend is toward salaried employment for physicians in
group-based practices, other professional groups have been studied for
decades as they have become employees and managers within large-scale
organizations (Goss, 1963; Blau and Scott, 1962; Hall, 1968; Sorensen and
2
Sorensen, 1974; Raelin, 1985). In most research o f this sort, engineers and
scientists have been studied.
It is clear that the physician in a large organization setting is now in a
position, as never before, to change career focus and to enter a medical
management role. Indeed, the changes we are witnessing in the health care
environment have served as a major impetus for the rapid development of
the role of the physician executive. Currently there is a shortage of
appropriately trained physician executives and this is believed to be one of
the limiting factors in the growth of the managed care industry (Nash, 1990).
A physician’s choice to enter medical management is a choice in
effect to change career. In making a career shift of this kind, a physician’s
professional role orientation is likely to conflict with managerial role
requirements, as the motivational patterns which underlie effective
functioning in each role are likely to differ. As a professional, the
physician’s motivations are expected to be to provide quality care and expert
advice to patients. As an employee of a large organization or as a physician
manager, the physician’s motivations are generally required to be more
organizationally focused and hierarchic in nature.
In this study the system type of the administrative hierarchy and
medical group practice systems within the HMO will be identified. The
HMO structurally can be described as a professional bureaucracy
3
(Mintzberg, 1981) and as such, is variably structured. How much of a
hierarchic or bureaucratic overlay has combined with the predictably
professional medical group practice, and conversely, how hierarchic and
professional the administrative system has become will be determined.
The motivational patterns of HMO administrators, physicians and
chiefs-of-service will then be examined; they are expected to differ
predictably in terms of the system’s variable structures. The potential
conflict between hierarchic and professional orientations is believed likely to
affect the work satisfaction and role stress of the three subject groups.
Finally, the choice to enter management for the chief-of-service will be
examined with respect to the factors motivating such a career shift from
practitioner to manager.
Characteristics of Professionals
As medicine becomes bureaucratized on a wide scale, we are more
and more applying our notions regarding professionals to the physician
context. For the last three decades, authors have attempted to clarify the
elements of a profession, or the individual characteristics of the professional.
Hall (1968) distinguished between professional attributes which are
structural from those which are attitudinal. Structural attributes include the
levels of educational and certification requirements for the occupation and
its professional associations. Occupations vary on the occupational
4
dimension, with engineering and accounting considered less professional
than science, law and medicine. In this regard, engineers and accountants
have been considered quasi-professional; as such, they are expected to be
more dependent upon and more interested in their organizations than pure
professionals, who remain strictly loyal to their profession (Barber, 1963;
Kerr et al., 1977). Attitudinal professional attributes, on the other hand,
include the individual’s sense of calling to the field and the extent to which
he uses colleagues as his major work reference. These attitudes and
behaviors of individuals constitute an entirely different kind of criterion than
the (structural) attributes of the occupation (Friedson, 1970).
Barber (1963) delineated four essential attributes which induce
professional behavior: a high degree of generalized and systematic
knowledge, primary orientation to community rather than self interest, an
internalized code of ethics leading to a high degree of self control, and
rewards which symbolize work achievement.
Many writers have defined a professional by identifying the criteria
essential for professional status (Wilensky, 1964; Vollmer and Mills, 1966;
Hall, 1968; Berg, 1983). Others have reviewed the literature and presented
characteristics of ideal professionals which have been commonly and
consistently used as criteria for defining a profession. The following
5
characteristics of individual professionals are presented by Kerr, Von Glinow
and Schriesheim (1977):
EXPERTISE, normally stemming from prolonged specialized
training in a body of abstract knowledge;
• AUTONOMY, a perceived right to make choices which concern
both means and ends;
COMMITMENT to work and the profession;
IDENTIFICATION with the profession and fellow
professionals;
ETHICS, a felt obligation to render service without concern
for self-interest and without becoming emotionally involved
with the client; and
COLLEGIAL MAINTENANCE OF STANDARDS, a perceived
commitment to help police the conduct of fellow professionals.
As Berg (1983) and others have discussed, any author’s particular list
is somewhat arbitrary in the selection, interpretation and magnitude of the
criteria deemed essential for professional status. It is also important to note
that the use of strict criteria is not adequate in viewing a profession because
professions are continuously in flux (Bucher and Stelling, 1977).
Professional vs. Bureaucratic Orientation
At the individual level there are some who do not possess
professional attributes who are in an accepted professional occupation
(Ritzer, 1972; Raelin, 1984). Just as occupations vary in terms of their
structural attributes, within an occupation, individuals vary as to their
conformity to attitudinal characteristics. For this reason, Kerr et al. (1977)
caution against arbitrarily selecting occupations for research and assuming
all members of the occupation to be professionally oriented. Individual
differences amongst professionals may vary considerably.
Gouldner (1957, 1958), in a classic study, conceptualized individual
variations of professionalism with the cosmopolitan-local construct.
Cosmopolitan professionals in organizations epitomize the professional
characteristics discussed above. They are committed to the profession and
not the organization, and respond to authority based upon professional
expertise as opposed to organization-based authority. Accordingly,
cosmopolitans are assumed to face particular problems in their socialization
within organizations. Highly professionalized employees have been found to
resist the influence of certain types of hierarchical leadership (Presthus,
1978; Ford, 1981; Howell and Dorfman, 1986). They are viewed as not
amenable to conventional bureaucratic control systems, which emphasize a
management culture concerned with company loyalty, financial soundness,
7
hierarchical control and growth (Ford, 1981; Raelin, 1985; Von Glinow,
1988). Locals are at the opposite end of the continuum. Gouldner believed
locals to be loyal to the organization, and more integrated and identified
with it. Essentially, then, cosmopolitans are pure professionals, and
managers, or those professionals more identified with the organization, are
locals.
Following Gouldner, researchers have found professionalism is not a
continuum, but a multi-dimensional property. Glaser (1963) identified the
local-cosmopolitan, the professional committed to both profession and
organization. Kornhauser (1962) also suggested that professionals can have
hybrid orientations combining both cosmopolitan and local properties. The
issue here is the relative commitment of professionals to profession and/or
organization, and the conflicts that may result. Because of a professional’s
training to adhere to professional principles, essentially this conflict is
between professional and organizational role requirements. Is one at the
expense of the other? D o professional and organizational identifications co
exist for some professionals, as has been suggested?
A professional’s orientation may be influenced by a variety of factors.
For instance, age and tenure have been found to accompany decreased
professional orientation and increased organizational orientation (Connor
and Scott, 1974; Kerr et al., 1977). This may be a relevant consideration in
8
the present study, given that physicians in management are likely to be older
as a group than practicing physicians (having spent time in clinical practice
prior to assuming a medical management position). What are the
orientations— professional and organizational— of physician executives within a
large HMO setting? D o they differ from those of practicing physicians?
Rotondi (1975) noted that organizational orientation occurred at the
expense of professional orientation. Similarly, Corwin (1961), in a study of
several hundred nurses and student nurses, found that professional and
bureaucratic roles conflicted. Corwin found that those who subscribed to
both roles simultaneously indicated that they were less able to carry out
their ideal roles in practice than those who subscribed to one predominant
role.
Sorensen and Sorensen (1974) discovered increases in bureaucratic
orientation and decreases in professional orientation from lower to higher
positions in an accounting firm. One explanation they discussed for the
decrement in professional deprivation at higher levels is modification of
original orientation-a downward revision of professional expectations with
higher rank, or perhaps opportunities to realize professional ideals increase
with rank. Sorensen and Sorensen concluded, "Part of the professional’s
problem seems to be adapting to the hybrid professional-bureaucratic
orientation (of the accounting organization), especially when bureaucratic
9
orientation is low." Their study highlights the inconsistencies between
professional and bureaucratic role expectations that pervade the roles of a
professional in a large, bureaucratic organization, and the resulting conflicts.
In a more recent study, Raelin (1985) identified role conflict as the
principal cause of deviant behavior amongst salaried cosmopolitan
professionals. Cosmopolitan professionals were found likely to experience
the six sources of role conflict, in alignment with the six characteristics of
professionals identified above by Kerr et al. (1977): expertise, autonomy,
commitment, professional identification, ethics and collegial maintenance of
standards. As Raelin states, "Conflicting expectations arise when the goals
and values of management do not match the goals and values of
professionals, who though employees, perceive themselves first as
professionals." Raelin (1985) noted specifically that for the cosmopolitan
professional, being put in a management role contributes to role conflict and
deviance behavior. Raelin concluded: "The professional does not want to
supervise and does so only when it becomes obvious to them that it is the
only way to earn more money and/or status."
In what is a central debate, others have taken positions counter to
those outlined above. Goldberg (1976) found evidence that even the
cosmopolitan professional may, at the high point of his career, turn toward
the organization for the purpose of "developing an organization around
himself (empire building)" or may become more involved in the basic
operation of the organization. Similarly, Glaser (1963) deduced that
cosmopolitan and local orientations may be fused by combining them with
institutional motivation. The professional, for Glaser, was able to
comprehend the congruence between the employer’s means and the ends of
professional endeavor.
Critical to the issue of professional versus bureaucratic orientation or
motivation is the conflict that is assumed to arise for the individual from
inconsistent role expectations of a single position. Role theory has been
used to describe the stresses involved in such situations. An abundant
literature investigating the relationship between role perceptions and work-
related attitudes and behaviors has developed over the past few decades.
Role conflict and role ambiguity are specific forms of role stress which have
been investigated and linked to dysfunctional work-related variables such as
job-related tension, job dissatisfaction, propensity to leave, turnover, anxiety
and lower job performance (Kahn et al., 1964; Rizzo, House and Lirtzman,
1970; Manning, Ismail and Sherwood, 1981; Fisher and Gitelson, 1983;
Jackson, Zedeck, Lyness and Moses, 1983). The strongest documented
outcomes of role conflict and role ambiguity are job dissatisfaction and job-
related tension (Rizzo et al., 1970; House and Rizzo, 1972; Beehr, Walsh
and Taber, 1976; Miles, 1976; Oliver and Brief, 1977-78; Brief, Aldag, Van
11
Sell and Melone, 1979). Scalzi (1984) found higher role conflict and
ambiguity associated with increased depression and decreased job
satisfaction among top level nursing administrators.
Role conflict and role ambiguity are likely to be experienced by a
physician practicing in a service provider role who must conform to a mixed
professional and bureaucratic orientation in a large group practice HMO.
For a physician executive it is likely to exist as well, requiring the physician
executive to integrate disparate professional and managerial role
requirements. The physician executive is expected to act toward other
physicians in the HMO as a colleague in service of professional ends; in the
organizational setting, however, the physician executive is expected to fulfill
managerial and organizational role requirements.
In addition to the likelihood of role stress, previous studies have
indicated that physicians experience dissatisfaction with various aspects of
their jobs in organizations (Ben-David, 1958; McElrath, 1961; Mechanic,
1975; Demlo, 1975; Lichtenstein, 1984). For physicians in group practices
and workers in other organizational settings, dissatisfaction with work is
generally correlated with increased turnover and low morale (Ross, 1969;
Porter and Steers, 1973; Prybil, 1974; Lichtenstein, 1984). Satisfaction with
work is therefore an important variable for study in an HMO practice
12
setting, and in this case, with respect to differing levels of professionalism
and bureaucracy in the HMO#
Furthermore, it has been argued that professional orientation may be
positively related to task involvement and job satisfaction (Dansereau, 1974;
Katzell, 1979; Howell and Dorfmann, 1986). More highly professionalized
workers are expected, in this view, to experience higher levels of satisfaction
with their work than those workers with less of a professional motivation.
Role Motivation Theories
Miner (1980, 1988) has proposed four role motivation theories which
offer an alternative approach to the study of the issues presented thus far.
The motivation theories assume that internal forces energize and guide
behavior, although the individual may not be fully aware of them. Similar to
need theories, such as McClelland’s (1961) need-for-achievement theory, the
Miner framework is concerned with internal motivational forces that
combine to influence performance in certain types of jobs and organizational
structures (Miner, 1988). Within each organizational context there exists a
basic understanding of how work roles can be performed well. An
individual’s motivational patterns are assumed to combine with
organizational role prescriptions to induce work energy. Of interest to the
present study are Miner’s notions of professional motivation and hierarchic
13
(managerial) motivation. Each of these role motivation theories are defined
below.
Professional role motivation theory applies to professionals employed
in professional contexts within large organizations. Work energy is viewed
as a result of the role requirements characteristic of a profession and the
professional’s norm transmitting organizations; thus, cosmopolitan rather
than local methods of influence are emphasized (Gouldner, 1957; Miner
et al., 1989). The five role prescriptions were derived from various
definitions of professionals and professional organizations, and from research
on professionals (Etzioni, 1964; Hall, 1968; Vollmer and Mills, 1966; Miner
et al., 1989; Sorensen and Sorensen, 1974; Satow, 1975). Miner maintains
that professional motivation will predict career accomplishment and
effectiveness.
The five roles and corresponding motivational forces are as follows:
1. Role: knowledge acquisition. Motivation: A desire to learn. In a
professional system, it is essential that technical knowledge and
expertise be developed, transmitted, and used in the service of clients.
2. Role: independent action. Motivation: A desire to work
independently. Professionals have relationships with clients that
require independent action based on an individual’s best professional
14
judgment. Thus, a professional is expected to be an independent
person and desire to act independently of others.
3. Role: status acceptance. Motivation: A desire to acquire status.
The provision of services to clients is predicated on client recognition
of the professional’s expert status. Professionals who lack status often
find that their services go unutilized.
4. Role: providing help. Motivation: A desire to help others. In a
professional system, the relationship between the professional and the
client is central, and involves the expectation that the professional
will help the client as much as possible. This type of motivation may
reflect a desire to serve others or an element of personally
experienced helping power.
5. Role: professional commitment. Motivation: A value-based
identification with the profession. Professionals should feel strongly
committed to their profession and to its ethical norms.
Miner (1981) operationalized the professional role motivation theory
with the Miner Sentence Completion Scale-Form P, a projective instrument.
The professional theory has been tested twice. The first study (Miner,
1980b) involved management professors who were members of the Academy
of Management. The subjects completed Forms P and FI of the Miner
Sentence Completion Scale and responded to six criteria measures
15
considered indicative of professional success. The guiding hypothesis for the
study was that the professional theory would more effectively predict
professional career accomplishment than the hierarchic theory for this
professional sample. Within the professional domain, other types of motives
were not expected to yield evidence of empirical relationships with the
success criteria.
Miner found strong support for the hypotheses of the study; the data
confirmed the professional theory within the professional domain while
indicating no validity for the hierarchic theory within the professional
domain. Miner concluded that although the findings as a whole did not
necessarily support the construct validity of the separate subscale measures,
they did give credence to the belief that Form P, as a whole, taps what is
considered to be professional motivation and this motivation is a factor in
professional success.
Miner also found in this study that holding an administrative position
was strongly and consistently related to professional motivation. Hence the
professionals with greater professional motivation became the administrators
within the professional system. The administrators in the sample were
department heads, program chairpersons, associate deans or deans. In such
positions, these individuals were still heavily involved in the professional
16
system. The data suggest that the administrators were senior professionals,
rather than hierarchic managers.
The professional role motivation theory and MSCS-Form P were
further validated by Miner et al. (1989) in a study of labor arbitrators. The
theory’s external validity was supported with this different group of
professionals. The data indicated that the labor arbitrators worked in a
predominantly professional context and that professional motivation was
closely associated with criteria of arbitrator effectiveness.
Miner’s hierarchic role motivation theory is by far the one with the
longest history and the most research support. Three decades of research
including over 33 studies has been conducted with the hierarchic theory,
which applies to managers within the domain of the medium to large
bureaucratic organization (Miner, 1985). Outside of the hierarchical domain
the theory is expected to have minimal application.
Hierarchic role motivation theory suggests that certain motives
contribute to being a better manager, being more satisfied with managerial
work, and striving toward managerial positions. Specifically, six managerial
roles and motives are hypothesized by Miner to contribute to success and
satisfaction as a manager in a bureaucratic organization. The roles and their
motivational patterns are (Miner, 1988):
17
1. Role: positive relations with authority figures. Motivation: A
favorable attitude toward people in authority. In a hierarchy, there
must be communication and interaction with superiors, and favorable
attitudes toward authority figures facilitate this.
2. Role: competitive. Motivation: A desire to compete. As one climbs
toward the top of a hierarchic system, rewards such as promotion and
high salaries become increasingly scarce, and it is necessary to
compete with peers to attain them.
3. Role: imposing wishes. Motivation: A desire to exercise power over
others. A hierarchic system requires managers to impose sanctions
on, and otherwise influence their subordinates. Those who derive
satisfaction from these activities are more likely to perform them
successfully.
4. Role: assertive parental. Motivation: A desire to assert oneself. In
a hierarchic system, the managerial role is often modeled on the
parental role; accordingly, a take-charge attitude congruent with that
role is required.
5. Role: standing out from the group. Motivation: A desire to assume
a distinctive, differentiated status. In a hierarchic system, managers
must remain highly visible, while at the same time remaining apart
from the relative homogeneity of their subordinates.
18
6. Role: routine administrative. Motivation: A desire to perform
routine managerial duties in a responsible manner. In a hierarchic
system, various routine decision-making and communications tasks
must be carried out, so appropriate motivation for such matters is
required.
It is expected that those individuals who repeatedly associate positive
rather than negative emotions with the role prescriptions will tend to more
often meet organizational criteria of managerial effectiveness.
Research using the hierarchic theory and Miner Sentence Completion
Scale-Form H has been summarized in various publications (Miner, 1977,
1978, 1985). The findings support the hierarchic theory in predicting
advancement to higher levels of management and managerial success. The
subscales that correlate most strongly and consistently with managerial
success are a desire to exercise power, a desire to compete with peers and a
positive attitude toward authority figures. Miner concludes: "The
hierarchically appropriate relationships with superiors, peers and
subordinates are supported most consistently" (Miner, 1978). The other
three subscales are related to criteria of success less frequently, but all show
significance in some studies. In studies conducted outside the hierarchic
domain, there is generally a failure to yield significant findings, as the theory
predicts.
19
Miner has found higher hierarchic scores in general among the line
components of organizations, and lower scores among staff. No studies have
been conducted using the hierarchic theory within a health care setting.
It can be seen that the role requirements and motivational patterns of
the hierarchic and professional theories differ considerably; they are, in fact,
inconsistent on most dimensions.
The concept of role conflict suggests that conflict occurs when
incompatible demands are placed on an employee. Physicians, trained to
adhere to the principles and methods of their profession, assume a role in
an organization initially as a service provider. It seems logical to
hypothesize that to perform as both a professional and a manager would
create role stress and dissatisfaction with work for those who do not have
ample hierarchic motivation as well as professional motivation. Conversely,
it might also be expected that a person relatively high on both
hierarchic/managerial and professional motivation patterns would
experience less role strain in a professional/managerial role and greater
satisfaction with work than a person who is high on only one motivational
pattern. Miner contends that it is the individual highly motivated on the
professional dimension who is most likely to be promoted in a professional
system. Therefore, the high P, or cosmopolitan professional, is most likely
to be put in a position of medical management in which
20
hierarchic/managerial expectations are strongest. Role conflict, as well as
job dissatisfaction, would appear to be inevitable for such an individual
unless this physician is also sufficiently managerially motivated.
These issues are important and topical ones today for physicians, and
particularly for medical managers, as they enter positions which confront
them directly with conflicting professional and organizational role
requirements. Additionally, the structural type of the professional
organization— predominantly professional and/or bureaucratic— will likely
affect the relative fit of the physician in the role as well as the role strain
experienced by the physician within it.
Characteristics of Professional Organizations
A professional organization is most broadly defined as an
organization in which members of one or more professions play the central
role in the achievement of organizational objectives. Scott (1965)
distinguishes between professional organizations on the basis of the degree
to which professionals are subjected to external jurisdiction. In autonomous
professional organizations, professionals are the least subject to external
control by management, and in them, Scott assumed there to be the greatest
professional identity amongst individual professionals. Examples of these
are universities and professional service organizations. In heterononomous
organizations, according to Scott, professionals are subordinated to an
21
externally derived system. Examples are the public school and social work
agencies, which are affected and structured by administration and often by
government legislation. The professional department (i.e., a research and
development lab) within a larger organization is the third of Scott’s types.
In this context, the work of the professional is structured externally by
management.
Hall (1968) examined the degree of bureaucratization within the
three types of professional settings outlined by Scott. He found modest
negative correlations between professionalism and bureaucratization, and
proposed that (1) the presence of professionals affects the structure of an
organization because professionals have standards to which the organization
must adjust; and (2) the presence of bureaucratic systems may inhibit further
professionalism of weakly professionalized groups. Hall then challenged the
assumption in the literature that a professional department could be similar
in structure and operating norms to the rest of the organization of which it is
a part. Though he began in this way to differentiate between types of
systems, they were differences in levels of (Weberian) bureaucracy, not
differences in basic structural form.
Professionals are assumed to value loyalty to the professional group
and its norms, self-governance and autonomy. There is an obvious
incompatibility between this orientation and Weber’s concept of
22
bureaucracy. As Friedson and Rhea (1963) state: "The consensus seems to
be that those works (professionals) require a kind of autonomy that is
antithetical to Weber’s model of rational-legal bureaucracy." Though
acknowledging differences between professional systems and bureaucratic
ones, many authors continued to call professional organizations
bureaucracies, and to treat them as deviant cases (Goss, 1963; Hall, 1968,
1977; Scott, 1965).
Litwak (1961) suggested that Weberian, human relations and
professional models of bureaucracy be differentiated and used in
organizational analysis. This, in essence, was an early proposal for an
organizational typology or classification system, the value of which has been
advocated by researchers since that time (McKelvey, 1975; Filley and Aldag,
1978; Carper and Snizek, 1980).
Miner (1980a) proposed a typology in which professional systems are
considered as one of four parsimonious domains. The four limited domains
of organization in this view are hierarchic/managerial, professional, task/
entrepreneurial and group/sociotechnical. The primary methods of inducing
effort are, respectively, the manipulation of hierarchic sanctions, professional
norms, inherent task pushes and pulls, and group pressure (Miner, 1988).
Accordingly, each of these domains requires a different type of organization
structure, leadership, control system, and decision style. Of interest to this
23
study is the distinction between the hierarchic and professional domains or
structures, as discussed with respect to Miner’s motivation theory above.
The hierarchic or bureaucratic system is based upon Weber’s (1964)
writings and the operations of rational-legal authority. Hierarchic
organizations are characterized by the distribution of impersonal, rational,
legitimate authority among positions organized such that each lower position
is controlled and supervised by a higher position. Rules regulate the
activities and decisions of each position holder. Loyalty to the organization
and values congruent with organizational goals are demanded of position
holders. Power and prestige are distributed according to rank in the
hierarchy. Discretion in decision making is limited. Emphasis is placed on
efficient performance of duties assigned (Weber, 1947; Burns and Stalker,
1961; Oliver, 1982).
In professional structures, according to Miner, role requirements
come from the values, norms, ethical precepts and codes of the profession,
rather than from the organization hierarchy. The structure is flat, with
status differentiations based upon expertise and professional experience.
Members retain considerable independence. Professional organizations need
participation, commitment and support of professional norms, and power
must be primarily in professional hands. Professional structures often
24
include nonprofessionals in support roles, and when they grow larger, they
tend to operate with a hierarchic overlay (Miner, 1988).
Many authors have identified mixed hierarchical and professional
characteristics of professional systems (Parsons, 1957; Litwak, 1961; Bucher
and Stelling, 1969). Mills et al. (1983) proposed a power-authority
dichotomy in professional organizations, with authority at the top of the
organization flowing downward and power at the operational level of the
professionals, flowing upward.
Similarities exist between the Miner, Mills et al., and Mintzberg
frameworks for professional systems. Mintzberg (1981) delineates five
distinct organizational structures or configurations, each with a different task
and coordinative structure, environment, power structure, and internal
management system. Within the Mintzberg framework, the professional
bureaucracy is identified as both a different type of structure from the
machine bureaucracy, and as one in which dual structures exit. In the
professional bureaucracy, work is coordinated through the standardization of
skills by professionals (as opposed to work processes or outputs in a machine
bureaucracy). The professional bureaucracy requires highly trained
professionals in its operating core and considerable support staff to do the
routine work to back them up. Parallel systems are assumed to exist--one
democratic and decentralized with bottom-up power for the professionals,
25
and a second bureaucratic and hierarchic with top-down control for the
support staff.
Formidable differences between hierarchically structured and
professionally structured sub-units are assumed to be present in
organizations which employ professional workers. Yet, more often than not,
our research is not contextually based, or assumes a standard hierarchic
context across structures and sub-units. Given the highly differentiated
nature of health care, it is important to take into account the system type
and begin to understand how these structures may differ from a hierarchic
model and thereby significantly affect empirical outcomes.
In the present study, an identification of the organizational structure
will be made in order to then examine the motivations of key actors which
exist across varying structures. An instrument for classifying organizations
and organizational sub-units according to hierarchic and professional system
type will be used for system identification (Oliver, 1982).
Oliver Organization Description Questionnaire
Oliver (1982) developed and tested the Oliver Organization
Description Questionnaire (OODQ), based upon Miner’s (1980a) role
motivation theory as the theoretical base. Each of the Miner motivation
theories are assumed to exist within a limited domain-hierarchic
(bureaucratic), professional, task (entrepreneurial), or group
26
(sociotechnical). In his study, Oliver contends that these separate and
independent domains or philosophies of management exist; that their
characteristics can be effectively measured, scaled and compared; and that
organizations can be classified for both descriptive and normative purposes
(Oliver, 1982).
Oliver administered his items to samples of managers, professionals,
entrepreneurs, and individuals in autonomous work groups established on an
a priori basis, and then used these data to select those responses that best
discriminated between the groups. Table 1 indicates the organization scores
of the 29 organizations in the development sample. Data regarding criterion
validity is presented in Table 2 (Oliver, 1982). As indicated, the mean score
for each scale is nearly twice as high in its home domain as in the total
sample and even higher when compared to other sample scores. The four
scales are found to be slightly negatively correlated (-.17 to -.43) with the
exception of the P scale and T scale, which are slightly positively correlated
(.11) at the .018 significance level. Work in professional organizations
appears to have some of the characteristics of work in task organizations.
Relevant to the present study, the organizations scoring significantly
high on the professionalism scale were the independent professionals.
Within professional systems, Oliver found the leaders to be those
27
TABLE 1
Organization Scores and Classification
in Oliver Sample of Organizations (1982)
H P T G
Organization N Score Score Score Score Classific;
UndergraduateFinance Students 37 5.7 4.0 8.6 1.5 T
U.S. Army Instructors 11 7.6 7.6 1.9 2.0 H/P
Prison guards and working prisoners 21 10.6 4.4 2.4 2.0 H
Independent professionals 46 1.0 11.8 4.9 1.9 P
Entrepreneurs 30 .9 5.3 10.2 1.5 T
Real estate sales firm 5 .4 7.8 11.0 2.4 T
Large air-conditioningmanufacturer 10 10.4 4.3 .7 4.4 H
Large electricutility 7 10.0 5.1 3.0 1.2 H
Real estate sales firm 4 .3 6.3 15.0 1.0 T
Real estate sales firm 4 3.2 7.6 9.4 3.4 T
Commission salespeople (traveling) 9 6.8 6.5 9.8 1.1 T
Real estate sales firm 2 .5 10.0 8.5 1.5
pa
U.S. Army trainees 27 6.9 3.8 3.0 2.4 H
Real estate sales firm 4 2.5 6.7 8.5 1.7 T
Multinational drug manufacturer 24 11.9 2.5 2.1 3.4 H
Ministerial association 9 1.1 5.7 8.1 6.4
State hospital chaplains 10 6.9 8.4 4.7 3.3 p
Certified public accountants 7 5.5 9.1 3.1 2.2 p
College professors 29 7.4 10.5 3.9 2.4 p
Large textile manufacturer 6 11.0 4.6 4.6 1.3 H
Ministerial association 4 4.5 7.2 5.5 1.7 p
U.S. Civil Service 7 10.1 5.7 3.5 2.0 H
Sociotechnical office unit 5 4.1 2.8 3.1 8.6 G
Sociotechnical manufacturing unit 21 4.2 1.4 2.7 9.3 G
Sociotechnical manufacturing unit 23 3.4 2.3 2.5 10.5 G
Sociotechnical manufacturing unit 18 3.6 2.0 2.5 10.5 G
Sociotechnical office unit 6 7.5 5.3 5.1 2.6 Ha
Sociotechnical manufacturing unit 31 6.5 2.3 2.0 7.9 G
Sociotechnical manufacturing unit 21 5.2 3.0 2.5 10.3 G
a Unexpected classifications.
28
TABLE 2
Subsample Means from Oliver Sample of Organizations (1982)
Domain Group H Score P Score T Score G Score
Hierarchic (n=107) 9.6 4.3 2.4 2.5
Professional (n=105) 3.8 10.2 4.8 2.6
Task (n=101) 3.8 5.3 9.3 1.6
Group (n=125) 4.9 2.4 2.6 9.1
Total sample (n=438) 5.75 5.44 4.66 4.24
29
professionals perceived to be most competent in the technical, professional
sense.
The organizations scoring significantly high on hierarchy in Oliver’s
study were the manufacturers, government agencies and prison workers.
Oliver predicts that within a professional bureaucracy, significant degrees of
both hierarchy and professionalism will be found.
Oliver states that more research is needed using the OODQ in a
variety of organizations. Health care settings are missing from Oliver’s
sampled organizational settings altogether.
The HMO in the present study is believed to be variably structured as
a professional bureaucracy; significant degrees of hierarchy are expected
within the administrative structure and significant degrees of professional
orientation are expected within the medical group practice structure of the
medical center. Once the system types are identified, the hierarchic and
professional motivations of administrators, physicians and physician
managers (chiefs-of-service) within the two contexts will be investigated.
Physician Executives
The more externally controlled health care environment which exists
today has provided the major force behind the rapid development of the
physician executive role. By becoming medical managers, physicians have a
way of regaining a degree of professional control and autonomy (Nash, 1990).
30
______
Less than three percent of all physicians spend most of their
professional time performing administrative tasks. Though this is a small
percentage, the American Medical Association (AMA) reports the number
of physicians in this category has quadrupled between 1965-1985; this is
compared with an increase of less than double in the total number of
physicians during the same period (AMA, 1985). From other sources, it is
also apparent that there is an increasing interest on the part of physicians in
joining physician executive associations, and for enrolling in advanced degree
programs in health care management (Schenke, 1986; Rodwin, 1986).
Though there appears to be strong interest in the medical profession
for a medical management career focus, this trend must be considered in
light of the increased opportunities for physicians to enter management
roles. There is an irony to this in the HMO situation. Physicians often site
their reasons for joining an HMO to be the imagined freedom from
administrative burdens. Yet, within HMO’s opportunities and needs exist in
great numbers for physicians to take active management roles.
Abrahamson (1967) found that engineers’ interest in managerial
careers was inversely related to their length of training. Given the extensive
medical education and specialty training required for the physician, what
would cause a physician to make such a formidable career change into
31
management? A move into management is, in fact, a career change
requiring a new set of orientations and skills.
There is little existing research on physicians in management roles.
Betson (1984) conducted a comprehensive study of physicians in
management, although the focus was the tasks performed in these roles, not
motivational and choice dynamics.
In a dissertation, Montgomery (1987) compared practicing physicians
and physician executives on demographic characteristics, motivations and
professional commitments. The medical managers in her study were drawn
from different organizational settings and held different position levels
within their organizations. Twenty-four percent of these medical managers
were department level, comparable to a chief-of-service; 57% were at a
medical director level.
Montgomery (1987) found that the major reason physicians enter
management is the attraction and appeal of management, rather than
dissatisfaction with medical practice. However, dissatisfaction with practice
did play a larger role in the decision to enter management for the post-1980
cohort of the Montgomery sample, indicating increasing frustration with the
changes imposed on practice by the competitive/regulatory health care
environment of the last decade. Montgomery’s practicing physician group
also indicated a higher level of satisfaction with actual medical practice than
32
practice than did the physician executive group. Montgomery states:
"Management... is a new-found appeal, which reflects the change in the
opportunity structure across cohorts... Similar levels of dissatisfaction
between physician managers and physicians do not produce similar levels of
interest in management... the effect of individual preferences is also at work
in career move decisions." Montgomery assumes physicians choose medical
management roles, taking advantage of today’s changing opportunity
structures.
Though many physicians are in fact making choices to enter medical
management, there is some evidence that many are entering into these roles
without making a deliberate choice or being fully aware of the implications
of their decision. In the AM A records of licensed physicians in the U.S.,
physicians who report spending over 50% of their time on administrative
duties are considered to be in administrative roles. Kindig and Lastiri
(1986) sampled this group of physicians and found that one-fourth of them
responded that they did not consider themselves to be in medical
administration roles. Some physicians may not consider themselves
primarily physician managers even if they spend more than half their time
on administrative duties, while others who spend just half or less may
consider their management position a principle career focus (Montgomery,
1987). This may not be surprising if one considers that a career move into
33
management may alter a physician’s social and professional identity.
Additionally, medical management roles traditionally have been of less
status and prestige than those of practicing medicine (Shortell, 1974; Abbott,
1981).
In an examination of the reasons physicians become managers and
sometimes fail, McCall and Clair (1989) explored the issue of how physicians
get into management roles to begin with. They outlined six pathways from
medicine to management:
MANAGEMENT B Y EVOLUTION: The physician began
taking on small-scale administrative duties. Slowly, these
duties grew to larger dimensions. The physician never had the
serious intention to manage.
MANAGEMENT B Y EXPERTISE: The physician was
approached and asked to take on a management role on the
basis of outstanding accomplishment or skill, i.e., specialized
medical credentials, national reputation, network of contacts,
research record, etc. Rarely was the outstanding characteristic
related to management qualities.
MANAGEMENT B Y DEFAULT: There was a need for
someone to take the position, but no one available or willing.
The physician agreed after being persuaded, or as a way to get
34
resources, to help out, or to keep others from managing
him/her.
MANAGEMENT B Y CHOICE: The physician deliberately
chose a medical management career path for any of a variety
of reasons, i.e., an interest in business, a skill with people, the
desire to build something, a new kind of challenge, to
contribute on a greater level to patients and society, power.
This could also be a choice away from clinical practice due to
burnout or boredom.
ORGANIZATIONAL CHANGE: The physician found him or
herself in a manager role as a result of a merger, acquisition,
organization restructuring, etc.
MANAGEMENT B Y CULTIVATION: The organization had a
planned developmental process to prepare the physician for
the manager role through job experiences, management
development and/or a mentoring relationship.
McCall and Clair conclude that, overwhelmingly, physicians enter
management for irrelevant or wrong reasons. Often a conscious choice is
not made at the outset, and the physician is therefore ill prepared or
unmotivated for the management role.
35
Put another way, Lorsch and Mathias (1987) discuss the selection of
professionals to manage other professionals. After identifying the skills
these professionals must develop as managers, the authors conclude by
stating that without a genuine interest and motivation for managing, these
people won’t be good picks. "Ideal candidates... are accomplished producers
who are enthusiastic about taking on managerial responsibilities and
interested in having their careers move in this direction."
There is ample reason to believe that within the HMO system of the
present study, though the opportunity structures are in place, medical
managers may not always be making career choices to enter their
management roles. First of all, many physicians select into the HMO to
avoid administrative responsibilities. Secondly, to become a chief-of-service,
physicians are surveyed from within each medical center specialty group only
(not from outside the HMO or from candidate pools of the same specialty
across the HMO system); they are then appointed by the medical director
with the advice and consent of the department physicians. Because of this
procedure, individual chief-of-service choice to enter their role will be
examined against the dynamics and pressures of the system in placing
physicians who might not otherwise make these choices into management
roles.
36
In sum, the central interest of this research concerns the professional
and hierarchic (managerial) motivations of administrators, physicians and
physician managers (at the chief-of-service level) in a successful Health
Maintenance Organization. This interest will be examined by testing a
number of hypotheses about the structural type of the administrative and
physician system within the HMO; the motivational patterns of
administrators, physicians and chiefs-of-service are expected to differ
predictably in terms of the HMO’s variable structures.
Specific to chiefs-of-service, it is predicted that many chiefs-of-service
in the study will indicate that choice is not descriptive of how they entered
their medical management position. This choice/no-choice dynamic is
presumed likely to relate to the chief-of-services’ professional and hierarchic
role motivation, satisfaction with work, desire to remain in medical
management in the future and age.
Research Hypotheses
The present study has been designed to test the following research
hypotheses:
H I The Administration system within the organization will
be identified as primarily a hierarchic system.
H2 In the Administrative system, based upon what is found
to be the predominant system type in H I (H, P, or
37
mixed H and P), the matching motivation will be found
to be most elevated for the administrator group.
H3 In the Administration system, based upon what is found
to be the predominant system type in HI, the matching
motivational constellation will correlate positively with
measures of satisfaction with work. In this system, the
matched motivational constellation will correlate
negatively with measures of role conflict and role
ambiguity.
H4 The Medical system within the organization will be
identified as primarily a professional system at both the
physician and chief-of-service levels.
H5 In the Medical system, (a) P motivation will be
significantly higher than H motivation for the physician
and chief-of-service groups; (b) Both H and P
motivation will be higher for the chief-of-service group
than for the physician group.
H6 In the Medical system, P motivation will correlate
positively with satisfaction with work. In this system, P
motivation will also correlate negatively with measures
of role conflict and role ambiguity.
38
H7 If the chief-of-service group identifies a mixed H and P
system, then the chiefs-of-service with motivational
patterns elevated on H, P, or H and P will report
greater satisfaction with work and less role conflict and
role ambiguity than those physician mangers with
motivation patterns which are not elevated on either
dimension. If the chief-of-service group identifies a
predominantly H or P system type, then those chiefs-of-
service with the single, matching motivational pattern
will report greater satisfaction with work and less role
conflict and role ambiguity than those without it.
H8 For the chief-of-service group, those chiefs who entered
their management role through a form of personal
initiation or choice will report (a) higher levels of P
motivation in a professional system and higher levels of
P, H or P and H motivation in a mixed system;
(b) greater satisfaction with work; (c) a stronger desire
to remain in medical management in the future; and
(d) being younger in age than those who did not choose
to enter a medical management role.
39
CHAPTER TWO
Procedure and Methodology
Procedure
The design was a correlational field study. Survey data were
collected from a sample of administrators, physicians, and chiefs-of-service of
a large for-profit Health Maintenance Organization (HMO) in the
Southwestern United States. The HMO provided service to HMO
subscribers through decentralized medical center outpatient facilities.
Within the outpatient organization there existed a medical group practice, a
flat organization of physicians with a chief-of-service heading up each
medical specialty area. The chiefs-of-service were, for the most part, chosen
from within their department and appointed into their positions by a
Medical Director, upon the advice of the department physicians; the consent
of the department physicians was also necessary for a chief to be confirmed
in the role. Within the outpatient organization there was also an
administrative staff organized more hierarchically, with reporting
relationships to other administrators.
Data were collected at one point in time. Sudman (1985) reported
several reasons why professionals are reluctant to respond to surveys, and
identified physicians in general as notoriously poor respondents. Therefore,
the researcher made a ten-minute appearance at meetings of the different
40
subject groups to introduce the research study and questionnaire.
Questionnaires were distributed with self-addressed envelopes for
respondents to return directly to the researcher.
Also to encourage response, the survey for this research was
accompanied by a cover letter from the researcher on University stationary.
It assured subjects that their individual responses would not be seen by the
HMO’s management and made clear that participation in the project was
voluntary.
Sample
Administrators
Table 3 provides a breakdown of the demographic variables reported
in percentages for the Administrator group. These subjects were 67
employees of an HMO who held administrator roles in three medical center
locations. Within this population, there were 53 females and 13 males. The
subjects included nine assistant medical center administrators, four
administrative assistants, 28 department administrators and 23 assistant
department administrators (supervisors). The age of the subjects ranged
from 25 to over 60 years, with 64% falling between 35-49 years. Eighty-
three percent of the subject group was Caucasian. All subjects completed
high school, 12 reported completing some college, 18 held bachelors degrees
and 35 (53%) held masters degrees. Of those having completed a master’s
41
TABLE 3
Frequencies of Demographic Variables Reported in Percentages
for the Administrator Group (N = 67)
Variable %*
Gender
Female 81.5
Male 18.5
Age
25-29 4.5
30-34 12.1
35-39 21.2
40-44 21.2
45-49 21.2
50-54 10.6
55-59 7.6
60 & over 1.5
Position Title
Asst. Medical Center 13.6
Administrator
Administrative Assistant 6.1
Department Administrator 42.4
Asst. Department
Administrator 37.8
Ethnic Group
Black 1.5
Caucasian 83.3
Hispanic 7.6
Other 7.6
Formal Education (Highest Completed)
High School
Some College 1.5
College Degree 18.2
Masters Degree 27.3
53.0
*NOTE: All percentages are rounded to the nearest tenth; cumulative
percentages which are not equal to 100 are due to rounding
error.
TABLE 3 (continued)
Variable %*
Major Undergraduate Area of Study for those with Bachelors Degrees and
Above
Health Care Administration 17.0
Occupational Therapy 1.9
Nursing 26.4
Chemistry 1.9
Health Science 5.7
Sociology 7.5
History 3.8
Psychology 7.5
Business Administration 9.4
Pharmacy 3.8
Biology 5.7
Microbiology 1.9
Nutrition 1.9
Health Education 1.9
Occupational Health 1.9
Zoology 1.9
Graduate Degree Area of Study
Health Service 29.2
Administration
Medical Technology 2.4
Nursing Administration 4.9
Hospital Administration 4.9
History 2.4
Nursing 7.3
Social Work 9.8
Systems Management 2.4
Clinical Psychology 2.4
Business Administration 7.3
Human Behavior 2.4
Public Health 7.3
Public Administration 4.9
Counseling 2.4
Radiology 2.4
Health Science 4.9
Biology 2.4
43
level degree, 54% completed the degree in an area of management or
administration.
Physicians
Table 4 provides a breakdown of the demographic variables reported
in percentages for the HMO physicians group. The subjects were 66
physicians from three medical center locations. All were employed to
provide clinical service to the HMO client population. Within this group, 55
were male and 11 female. The age of the physicians ranged from less than
30 years to over 60 years, with 70% falling between 30-44 years. With
regard to ethnic background, 14 were Asian, 40 Caucasian, and two
Hispanic. Though they were all providing clinical service through the
departments of Family Practice or Internal Medicine, 35% identified Family
Practice and 57% identified Internal Medicine to be their primary specialty
areas. Most, 91%, were board certified.
Over one-half of this subject group worked as physicians in another
setting previous to their present employment. O f those with prior
experience of this kind, 86% were employed in a role providing clinical
service.
With respect to the physician subject group’s perception of physicians
in a management or chief-of-service role, 51% perceived a physician in such
a role as primarily in an administrator role as opposed to the role of a
44
TABLE 4
Frequencies of Demographic Variables Reported in Percentages
for the Physician Group (N = 66)
Variable %
Gender
Female 16.7
Male 83.3
Age
Less than 30 3.0
30-34 25.8
35-39 18.2
40-44 25.8
45-49 10.6
50-54 6.1
55-59 6.1
60 & over 4.5
Ethnic Group
Asian 21.2
Caucasian 74.2
Hispanic 3.0
Other 1.5
Clinical Specialty (Primary)
Family Practice 35.4
Internal Medicine 56.9
Oncology 1.5
Infectious Diseases 1.5
Cardiology 3.1
Nephrology 1.5
Board Certified
Yes 90.5
No 9.5
TABLE 4 (continued)
Variable %
Perception of a Physician in Medical Management Role (i.e., Chief-of-Service)
as Primarily a Physician or Administrator?
Physician 39.7
Administrator 50.8
Other 9.5
Primary Peers of Physicians in Medical Management Roles?
Practicing Physicians 30.8
Other Physicians in Medical 63.1
Management
Non-Physician Health Care 6.2
Administrators
Division of Work Time Between Patient Care and Administration?
- % of Time on Patient Care:
50% 1.5
60 1.5
70 7.6
75 1.5
80 10.6
90 13.6
95 21.2
98 4.5
99 1.5
100 36.4
- % of time on
Administration
0%
1
2
5
10
20
30
40
50
46
40.9
1.5
4.5
19.7
12.1
10.6
6.1
1.5
3.0
TABLE 4 (continued)
Variable
%
Medical Management Career Plans
Would like Medical Management 24.6
Position
No decision 13.8
No desire 41.5
Not seriously thought about it 20.0
NOTE: All percentages are rounded to the nearest tenth; cumulative
percentages which are not equal to 100 are due to rounding
error.
47
practicing physician. Their perception was also strong (63%) that the
primary peer for a chief-of-service is another chief-of-service.
Seventy-seven percent of the physician subject group reported
spending between 90 to 100% of their work time on direct patient care, with
36% reporting spending 100% of their time so engaged. Alternately, 32% of
this subject group reported spending five to ten percent of their work time
on administrative activity; 41% reported spending no time on administration,
and 21% reported spending 20% or more.
When asked if they had any career plans which involved assuming a
medical management position in the future, 25% of the physician group
indicated a preference for doing so, while 42% expressed a clear preference
for not assuming such a role. Fourteen percent indicated they had made no
decision in this area, and 20% said they had not thought seriously about
such a career change.
Chiefs-of-Service
Table 5 provides a breakdown of the demographic variables reported
in percentages for the HMO chief-of-service group. The subjects were 56
chiefs-of-service from four medical center locations. Fifty-two were male
and four were female. Their ages ranged from 35 to over 60 years, with
62% falling between 40-54 years. With regard to ethnic background, 43
were Caucasian, eight Asian, one Black, and one Hispanic.
48
TABLE 5
Frequencies of Demographic Variables Reported in Percentages
for the Chief-of-Service Group (N = 56)
Variable
%
Gender
Female 7.3
Male 92.7
Age
30-34 0
35-39 18.2
40-44 23.7
45-49 16.4
50-54 21.9
55-59 14.5
60 & over 5.5
Ethnic Group
Asian 14.5
Caucasian 78.2
Hispanic 1.8
Black 1.8
Other 3.6
49
TABLE 5 (continued)
Variable %
Clinical Specialty (Primary)
Radiology 3.8
Pediatrics 17.0
Urology 3.8
OB/GYN 9.4
Anesthesia 3.8
Neurology 7.5
Psychiatry 5.7
General Surgery 1.9
Family Practice 7.5
Dermatology 5.7
ENT 3.8
Pathology 5.7
Internal Medicine 1.9
Opthamology 7.5
Physical Medicine 5.7
Allergy 1.9
Orthopedics 5.7
Emergency Medicine 1.9
Board Certified
Yes 88.7
N o 11.3
Self Perception of Professional Identity
Physician 89.1
Administrator or Manager 4.3
Other 6.5
Do Other Physicians Perceive You as Primarily a Physician or
Administrator?
Physician 75.6
Administrator 11.1
Other 13.3
50
TABLE 5 (continued)
Variable %
Primary Peers of Physicians in Medical Management Roles?
Practicing Physicians 85.2
Other Physicians in Medical 14.8
Management
Non-Physician Health Care 0
Administrators
Division of Work Time Between Patient Care and Administration?
- % of Time on Patient Care
25% 2.2
33 2.2
40 4.3
45 2.2
50 6.5
60 4.3
65 2.2
70 2.2
75 2.2
80 19.6
85 15.2
86 2.2
90 21.8
95 10.9
98 2.2
- % of Time on Administration
2% 2.2
5 10.9
7 2.2
10 30.4
15 13.0
20 10.9
25 2.2
30 4.3
40 6.5
45 2.2
50 8.7
55 2.2
67 2.2
75 2.2
51
TABLE 5 (continued)
Variable
Medical Management Career Plans
Would like to remain in 54.8
current position
Would like different 18.9
management position
Not sure if want to remain 18.9
in management
D o not desire to remain in 7.5
management
Medical Management Experience and Beliefs
The extent chiefs-of-service report the following contexts applicable to
how they entered medical management:
1 2 3 4 5
Not at all
Descriptive
Slightly
Descriptive
Moderately
Descriptive
Quite
Descriptive
Extremely
Descriptive
Evolution 35.6 15.6 15.6 17.8 15.6
Expertise 17.8 13.3 24.4 40 4.4
Default 37.8 15.6 15.6 13.3 17.8
Choice 46.7 11.1 20 22.2 —
Organiza
tional
Change
73.3 6.7 15.6 4.4
Cultivation 61.4 20.5 9.1 9.1
NOTE:
All percentages are rounded to the nearest tenth; culmulative
percentages which are not equal to 100 are due to rounding
error.
52
This group was made up of chiefs from 18 clinical specialty areas.
The most highly represented specialty was pediatrics, with nine individuals
or 17%of the subject group. Eighty-nine percent of the group was board
certified in the specialty area they managed.
As with the physician group, over one-half (55%) of the chiefs were
employed in another health care setting prior to joining the HMO. Of those
with prior experience of this kind, most (88%) were employed in a role
providing clinical service, similar again to the physician subject group.
With respect to professional identity, 76% of the chief-of-service
group believed they were viewed as primarily in practicing physician roles by
the practicing physicians. This is in contrast to the perception reported by
51% of the physician group, which viewed the chief as primarily an
administrator. It is important here to note that 89% of the chiefs identified
their professional identity to be most strongly that of a physician rather than
an administrator or manager.
Similarly, 85% of the chief-of-service group perceived the primary
peers of physicians in medical management to be practicing physicians rather
than other physicians in management. The practicing physicians, to a large
extent (63%), perceived other physicians in medical management to be the
primary peers of the medical managers.
53
It is clear from the reported time allocations spent on different work
activities that the chiefs perceive themselves to be primarily engaged in
clinical service. Thirty-five percent of this group reported spending 90% to
100% of their time on direct patient care (as opposed to 77% of the
physician group). Seventy-two percent reported spending 80% or more time
engaged in direct patient care. Conversely, 60% of the chief group reported
spending between two and 20% of their time on administrative activities.
They appear to be senior professionals or working supervisors, at this first tier
of medical management.
When asked if they would like to remain in a management role, 55%
of the chief-of-service group indicated that they would, and that they would
like to do this in their current position. Nineteen percent indicated a
preference for remaining in management, but in a different position.
Another 19% indicated not sure in this regard, and eight percent reported
that they did not desire to remain in a management role.
With regard to how they entered a management role, the chief-of-
service group identified the following situations to be from moderately
descriptive to extremely descriptive of their entry situation: Expertise (69%),
Evolution (46%), Default (46%), Choice (41%), Organization Change
(21%), and Cultivation (18%). As indicated in Table 3, no subjects
identified Choice as being extremely descriptive of their entry situation; 22%
54
reported choice to be quite descriptive, and 20% reported choice as
moderately descriptive. Even with this somewhat relaxed definition of choice, j
only 41% of the chiefs-of-service in this sample perceived their entry into [
t
i
their management role to have been a deliberate choice on their part. j
i
Methodology
i
Instruments !
i
As an example of the research questionnaire, the chief-of-service ,
questionnaire which contains all measures used is presented in Appendix 1. j
i
Data were collected for the study from the following six sources:
Demographic Data Form, Oliver Organization Description Questionnaire
(OODQ) (Oliver, 1981), Miner Sentence Completion Scale-Form H (Miner,
1977), Miner Sentence Completion Scale-Form P (Miner, 1981), Satisfaction
i
with Work from the Job Descriptive Index (Smith, Kendall and Hulin, 1969), j
and Role Ambiguity and Role Conflict (Rizzo, House and Lirtzman, 1970).
i
f
I
Demographic Data Form j
i
The Demographic Data Form was designed by the researcher for this j
study. The information requested on the form included the demographic
data presented in Tables 1, 2, and 3. The information requested varied
somewhat for the three subject groups. For example, as the chief-of-service
!
group was examined to a greater extent than the other groups in the i
i
research hypotheses, it was necessary to request additional information from
55
this group. Also, for the chief-of-service subject group, items from the
Montgomery (1987) study regarding professional identity were included for
comparative purposes.
As part of the Demographic Data Form, the chief-of-service group
was asked to identify the extent to which different situations were descriptive
of the way in which they entered a medical management role. McCall and
Clair (1989) proposed six possible paths to medical management: Evolution,
Expertise, Default, Choice, Organizational Change, and Cultivation. The
researcher developed a scale to operationalize this framework for the
present study. Responses by the chief-of-service group to these six possible
situations were indicated on a five-point scale, where 1 = not at all
descriptive to 5 = extremely descriptive.
Oliver Organization Description Questionnaire (OODOl
Each of Miner’s role motivation theories are believed to exist within
a limited domain. It is therefore necessary to identify the research domain
at the outset. The Oliver Organization Description Questionnaire is a 43-
item forced choice questionnaire designed to categorize organizations and
subunits of organizations into one or a combination of structural types.
Responses to the OODQ are scored on the basis of a prior item analysis
carried out so as to maximize the degree of difference between the measures
of the four systems. Scores are derived which describe the perceived work
56
context as primarily hierarchic or bureaucratic (H), professional (P), task or
entrepreneurial (T), and group or sociotechnical (G). These are in keeping
with Miner’s (1980a) theory of four basic types or theoretical domains of
organizational systems.
The score for each scale of the OODQ may range from a low of zero
to a high of 15. Unit or organization scores used for organizational
classification are calculated by aggregating individual scores and computing
the means. Mean hierarchic and professional scores of six and greater
indicate that a significant degree of hierarchy or professionalism is perceived
to be present in the system. Task and group scores of five or greater
indicate a significant degree of task motivation or group energy is perceived
to be present in the system.
Oliver (1982) reports internal consistencies using Cronbach’s alpha
for the scales. The values are r = .86 for the Hierarchic scale, r = .84 for
the Professional scale, r = .82 for the Task scale and r = .88 for the Group
scale. Details of the development of the OODQ are presented in Oliver
(1981, 1982).
Miner Sentence Completion Scale-Form H (Forced Choice).
The MSCS-Form H is a 40-item forced choice questionnaire designed
to measure an individual’s hierarchic, or managerial role-motivation
(H motivation). It measures the six variables of the hierarchic theory with
57
seven five-item subscales. Each subscale score can vary from +5 to -5, with
a total item score of from +35 to -35. There are five filler items, for a total
of 40 items. Miner estimates the total score reliability to be .83, based upon
repeat administrations over a 10-week interval (Miner, 1980b).
Form H has been validated for its construct, concurrent and
predictive validity over several years (Miner, 1977, 1978).
Miner Sentence Completion Scale-Form P
The MSCS-Form P is a 40-item projective instrument, designed to
provide a measure of professional, or specialized motivation (P motivation).
Each item is scored by determining the subject’s approach (+1), unknown
(0), or avoidance (-1) motivation. Total score and subscale scores may be
obtained.
There are five subscales for Form P, relating to the five motivation
patterns of Miner’s professional theory. Each subscale yields a score of from
+8 to -8. Together the subscale scores yield a total score of +40 to -40.
Miner reports that subscale scores correlate with the total score, of which
each is a part, in the range of .53 to .73 (Miner, 1989).
Because of the projective nature of the MSCS-Form P, scoring was
done by three independent raters, which included the researcher. A point-
by-point agreement formula was used to compare ratings as indicated by the
following:
58
Point-by-Point A greem ent------------- x 100
A+D
where
A = agreement between at least two of the three raters
D = all three raters indicate a different score
Scores for each item, subscale and total score were computed. A 97%
point-by-point agreement resulted. This interrater correlation is considered
to be very high.
Satisfaction with Work
This variable was measured by the Satisfaction with Work scale from
the Cornell Job Descriptive Index (Smith, Kendall and Hulin, 1969). Smith,
Kendall and Hulin define job satisfaction as "...the feelings a worker has
about his job." The satisfaction with work scale is concerned with the
intrinsic value and challenge of the work itself.
The authors report reliability a = .84. The scale has repeatedly been
shown to have acceptable validity and reliability (Smith, Smith and Rollo,
1974; Golembiewski and Yeager, 1978).
There are 16 items to this scale. Three points are given to a yes
response to a positive adjective, or to a no response to a negative adjective.
One point is given to a response of can’ t decide. The possible range is
thereby zero to 48.
59
Role Ambiguity and Role Conflict
These measures are based on the work of Rizzo, House and Lirtzman
(1970). Posner and Randolph (1981) report internal reliabilities as .74 for
role ambiguity and .84 for role conflict. These measures have been used
widely in role theory research and have been found to be a reliable measure
o f perceived role conflict and role ambiguity (Schuler, Aldag and Brief,
1977).
Rizzo et al. (1970) define role conflict in terms of congruency-
incongruency within the requirements of the role. Congruency is determined
in relationship to the set of standards for role performance. Role conflict
for these authors is either (1) conflict between the time, resources or
capabilities of the focal person and the defined role behavior; or (2) conflict
between the focal person’s internal values or standards and the defined role
behavior. Role conflict has been identified as a particularly important
situational variable in hospital organization research (Georgopoulous, 1975;
Chacko and Wong, 1984).
Role ambiguity as defined by Rizzo et al. (1970) is (1) the
predictability of the outcomes or responses to one’s behavior, and (2) the
existence or clarity of behavioral requirements, often in terms of inputs from
the environment, which would serve to guide behavior and provide
knowledge that the behavior is appropriate.
60
Role ambiguity was measured with six items; role conflict with eight
items. The items making up the component score were summed together,
i
and divided by the total respective number of items to generate a score in
the range of the original set. j
j
Data Analysis j
The research hypotheses delineated in Chapter 1 are repeated below, '
followed by the analysis procedure. Of note is that many of the hypotheses
i
required a comparison of hierarchic to professional motivation. As
described earlier, these two Miner scales contain different numbers of <
I
subscales and items per subscale. Therefore, for both H and P scales, scores !
i
i
were transformed into z-scores where necessary for hypotheses testing. The i
I
i
I
standardization was done separately for the administrative and medical j
systems around their respective means. i
l
H I The Administration system within the organization will
be identified as primarily a hierarchic system.
Analysis: Using the OODQ, organization type scores
will be calculated by aggregating individual scores to
compute subscales and overall means. Means will then
be compared to published norms for the four OODQ
scales.
i
61
In the Administration system, based upon what is found
to be the predominant system type in H I (H, P or
mixed H and P), the matching motivation will be found
to be most elevated for the administrator group.
Analysis: Create standardized scores for H and P
motivation. Resulting distribution will be divided into
three groups: individuals falling one standard deviation
or more above the mean, individuals falling one
standard deviation or more below the mean, and those
individuals falling between +1 and -1 standard
deviation. Comparison of scores on H and P motivation
to determine those individuals reporting equal levels on
both motivation patterns and those at different levels of
H and P motivation.
In the Administration system, based upon what is found
to be the predominant system type in H I, the matching
motivational constellation will correlate positively with
measures of satisfaction with work. In this system, the
matched motivational constellation will correlate
negatively with measures of role conflict and role
ambiguity.
Analysis: Based upon the results of H I, the dominant
motivational pattern(s) will be correlated with
satisfaction with work (expected to be positive) and with
role conflict and role ambiguity (expected to be
negative), using the Pearson product-moment
correlation procedure.
The Medical system within the organization will be
identified as primarily a professional system at both the
physician and chief-of-service levels.
Analysis: See Hypothesis 1, Analysis.
In the Medical system, (a) P motivation will be
significantly higher than H motivation for the physician
and chief-of-service groups; (b) both H and P
motivation will be higher for the chief-of-service group
than for the physician group.
Analysis: (a) See Hypothesis 2, Analysis; (b) T-tests
between independent groups on both P and H;
(c) subscales for P and H will also be examined using t-
tests to assess differences between the two groups.
In the Medical system, P motivation will correlate
positively with satisfaction with work. In this system, P
motivation will also correlate negatively with measures
of role conflict and role ambiguity.
Analysis: Correlations of P motivation with satisfaction
with work (expected to be positive) and with role
ambiguity and role conflict (expected to be negative).
Pearson product-moment procedure to be utilized.
If the chief-of-service group identifies a mixed H and P
system, then the chiefs-of-service with motivational
patterns elevated on H, P or H and P will report
greater satisfaction with work and less role conflict and
role ambiguity than those physician managers with
motivation patterns which are not elevated on either
dimension. If the chief-of-service group identifies a
predominantly H or P system type, then those chiefs-of-
service with the single, matching motivational pattern
will report greater satisfaction with work and less role
conflict and role ambiguity than those without it.
Analysis: T-tests between those with an elevated H, P
or H and P motivational pattern with those not
elevated, to the dependent variables of satisfaction with
work, role conflict and role ambiguity.
For the chief-of-service group, those chiefs who entered
their management role through a form of personal
initiation or choice will report:
(a) higher levels of P motivation in a professional
system and higher levels of P, H or P and H
motivation in a mixed system;
(b) greater satisfaction with work;
(c) a stronger desire to remain in medical
management in the future;
(d) being younger in age than those who did not
choose to enter a management role.
Analysis: For a-b, t-tests will be computed between
choice and no choice groups on P and H motivation
patterns and satisfaction with work. For c-d, a two-way
chi-square between choice and no-choice groups and
the dependent variables will be done.
CHAPTER THREE
Results
Hypothesis 1
The first hypothesis tested was that the administrative system within
the organization would be identified as primarily a hierarchic system type by
the manager subject group. The expectation was that these administrators,
working in supervisory and department manager roles, would report scores
above the published norms on the OODQ hierarchy scale, and below the
published norms on the other three OODQ scales (professional, task and
group).
Group means for the administrator group on the four OODQ scales
are presented in Table 6. As indicated, the administrator group reported a
mean score of 5.8 for the hierarchic-scale, 5.7 for the professional scale, 4.3
for the t-scale, and 3.5 for the group-scale. Oliver states that H-scores and
P-scores of +6 or greater indicate a significant degree o f hierarchy or
professionalism. Mean T-scores or G-scores of +5 or greater indicate a
significant degree of task motivation or group energy. The results indicate
the system to be most elevated on H and P, but below Oliver’s cut-off
criteria score on both. Hypothesis 1 is therefore not supported, or only
partially supported. The administrators describe their work context as a
66
TABLE 6
Comparison of Group Means for the Administrator Group (N = 69)
on the OODQ
OODQ Scale
(Possible Range 0- Mean SD
15)
Hierarchic
Professional
Task
Group
5.80
5.68
4.35
3.46
2.73
2.30
2.25
2.05
67
mixed H and P system type. Importantly, this predominant type is semi-
hierarchic and semi-professional.
Hypothesis 2
The second hypothesis tested was that in the administration system,
based upon what was perceived to be the predominant system type in HI,
the matching motivation would be found to be most elevated for the
administrator group. Because the system type was identified in H I as mixed,
that is semi-hierarchic and semi-professional, the matching motivation
pattern expected to be elevated here was also mixed, both H and P
motivation. Raw scores were transformed into standardized scores for H
and P motivation. From the resulting distribution, a High group was created
consisting of scores falling one standard deviation or more above the mean;
a Low group was created consisting of those scores falling one standard
deviation or more below the mean; and a Medium group was formed
consisting of the scores falling between +1 and -1 standard deviation. The
High, Medium, and Low scores were compared to determine which were at
equal or different levels. See Table 7 for a presentation of this information.
As indicated in Table 7, both hierarchic and professional motivation
were found to be at the same level for the largest percentage of the
administrative group. Hypothesis 2 is therefore supported.
68
TABLE 7
Comparison of Hierarchic to Professional Motivation
for the Administrator Group
High
Hierarchic
Motivation Medium
Low
Professional Motivation
High Medium Low
2 12 0
2.94% 17.65%
7 26 13
10.29% 38.24% 19.12%
0 6 2
8.82% 2.94%
Total 9 44 15
13.24% 64.71% 22.06%
Total
14
20.59%
46
67.65%
8
11.76%
69
Specifically, for 44% of the administrators, their hierarchy and
professionalism scores were statistically the same. For 37% of the
administrators, their hierarchy motivation score exceeded their
professionalism motivation score; and for 19% of the administrators, their
professionalism motivation score exceeded their hierarchy score. Again, the
largest percentage of the administrative group (44%) reported a mixed
motivation pattern with equal levels of H and P motivation, consonant with
the system type. Where one motivational pattern predominated, it was more
often the hierarchic than professional.
Hypothesis 3
For Hypothesis 3, the motivational constellation which matched the
system type was tested to determine if it correlated positively with the
measure of satisfaction with work, and negatively with measures of role
conflict and role ambiguity. This hypothesis was difficult to test given the
results of Hypothesis 1.
Since the system type was found to be mixed, semi-H and semi-P,
with the largest proportion of the managerial sample identifying an equal H
and P motivation, Pearson’s correlation procedure was used to look at the
relationship between both H and P and measures of satisfaction with work,
role conflict and role ambiguity. Table 8 presents the correlation coefficient
and criterion level data for this hypothesis.
70
TABLE 8
Pearson Product-Moment Correlations between Hierarchic and
Professional Motivation and Satisfaction with Work, Role Conflict
and Role Ambiguity for the Administrator Group
Satisfaction Role Role
Motivation with Work Conflict Ambiguity
Hierarchic .07 .01 -.11
(N=68)
Professional .29* .12 -.18
(N=60)
*p < .05
71
At the .05 level of significance, it can be seen that for the
administrator group hierarchic motivation was not found to be correlated
with satisfaction with work, role conflict or role ambiguity. Professional
motivation was, however, found to be significantly positively correlated with
satisfaction with work, as measured by the Job Descriptive Index.
Professional motivation was not found to be correlated with the other
measures. The hypothesis is therefore not supported, or only partially
supported. Given the nature of the system as determined by the OODQ,
this finding is not an unusual one.
Hypothesis 4
The fourth hypothesis predicted was that the medical system within
the organization would be identified as primarily a professional system type
at the physician and chief-of-service levels. Again the OODQ was utilized.
See Table 9 for a comparison of these mean scores.
As indicated in the Table, the physician group means are 6.1 on the
H-scale and 9.3 on the P-scale. For the chiefs-of-service, the group mean
was 5.3 on the H-scale and 8.9 on the P-scale. The physician group has
identified a fully mixed hierarchic and professional system, with both means
above the +6 criteria level for the OODQ. The P-scale far exceeds the +6
level, however. The physicians describe their work structure as strongly
professional, with a significant degree of hierarchy as well.
72
TABLE 9
Comparison of Group Means for the Physician and
Chief-of-Service Groups on the OODQ
Hierarchic Scale
N Mean SD
Physicians 69 6.13 2.95
Chiefs-of-Service 59 5.27 2.75
Professional Scale
N Mean SD
Physicians 69 9.30 2.73
Chiefs-of-Service 59 8.89 3.13
Task Scale
N Mean SD
Physicians 69 1.94 1.40
Chiefs-of-Service 59 3.25 2.21
Group Scale
N Mean SD
Physicians 69 3.74 2.43
Chiefs-of-Service 59 3.58 2.23
OODQ Scale (Possible Range 0 - 15)
The chief-of-service group means are in the same direction as those
of the physicians, but less pronounced for both H and P. At 5.3, the degree
of hierarchy is below the Oliver criteria level. This group has identified
their system type to be primarily professional.
For both groups the data indicate that the physicians and chiefs-of-
service work in a predominantly professional context. For the physician
group, a significant degree of hierarchy is also present. Therefore, the
hypothesis is supported.
Hypothesis 5
The fifth hypothesis tested has been divided into parts (a) and (b).
For the analysis the researcher also examined the subscales of H and P
motivation. These subscale results are discussed below as F15 (c).
Hypothesis 5a predicted that in the medical system, professional
motivation would be significantly higher than hierarchic motivation for the
physician and chief-of-service groups. As described earlier, individual scores
were transformed into standardized scores and the resulting distribution was
divided into High, Medium and Low groups based upon standard deviation
from the mean. These data are presented in Table 10. Note that for 58%
of the respondents, hierarchic motivation and professional motivation were
found to be at the same levels. For 27%, professional motivation exceeded
74
TABLE 10
Comparison of Hierarchic to Professional Motivation
for the Physician and Chief-of-Service Groups
Professional Motivation
High
Hierarchic
Motivation Medium
Low
High Medium Low
9
7.20%
7
5.60%
0
14
11.20%
52
41.60%
11
8.80%
0 20
16.00%
12
9.60%
Total 23 79 23
18.40% 63.20% 18.40%
Total
16
12.80%
77
61.60%
32
25.60%
75
hierarchic motivation. For 14%, hierarchic motivation exceeded professional
motivation. This result is similar to that found in the administrative system,
in that the mixed motivation pattern predominates. However, when a given
motivation pattern predominates in the medical system it tends to be the
professional. This part of the hypothesis is therefore partially supported.
Hypothesis 5b predicted that H and P motivation would be higher for
the chief-of-service group than for the physician group. The t-test was used
between independent groups on both H and P motivation. This t-test
analysis can be found in Table 11. Comparing the physician and the chief-
of-service subject groups on H and P motivation, it was found that the
physician group did not differ significantly from the chief-of-service group on
professional motivation, t(lll) = -.42, n.s. However, the chief-of-service
group was found to have significantly higher hierarchic motivation than the
physicians, t(124) = -2.18, p < .05. Hypothesis 5b is therefore partially
supported.
T-tests were used to assess differences between the physician and
chief-of-service groups on the subscales of H and P motivation. The only
significant difference found amongst the subscales for both H and P was for
a hierarchy subscale, Authority Figures, which could be expected based upon
the results of 5b. Table 12 presents the significant findings. Group
difference on Authority Figures (AF) can be seen to be significant at the .01
76
TABLE 11
T-tests between Physician and Chief-of-Service Groups on
Hierarchic and Professional Motivation
Professional Motivation
Group N Mean SD t-Value
Physicians 61 10.11 7.37
-.42
Chiefs-of-
Service
52 10.69 7.34
Group N
Hierarchic Motivation
Mean SD t-Value
Physicians 67 1.90 5.25
-2.18*
Chiefs-of-
Service
59 4.12 6.18
*p<.05
77
TABLE 12
Significant T-tests between Physician and Chief-of-Service Groups
on Subscales for Hierarchic and Professional Motivation
Subscale: Authority Figures (H)
Group N Mean SD t-Value
Physicians
Chiefs-of-
Service
67 .06
59 .71
1.49
1.50
-2.44**
Group
Subscale: Accepting Status
N Mean SD t-Value
Physicians 61 2.10 2.72
Chiefs-of- 52 3.02 2.89
-1.74,
p=.08
Service
*p<.05
**p<.01
78
level, t(124) = -2.44, p < .01. The chief-of-service group is significantly
higher than the physician group on having a favorable attitude toward
people in authority. Of note is that of the six subscales of hierarchic
motivation, AF is one of the three that prior research has indicated
correlates most consistently with managerial success within the large,
hierarchic organizational domain. The other subscale t-tests showed no
significant differences on hierarchy. The AF subscale is most likely
accounting for much of the difference between the chiefs-of-service and the
physicians on hierarchic motivation overall.
Within the professional subscales, there were no significant
differences found between the two groups. There is, however, a tendency
for the chief-of-service group to score higher on Accepting Status than the
physician group. At a .09 level of significance, t(lll) = -1.74, p = .09, it can
be said that a trend exists for chiefs-of-service to score higher than
physicians on their desire to acquire expert status.
Hypothesis 6
The sixth hypothesis predicted that for the combined physician and
chief-of-service group there would be a positive correlation between
professional motivation and satisfaction with work, and a negative
correlation between professional motivation and role conflict and role
ambiguity. This was tested using the Pearson product-moment correlation
79
procedure. As displayed in Table 13, no significant correlation was found
between professional motivation and any of the three criterion measures.
Clearly, Hypothesis 6 is not supported.
Hypothesis 7
The chief-of-service group identified their system type to be primarily
professional. Therefore, the seventh hypothesis tested if those chiefs-of-
service with elevated professional motivation would report more satisfaction
with work and less role conflict and role ambiguity than those chiefs-of-
service with professional motivation which was not elevated. Again,
elevation on motivation pattern was defined as having a standardized
professional motivation score of +1 standard deviation above the mean.
See Table 14 for the results of this t-test procedure.
A significant difference between those elevated on professional
motivation and those not elevated was found to exist with respect to
satisfaction with work (as indicated on the Job Descriptive Index). Those in
the chief-of-service group with elevated professional motivation are more
satisfied in their jobs than those with lower levels of professional motivation,
according to this index. The difference in the means (not elevated = 32.6;
elevated = 41) is quite large; even based upon six observations this would
be likely to occur in the population from which this sample is taken.
80
TABLE 13
Pearson Product-Moment Correlations between Professional Motivation and
Satisfaction with Work, Role Conflict and Role Ambiguity for Combined
Physician and Chief-of-Service Group
Satisfaction Role Role
With Work Conflict Ambiguity
Professional .15 .05 -.08
Motivation
NOTE: Sample sizes ranged between 113 and 124.
81
TABLE 14
T-tests between Chiefs-of-Service With and Without Elevated Professional
Motivation on Variables of Satisfaction With Work, Role Conflict
and Role Ambiguity
Elevated Not Elevated
N=6 N=53
Mean SD Mean SD t-Value
Satisfac- 41.00 2.28 32.60 8.87 -5.48***
tion With
Work
Role 3.94 .82 3.84 .51 .28
Conflict
Role 1.89 .70 1.95 .62 .21
Ambiguity
***p<.001
82
Role conflict and role ambiguity were unrelated to elevated
professional motivation. Hypothesis 7 is therefore partially supported.
Hypothesis 8
For this hypothesis the chief-of-service group was divided into two
groups— those who reported having entered a management role through a
form of personal initiation or choice, and those who indicated that choice
was not descriptive of how they entered their role. A choice response was
defined as a response of 3, 4 or 5 to Question 4 on the Medical
Management Experience and Beliefs Questionnaire, where 3 = moderately
descriptive, 4 = quite descriptive, and 5 = extremely descriptive of choice as
the context in which they entered their management role. It was
hypothesized that those who entered their roles through choice would report
higher levels of hierarchic and professional motivation and greater
satisfaction with work, a stronger desire to remain in medical management
in the future, and be younger in age than the no-choice group.
Table 15 presents the t-test procedure data for hypotheses 8a-b. Not
Choice indicates those not in a management role by choice, here 39 of the
59 respondents. The By Choice group is comprised of those respondents
who have indicated that they chose to enter medical management. There
are 20 respondents in the choice category. As indicated in the table, there
were no significant differences found between the choice and no-choice
83
TABLE 15
T-tests between Chief-of-ServIce Choice and No-Choice Groups with H and P
Motivation, Satisfaction With Work, Role Conflict and Role Ambiguity
Not Choice Choice
(N=39) (N=20)
Mean SD Mean SD t-Value
Hierarchic 3.33
Motivation
Profes- 11.65
sional
Motivation
Satisfac- 32.69
tion With
Work
Role 3.93
Conflict
Role 2.0
Ambiguity
6.31 5.65 5.78 -1.41
6.57 9.68 8.96 .84
9.80 34.95 6.43 -1.06
.54 3.69 .50 1.68
.66 1.84 .54 .98
84
groups on H and P motivation and the measure of satisfaction with work.
Hypotheses 8a-b are not supported.
With the t-test procedure used for hypotheses 8a-b, means were
computed and compared between groups. For hypotheses 8c-d, the variables
are categorical. A chi-square test was therefore done for these hypotheses.
In Hypothesis 8c, it was hypothesized that the choice to enter a
management role would be positively related to a desire to remain in
medical management in the future. As indicated in Table 16, 95% of those
respondents who chose medical management want to continue in such a role
in the future. By contrast, only 62% of those who did not choose medical
management are interested in continuing in this kind of role. The choice to
enter into medical management is significantly related to the desire to
continue in medical management, x2 (1) = 6.81, p < .05.
In Hypothesis 8d, it was predicted that those physicians choosing
management would be younger than those who did not choose the role. The
chiefs-of-service were divided into those under 40 years of age and those
over 40 years. It can be seen from Table 17 that 39 respondents are in the
no-choice group; 20 in the choice group; 12 are under 40 years and 47 are
over 40 years. Fifteen percent of the no-choice group is under 40 years old.
Thirty percent of the choice group is under 40 years. A significant
relationship was not found and the hypothesis is not supported. However,
85
TABLE 16
Comparison of Chief-of-Service Choice and No-Choice Groups with Desire to
Remain in a Medical Management Role in the Future using Chi-Square Test
Desire to Remain
in Medical Management
YES NO
No 23 13
Choice 62.16% 35.14%
Choice 18 1
94.74% 5.26%
x2(1)=6.81, p<.05
86
TABLE 17
Comparison of Chief-of-Service Choice and No-Choice Groups with Age
Using the Chi-Square Test
Under 40 Over 40
No
6 33
Choice 15.38% 84.62%
Choice
6 14
30.00% 70.00%
x2(1)=1.74, n.s.
87
the direction of the percentages is in the hypothesized direction. From the
comparison of percentages, the choice group is younger than the no-choice
group. Even though the percentage for the under 40 age group is double
that for the choice group, there is not enough of a difference given the
sample size to be statistically significant.
To summarize the findings from Hypothesis 8, the choice to enter
medical management was not found in this study to be related to higher
levels of H and P motivation or satisfaction with work. A choice to enter a
medical management role was found to be significantly related to chief-of-
service desire to remain in medical management in the future. There is
some indication that those chiefs-of-service under 40 years of age are
making a choice to enter management more often than those in the over 40
year old group.
88
CHAPTER FOUR
Discussion, Implications, Conclusions
Overview
Today medicine and health care delivery have become
organizationally based on a broad scale. The trend is toward salaried
employment for physicians in group-based practices, with the most common
of these being the Health Maintenance Organization (HMO).
The literature on management and organization has paid little
attention to physicians in bureaucratic settings, and particularly to physicians
who enter management roles within these settings. Though other
professional groups have been studied for decades, studies of other
professions that have established a management segment generally reveal
the differences rather than similarities across professions; thus, only limited
guidance is offered from this literature from which to predict the future of a
management element within medicine (Montgomery, 1987).
The changes we are witnessing in the health care environment have
served as a major impetus for the study of complexly structured health care
delivery systems and the physicians who are now employees and managers
within them. As the technical and institutional nature of medical work has
become increasingly complex, research needs to be carried out by
institutional setting to be valid (Light and Levine, 1989).
89
This research examined the different motivational patterns of
administrators, physicians and chiefs-of-service (physician managers) in a
specific HMO setting. The objective was to gain insight into the
motivational dynamics of these health care professionals--and particularly
physicians--a group which is important to the future of health care delivery
systems.
Within the HMO setting of the research, the professional physician
group practice system was supported by a more hierarchically structured
administration system. It was hypothesized that these two systems would
differ in structural characteristics and that the subject groups studied within
these structures would identify motivational patterns which matched the
variable system types.
The research also tested a number of hypotheses concerning
motivational dynamics, work satisfaction and role stress. Specifically, those
subjects with motivational dynamics which matched the system type within
which they worked were expected to report higher satisfaction with work and
lower role stress.
A focal aspect of the study related to the chief-of-service-both by way
of comparison of motivational dynamics with the lay administrators and
practicing physicians, and with respect to his/her motivational dynamic when
entering medical management. More and more today, the large
90
bureaucratic setting is the arena in which the physician works and
management career choices are made.
Within the HMO, chiefs-of-service are selected from within their
medical specialty department and appointed by the medical director with the
advice and consent of the department physicians. It was assumed that
because of this informal and somewhat democratic selection process, the
choice issue warranted investigation; that perhaps a significant number of
chiefs in the HMO had not made a career choice to enter management
when they assumed the chief-of-service role. Those chiefs, who in addition
to being appointed into position, also made a choice for their careers to
move in this direction were hypothesized to be more professionally
motivated, report greater satisfaction with work, report a stronger desire to
remain in medical management in the future, and be younger in age than
those who entered management through a situation in which it was not a
clear career choice by them to do so.
The findings of this study are mixed in terms of support for the
research hypotheses. Results reveal that the HMO is in fact variably
structured, as the different subject groups identified differing structural
characteristics to be present in the administrative and physician settings.
The HMO system types were different in some cases than predicted
however, which served to highlight the uniqueness of the HMO system and
91
contribute to our understanding of it. The findings suggest that it is because
of the HMO structural deviations from more classic bureaucratic and
professional systems that some of the research hypotheses were not
supported.
Results of the hypotheses testing will be discussed specifically by
subject group(s) below. Following this, the implications that these results
have for the management of the HMO organization as well as for future
theory and research will be delineated.
Discussion
Administrators
Though the administrative system within the medical center was
hypothesized to be primarily a hierarchic system, the administrator subject
group perceived the system type to be both hierarchic and professional in
nature. The OODQ mean scores, at 5.8-H and 5.7-P, are below the cut-off
of 6.0 required by Oliver for a fully bureaucratic or professional structure to
be present. The system type is therefore semi-hierarchic and semi-
professional, indicating that the work in this system has some of the
characteristics of work in both bureaucratic and professional organizations.
In a professional bureaucracy the existence of dual structures is
expected— one of highly trained professionals organized in a democratic
structure, and a second support structure which is bureaucratic with top-
92
down authority. It is plausible that within a professional bureaucracy, the
administrative system is only semi-hierarchic because of its charter to act in
support of the professional group. Though the systems run parallel, they are
not separate and self-contained; a degree of hierarchy is necessary within the
administrative component but within the bounds of and subservient to an
essentially professional organization. Hence, the levels of both hierarchic
and professional system perceived by the administrators.
To further this explanation, Harrison and Kimberly (1988) in a review
of HMO issues and problems state that the most important but most difficult
group to manage in an HMO is the medical staff. A participatory but firm
style is required. Stated an HMO representative from the study, "Managers
in health institutions cannot impose a hierarchical management structure on
physicians and, in fact, should make governance participatory on every level."
The findings from the present study may be understood in light of the
necessity for the administrators to work closely and in conjunction with such
a physician group. This may well explain the lower than expected levels of
hierarchy that were found present in the administrative system.
In Hypothesis 2, the motivational pattern of administrators which
matched the system type for the administrative system was expected to be
elevated, i.e., mixed hierarchic and professional motivation. This was, in
fact, found to be the case. For 44% of the administrators, the hierarchic
93
and professional motivation scores were statistically the same. Where one
motivation pattern predominated, it was more often the hierarchic than the
professional. What is most distinctive about these administrators in a
motivational sense is their dual or hybrid motivational pattern, which is a fit
with their work context.
With respect to the professional motivation of this group, it is
important to note that in addition to being members of a professional
organization, many of the HMO administrators are professionals in their
own right. As indicated in the demographic data for this subject group
(Chapter Two), 53% hold degrees at the Masters’ level. This may account
for the level of professional work system perceived to be present by the
administrative group on the OODQ, as well as for the administrative group’s
elevated professional motivation.
Furthermore, as a medical care delivery organization, the HMO
perpetuates the professional values of the medical profession. The
relationship between individuals and the organizations in which they work is
an important factor in determining the professional status of those
individuals (Pilgrim, 1986). These administrators work in close coordination
with physicians. In many cases, the administrators not only have Masters’
degrees, but are trained in nursing or other health care occupations. Given
that the HMO is physician-dominated, the values, norms and ethical codes
94
of the medical profession and of the HMO form of health care predominate
for the administrators as strongly as does the hierarchic influence.
Finally, for the administrator group, the motivational constellation
which matched the system type was tested to determine if it correlated
positively with satisfaction with work and negatively with role conflict and
role ambiguity. Results revealed the hierarchic motivation pattern not to
correlate significantly with the criterion measures. Professional motivation
was found to be significantly correlated with satisfaction with work, but not
with role conflict and role ambiguity.
The lack of expected relationships here is understandable, given that
the administrative group did not fully meet the Oliver criteria for either a
fully hierarchic nor fully professional system. The hypotheses were
formulated on the basis of pure system type. Also, as will be discussed with
respect to the physician subject groups, role motivation does not appear to
be related to role conflict and role ambiguity generally.
Yet, those administrators with higher professional motivation were
found to be significantly more satisfied with their work. This observation
suggests that highly professional administrators may derive satisfaction out of
their role as a medical and HMO professional. Additionally, by definition a
professional values acquiring knowledge, autonomy, status, being of service,
and professional commitment and ethical norms. Haga, Graen and
95
Dansereau (1974) found in a longitudinal study that managers highly
oriented to professional reference groups shape their work roles in markedly
different ways than less professionally oriented managers. Differential levels
of professionalism may be in this way related to different levels of task
involvement and work satisfaction.
The Medical System— Practicing Physicians and Chiefs-of-Service
The physician group means are 6.1 on the H-scale and 9.3 on the P-
scale of the OODQ. The Oliver criteria for a fully professional and fully
hierarchic system type is a mean of 6.0 and above. The physician group
therefore describes their work structure as strongly professional, with a
significant degree of hierarchy as well.
The chief-of-service group means are 5.3 on the H-scale and 8.9 on
the P-scale of the OODQ. This group has identified their system type to be
primarily professional, with some of the characteristics of hierarchic systems.
Oliver’s (1982) results indicate mean scores for independent
professionals to be 1.0 on the H-scale and 11.8 on the P-scale. Both HMO
subject groups of physician professionals perceive considerably more
bureaucracy than do the independent professionals, as would be expected in
this large HMO setting. Oliver’s sample of Certified Public Accountants,
with OODQ mean scores of 5.5 on the H-scale and 9.1 on the P-scale, are
similar to the physician group means in the present study. This would
96
support Hall’s (1968) finding of negative correlations between
professionalism and bureaucratization. A certain level of bureaucratization
may be necessary, according to Hall, to maintain social control. Engel
(1969) demonstrated likewise that it is not bureaucracy per se, but the
degree of bureaucracy that limits autonomy. In the Engel study, physicians
in moderately bureaucratic settings perceived themselves as having greater
autonomy than those in nonbureaucratic or highly bureaucratic settings. So
the issue seems to be one of balance; if a balance is not maintained then the
conflict for professionals is likely to develop between professional and
bureaucratic orientation. It is a signpost for the HMO to heed as
professional structures tend to develop more and more of a hierarchic
overlay as they increase in size.
On the other hand, corporatization of medicine has occurred in part
from the excesses and deficiencies of a highly professionalized health care
system (Light and Levine, 1989). Examples of this have been the
professional emphasis on increasing levels of specialization resulting in
fragmented and dehumanizing care, and the professional emphasis to provide
the best clinical care regardless of cost which has led to over-use of medical
tests and procedures and cries for accountability. Levels of professionalism
and hierarchy needed for effective functioning of the system are not yet
known. Results from the present study and existing research suggest that a
97
blending of professionalism with hierarchical control is necessary to avoid
professional excess in medicine.
Of the three subject groups, the physician group perceives the
greatest level of hierarchy to be present in their system. The standardization
of skills, office visit time allotments and medical norms for treatment are
highly formalized for practicing physicians in the HMO. At the chief-of-
service level, though the chiefs are dealing with administrative issues as part
of their jobs, they report fewer hierarchic characteristics in the system.
Quite possibly, there is less standardization to this managerial aspect of their
work. Being in the chief role they may also perceive themselves as having
more control over their work.
With regard to motivational dynamics, the combined physician and
chief-of-service group was found to have a mixed motivational pattern most
predominantly; for 58% of the subjects, hierarchic and professional
motivation were found to be at the same levels. The result here is similar to
that found in the administrative system, in that the mixed motivation pattern
predominates. However, when a single pattern predominates in the medical
system, it is more often the professional than the hierarchic.
These findings may help us to understand the generally high levels of
satisfaction with work in the HMO. Professionals, according to Sorensen
and Sorensen (1974), have difficulty adapting to both a professional and
98
bureaucratic orientation, particularly if bureaucratic orientation is low. The
physician groups in this study appear to be both professionally and
hierarchically motivated.
It is curious however, that hierarchic motivation is so strongly
indicated in the HMO samples of physicians and chiefs-of-service.
According to the HMO spokesmen on physician selection, when physicians
elect to join this HMO, they are selected for their commitment to this form
of health care delivery. This could account for the levels of hierarchic
motivation found in this study to some extent. There is a form of realistic
job preview and the physician can select into the HMO with some
understanding of what will be required. On the other hand, physicians are
prototypical professionals in many respects and it is difficult to understand
how equal levels of hierarchic motivation can accompany such a strong
professional value set for the majority.
The adaptive process of professionals in bureaucratic settings might
offer insight into the findings in this study of such an elevated bureaucratic
orientation. Sorensen and Sorensen (1974) noted that professional
conceptions are challenged and transformed by the requirements o f the
bureaucratic setting. Vollmer (1966) indicated that professionals may adapt
to a bureaucratic environment by becoming less professional and more
bureaucratic through socialization. Likewise, Derber (1982) claims that
99
professionals (specifically physicians in this case) accommodate to
corporatization by desensitizing themselves, by disassociating from the goals
of the institution, and/or by denying that control over the product of their
work is all that important. What matters is that one does one’s work well...
Physicians, like other professionals, are trained to make an end out of means
as a way of resolving troublesome sources of uncertainty (Light, 1979).
It is important to understand what internal process is occurring with
physicians in bureaucratic settings. Though the present research cannot
clarify the reasons for the elevated hierarchic motivation amongst the HMO
physicians, it certainly raises the possibility of an adaptation to bureaucracy
by the physician groups. The impact of (professional corporatization) on
consciousness, work, and the profession are often described but not yet
deeply understood (Light and Levine, 1989).
When contrasting the physician and chief-of-service groups on
motivational dynamics, results indicate that the groups did not differ
significantly on professional motivation. This data refutes Miner’s findings
that it is the individual higher on professional motivation who is promoted
or becomes the senior professional in a professional system. Again, this
result could be expected given the HMO selection procedure for chiefs-of-
service and the general avoidance by physicians of the business side of
health care. Yet, it is worrisome given that supervision of professionals is
100
rooted in technical competence (Miner, 1980; Oliver, 1982; McCall, 1983).
Perhaps the professional motivation in the HMO is not at the level it could
be, were professional leadership stronger.
The chiefs-of-service may not be more professionally motivated than
the practicing physicians; but they were found to be significantly more
hierarchically or managerially motivated than the physician group.
Montgomery (1987) found in this regard that control-related goals were very
important for all physicians, but that physician managers were significantly
more oriented toward positions of power as well.
What is apparent is that there does seem to be some appropriate fit
occurring within the HMO between the chiefs and their role prescriptions.
The chiefs-of-service are older as a group than the physicians in this study.
Perhaps age and tenure are relating here to increased hierarchic motivation,
as found by Connor and Scott (1974) and Kerr et al. (1977).
Though the chiefs perceive less of a hierarchic component to be
present in their work system than do the physicians, they themselves were
found to be more strongly managerially motivated, that is, they are more
motivated to work within a hierarchic system. The managerial aspects of the
chief role, it would appear, would be less likely to cause conflict for the
chief group given the group’s elevated hierarchic motivation.
101
There was one subscale on Miner’s hierarchy measure in which
significant differences were found between the practicing physician and
chiefs. This was the subscale of Authority Figures (AF). The chiefs-of-
service have a more favorable attitude toward people in authority generally I
i
than do the practicing physicians. This would presumably facilitate the
communication and interaction necessary between levels of management.
Finally, for the combined physician and chief-of-service group, no
correlations were found between professional motivation and work
satisfaction. This result may be an artifact of this research sample. These
groups, in general, are both highly professional and satisfied with their work;
hence there was not enough variability in the sample for significance to be i
found.
It should be noted additionally that with regard to the role stress
!
measures, motivational patterns were not found to correlate significantly
with these variables across subject groups. A basic conclusion of the present
research is that role motivation patterns are not related to the role stress
measures of role conflict and role ambiguity generally.
Chiefs-of-Service
Those in the chief-of-service group with elevated professional
motivation were found to be more satisfied in their jobs than chiefs with
lower levels of professional motivation. Professional motivation, as was true
102
for the administrative group discussed earlier, is closely associated with
satisfaction with work.
Within the chief-of-service group, there were in fact a larger number
of chiefs who indicated that they entered medical management in some way
other than through intentional choice; this allowed for the testing of
Hypothesis 8. Thirty-nine of the 59 respondents in the subject group were in
the no-choice group, leaving 20 who indicated a career choice was made. It
should be noted that the definition of choice was relaxed somewhat to
include respondents indicating a 3 {moderately descriptive), a 4 {quite
descriptive), or 5 {extremely descriptive), on the response scale. Nearly one-
half of the respondents indicated a "1" response for this item, or not
descriptive at all. This result would tend to indicate that within the HMO
studied here, physicians are entering medical management for inappropriate
reasons.
On the other hand, Montgomery (1987) found the attraction to
management to be the primary reason for the medical managers in her study
to enter management. Over 50% of the Montgomery sample of medical
managers were at a medical director level, however, which is another level
up in the medical hierarchy. It is less likely that a physician would proceed
this far into management without clearly choosing to do so.
103
An interesting curiosity in the findings is that such a large number of
chiefs report not choosing their roles, and yet as discussed above, they report
being significantly more hierarchically motivated than the practicing
i physicians. They seem to be claiming not to have chosen or wanted the
role, yet they are motivated in the managerial sense for it.
A plausible explanation for these apparent inconsistencies may be
found in the history and status of medical management. Traditionally, these
positions have been of less status and prestige than those of practitioners
(Shortell, 1974b; Abbott, 1981). In both the Montgomery research and the
present study (see demographic data), the chiefs-of-service were likely to
professionally identify most strongly with practicing physicians, while the
practicing physicians emphasized the manager aspect in the medical
manager’s professional identity. The practicing physicians are likewise more
likely to perceive the primary peers of medical managers to be other
medical managers. Montgomery interprets this as a tension within the
medical profession about the legitimacy of physicians in management roles.
Montgomery (1987) states: "The reluctance to accept a new segment is
based on a belief that the new group somehow diminishes the traditional
ethic or mission of the existing profession." It would appear likely that
though physicians may assume management roles, and may even be
motivationally suited to them, they nonetheless are affected by the negative
104
image of the medical managers of days gone by. Additionally, they may be
clinging to the primary professional identity that it took them several years
of medical education to attain.
The results of the final hypothesis revealed that the choice to enter
the management role was not found to be related to higher levels of H and
P motivation or work satisfaction. Choice was found to be significantly
related to chief-of-service desire to remain in medical management in the
future. In other words, 95% of those respondents who chose medical
management want to continue in such a role. By contrast, only 62% of
I
those who did not choose medical management are interested in continuing j
in this kind of position. For comparison purposes, an overwhelming
percentage (89%) of Montgomery’s (1987) physician executives indicated the
intention to remain in management. From this comparison it would appear
that within the HMO in the present study, many chiefs are not wanting to
assume the chief role, and therefore do not wish to continue in it. This
would indicate a need for the HMO to examine its selection process for
medical managers.
There is some indication, this time contrary to the Montgomery
findings, that those chiefs-of-service under 40 years of age are making a
choice to enter management more often than those in the over 40 year old
group. Montgomery (1987) found in this regard that physicians in the post-
105
i
1980 cohort entered management at an older age than physicians in earlier
cohorts. The result of a tendency toward earlier entry in the HMO research
appears to be an occurrence specific to this HMO setting.
Finally, sample sizes for the chief-of-service choice/no-choice
hypotheses testing were relatively small. When the group was used as a
whole with 59 cases, sample size was sufficient. As with the hypothesis j
testing relating to chief-of-service age, pulling out sub-sets of the chief
sample was required and made for limited sample size. Hypotheses not
supported might have been supported had (sub) sample size been larger.
Implications for HMO Management
A number of implications for management of the HMO are suggested
t
by the results of the present research: i
i
I
(1) There are clearly implications from this research for HMO selection |
I
and development practices for medical managers. The relationship
found for the chief-of-service group between choice to enter medical
management and desire to remain in medical management in the
future suggests that the HMO monitor and control the selection of
chiefs-of-service more closely regarding this choice variable. McCall
and Clair (1989) found that for those medical managers who did not
choose to have their careers move into management, commitment to
I
I
the job was lacking, the physician managers viewed managing as j
I
I
i
106
secondary to clinical practice, they ignored the expectations of the
organization or superiors, and/or they became bored with the
administrative aspects of their jobs. These individuals frequently
failed at their task, because it was not in their heart to manage.
Potential chiefs need to clearly understand the role requirements of
the chief position before accepting it. This can be facilitated through a
realistic job preview, talking with chiefs who are acknowledged to be
performing well in the role, and discussing the pros and cons of such a move
for a practicing physician with physicians and chiefs-of-service alike. Such
an understanding of the role would improve the initial self-selection process.
From the organization’s standpoint, role requirements must be
clarified. Candidate assessment then needs to include demonstrated skill in
these requirements, where possible. Within the HMO in the present study,
a physician is not eligible for chief status until having been with the
organization for a few year’s time. The HMO therefore has ample
opportunity to assess candidates with respect to demonstrated ability in
physician team leadership.
In recent years, the number of assistant chief positions has increased
throughout the HMO. These are generally in the larger medical
departments i.e., family practice, pediatrics and internal medicine. Where
possible, this career ladder needs to be made a requirement for succession
107
into the chief role, thereby providing somewhat for the needed
developmental process into medical management. i
Also from the standpoint of the organization, the HMO needs to
consider instituting a more open selection process, whereby a pool of
candidates for a specialty area would be drawn from across the HMO
system. This HMO is fortunate in having many medical centers and regional
areas from which to draw candidates. Some useful cross-fertilization
between areas and regions could result as well. Most of all, this would
provide for a greater probability of selecting a candidate who is motivated
i
and competent at managing. Though this may meet with political opposition !
within the HMO, the selection process needs to be from amongst a larger
candidate pool. !
i
Finally, the HMO could consider hiring from outside the HMO j
system entirely, although it would fly in the face of 40 years of tradition to
do so. Barring this, when hiring physicians into the organization initially the
I
selection criteria need to be broadened from a good team player to for some, 1
a good team leader orientation. A system for identification and cultivation of
high potential medical managers could in this way be instituted from time of j
selection.
Each of these recommendations is, of course, toward the end of
selecting high performing medical managers and improving physician
108 ;
leadership throughout the HMO. Once selected, the HMO already has in
place a physician executive training program to develop and enhance skills
needed in such management roles.
Successful organizations look for ways to develop their managers also
through on-the-job experience (Kotter, 1988). Again, the present HMO is
large, decentralized, and there is ample opportunity because of this for
systematically creating on-the-job learning and development opportunities
for medical managers. Careful consideration by joint Human Resources and
medical manager teams needs to be given to how this would best be done
and action taken to put such systems in place.
There may also be a need indicated in the results of this study for the
HMO to monitor and control the performance of its chiefs-of-service; some
chiefs may be continuing to perform primarily as clinicians and thereby not
performing the managerial and administrative aspects of the chief role.
Role performance and effectiveness were not identified in this study, but
from the reported time allocations reported in Chapter Two, it is evident
that the chiefs perceive themselves to be primarily engaged in clinical
service. It was not possible to assess the appropriateness of this data herein.
(2) Miner (1980) suggests five ways professional organizations can instill
professional values and meet the needs of its professional members.
They are: (a) Foster the development and dissemination of
109
knowledge to members; (b) Protect the freedom of members to act
with professional independence; (c) Foster the prestige and status of
the profession and of its individual members; (d) Create opportunities
for members to serve clients; and (e) Define a full-fledged profession
with appropriate norms and values.
Given that the hierarchic overlay was found to exist to a significant
extent within the physician group, the HMO needs to monitor the balance
between professionalism and bureaucracy in the medical system. If a
balance is not maintained in favor of the professional characteristics of the
system, conflict for the professionals will no doubt increase as the
professional performance of the HMO declines. The suggestions outlined
above by Miner are useful guidelines for maintaining and enhancing the
professional character of both administrative group and the medical
organization. In general, the organization needs to perpetuate the
behavioral manifestations of professional values. It is also recommended
that acts of professional excellence be systematically rewarded.
With respect to the medical managers, the case has been made by
Montgomery for a bona fide medical management sub-specialty within
medicine. In the current research, the greatest percentage of the chief-of-
service subject group perceived their professional identity to be that of a
practicing physician, as opposed to an administrator or manager. Again,
110
with respect to Miner’s five guidelines outlined above, it is recommended
that the HMO promote medical management as a full-fledged profession and
thereby increase the status of medical management positions. Reward
structures which have traditionally not rewarded those physicians who take
on management roles would need to be changed. Networking of medical
managers, perhaps as an outgrowth of the physician executive training, must
be fostered for a new professional identity to take hold. With an
improvement in the status and image of physician managers, quality
candidates would more readily be drawn to the role and those in such roles
would have greater opportunity and efficacy for effective leadership.
(3) Currently, chiefs-of-service within the HMO can go back into full- !
|
time practice if they do not wish to continue in a role as chief. They
can do this at any point, but the general term cut-off point is at the
end of six years. It is not known by the HMO, however, how many
chiefs in fact elect to do this, nor what their exit and re-entry !
i
i
experience is like back into full-time practice. Often, failure to j
perform well in a job can have detrimental psychological effects
(Sprague, 1984). The chiefs undergoing such experiences and the
system as a whole would greatly benefit from an understanding of this <
j
process. It is therefore recommended that an assessment be done
and records kept to track this occurrence in the HMO; it would
111
provide for useful feedback and planning of the medical management
selection and development system.
Implications for Future Research
The sampling for this research was limited to one HMO setting.
Therefore, inferences from these findings may be generalized to other
similarly structured HMO systems, but not to health care systems generally.
The research to date related to physicians and physician managers is
very limited; additional research endeavors are warranted to further
understand these groups in today’s turbulent health care environment.
Replication of this research with physicians in other health care
delivery systems would add to our understanding of these structures and the
professionals who work within them. Specifically, today physicians work in
such structures as independent or small specialty-based group practices, non
profit and for-profit HMO’s, Preferred Provider Organizations (PPO’s) and
hospitals. Future research is needed to understand what kinds of structural
arrangements result in increases or decreases of professionalism and the
professional’ s satisfaction with work. It is recommended that the system or
structural setting of the research be identified at the outset, before testing
additional hypotheses.
Replication of the current study would also prove useful with respect
to physician manager motivation-professional, managerial and in entering
112
1
the management role. A management segment within medicine is emerging,
and little is known about the direction it is taking.
The small sample size in testing some of the chief-of-service
hypotheses also suggests that the chief-of-service hypotheses in the present
study be replicated with larger sample sizes.
Research is needed as well which breaks out different levels of
medical management and begins to identify characteristics of the different
levels. The present research sampled the chief-of-service level only, which is
akin to the senior professional or supervisory level within corporate
structures. McCall and Clair (1989) distinguish between two key levels. At
the first management entails few major changes, such as supervising a small
group in a narrow medical specialty, keeping a hand in providing patient
care, and working with bosses and subordinates who are also physicians. At
the next level more significant changes are demanded, as the role requires
that the physician deal with non-physician bosses and subordinates and
perform such new functions as budgeting and financial responsibility for
revenue production, marketing, strategic planning and community relations.
More work is needed regarding the whole area of assessing role
effectiveness. For instance, further work on hierarchic and professional role
motivation with physicians should include assessing the subject’s job
performance or effectiveness in the role. Likewise, as differential levels of
113
professionalism were in this study related to increased work satisfaction, it is
important to examine whether or not elevated professionalism relates to
performance indicators such as providing higher quality service. There is
some evidence that for professional workers, job satisfaction and
performance are positively related (Lichtenstein, 1984). Thus, with regard to
chief-of-service choice to enter, choice to enter might be explored to identify
its relationship to job performance as a chief.
Finally, the adaptive and socialization processes of physicians as they
work within bureaucratic structures would be a fruitful direction for future
research. Research of this kind might well suggest direction for maintaining
high levels of physician professionalism and effectiveness, and thereby help
to insure integrity of our health care delivery systems as medicine becomes
corporatized on a large scale.
Conclusions
The administrators and physicians of the HMO in the present study
work within a mixed hierarchic and professional environment. The HMO is
variably structured, that is, these subject groups report very different levels
of hierarchy and professionalism characteristic of their separate work
contexts. The greatest percentage of each subject group in the study are
motivated by both hierarchy and professionalism. Additionally, the chiefs-of-
t
i
114 i
service in the HMO report significantly greater levels of hierarchic or
managerial motivation than do the practicing physicians.
These relatively elevated levels of hierarchic motivation for all subject
groups may well help the professional in accommodating to work in
corporatized medical organizations. Literature suggests, however, that highly
bureaucratized work contexts have significant effects on professional
workers, with the potential to decrease morale, productivity and quality of
service. As reported herein, professionalism relates closely with satisfaction
with work for two subject groups. Maintaining a professional work system
and avoiding excesses in a bureaucratic overlay is therefore an essential
charter for the health of the HMO in the future.
Also important to the future is the way in which the management
segment within medicine emerges and develops within the HMO. Within
the current study a significant number of physicians in the chief-of-service
role indicated that it was not their choice to have their careers move toward
medical management. Choosing a management career course was found to
be closely related to desire to remain in the management role in the future.
Ultimately, physicians in management roles who have not chosen them auger
for decreased satisfaction and potentially deviant behavior on the part of the
individual professional (Raelin, 1985).
115
Finally, professional excesses have been demonstrated over many
years in medicine. These excesses have in part resulted in the current
restraints on medicine and rise in managed care forms of health care
I
delivery. A blending and balance of medicine and hierarchy appears
essential in the current regulated health care environment.
As more physicians work and make their careers in large corportized
settings, the manner in which both the professionals and the professional
institutions deal with professionalism and hierarchy will become increasingly
important. As Light and Levine (1989) suggest, perhaps the very notion of
what it means to be professional is undergoing basic change. Certainly this
appears to be the case as the practice of medicine becomes inextricably tied
to the characteristics of the complex organizations in which patient care is
taking place.
1 1 6
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New Jersey: Prentice Hall.
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high-tech employees. Cambridge, Massachusetts: Ballinger
Publishing Company.
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York: Free Press.
Wilensky, H. L. (1964). The professionalization of everyone? American
Journal of Sociology!. 70: 137-158.
126
Wohl, S. (1984). The medical industrial complex. New York: Harmony
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Yukl, G. A. (1981). Leadership in organizations. Englewood Cliffs, NJ:
Prentice-Hall.
Appendix A
U n i v e r s i t y o f S o u t h e r n C a l i f o r n i a
S c h o o l o f B u s i n e s s A d m i n i s t r a t i o n
L os A n g e l e s 90089-1421
(213) 740-0728
D e p a r t m e n t o f M a n a g e m e n t
a n d O r g a n i z a t i o n
Dear Health Maintenance Organization Executive:
You are part of a unique health care delivery organization at a
time when the medical field is changing rapidly. This research
effort is designed to aid in understanding this change, and
particularly in learning about the role of physician executives
within an HMO setting.
The important role of physician executives within health care
delivery is well recognized today. Yet, little systematic
research has focused on this area. This questionnaire is
therefore designed to learn about your opinions, background,
career paths from clinical practice to management, and your
reasons for making the choice to enter a management position.
Your responses to this questionnaire will be processed by
computer at USC. CONFIDENTIALITY OF YOUR RESPONSES IS ASSURED.
No one from the Health Maintenance Organization will see your
individual responses to the questionnaire. Summarized results
will be used for research purposes, and are available to you upon
request.
There are no right or wrong answers to the questionnaire. For
the results to be useful it is important that you answer each
question frankly and honestly.
After completing the questionnaire, place it in its envelope and
mail it to USC.
I want to thank you for your cooperation and assistance. It is
greatly appreciated! If you have any questions about this
research, please contact me at the above address or telephone
number.
Lynn Newman
use
128
YOUR BACKGROUND AND EXPERIENCE
In this section, please check the most appropriate answer to each question, or fill in the blank
with legible print.
1. Organization Position:
Medical Director _____________
Chief-of-Service _____________
Asst. Chief-of-Service _____________
Other (Specify) ________________________________________
2. Age:
1. From 30-34 years
2. From 35-39 years
3. From 40-44 years
4. From 45-49 years
5. From 50-54 years
6. From 55-59 years
7. 60 years or older
Sex:
Male
Female
4. Ethnic Origin:
Black
Asian or Pacific Islander
Caucasian
Hispanic
American Indian
Other (Specify)
5. Year Graduated from Medical School:
Area of Clinical Specialty(ies) Board Certified?
a) _____________________________ yes ________ no
b) _____________________________ yes ________ no
129
7. Length o f time employed by this Health Maintenance Organization:
a) as a clinician _______ years
b) in physician management role(s) _______ years
8. After becoming an M.D., did you work in another setting or organization before
coming to this Health Maintenance Organization?
no ________
yes ________
If yes, specify position _________________________________________
130
MEDICAL MANAGEMENT EXPERIENCE AND BELIEFS
Listed below are different ways that physician managers say they got into a medical
management position in the first place. Think back to the time when you FIRST entered a
role of this kind, such as chief-of-service, etc. Indicate the extent to which each of the
following describes how that happened for you personally, by circling the appropriate number.
1 2 3 4 5
Not at all Slightly Moderately Quite Extremely
descriptive descriptive descriptive descriptive Descriptive
Descriptive?
9. EVOLUTION. You began taking on small-scale 1 2 3 4 5
administrative duties. Slowly, these duties grew to
larger dimensions.
10. EXPERTISE. You were approached and asked to 1 2 3 4 5
take on a management role on the basis of
outstanding accomplishment or skill, i.e., specialized
medical credentials, network of contacts, etc.
11. DEFAULT. There was a need for someone to take 1 2 3 4 5
the position but no one available or willing. You
agreed after being "persuaded," or as a way to get
resources, to help out, or to keep others from
managing you.
12. CHOICE. You deliberately chose a medical 1 2 3 4 5
management career path for whatever reasons, i.e.,
interest in business, tired of clinical practice,
opportunity for contribution to the field, etc.
13. ORGANIZATIONAL CHANGE. You found 1 2 3 4 5
yourself in a manager role as the result of a merger,
acquisition, organization restructuring, etc.
14. CULTIVATION. Your organization had a planned 1 2 3 4 5
developmental process to prepare you for the
manager role through job experiences, management
development and/or a mentoring relationship.
15. OTHER. Please specify. ___________________________________________________
131
16. How have you divided your professional work time between patient care and
administration? (complete each column, please)
NOW EXPECTED IN 5 YRS.
1 % time on patient care % %
2 % time on administration % %
3 % time o n ________________________ % %
4 % time o n ________________________ % %
100% 100%
17. D o other physicians think of you PRIMARILY as a physician or as an administrator
(check one)?
1______ _____________ as a physician
2 _____________ as an administrator
3 _____________ other (specify)_________________________________________
18. How do you MOST OFTEN think of yourself (i.e., your professional identity) (check
one)?
1______ _____________ as a physician
2 _____________ as an administrator or executive
3 _____________ other (specify)_________________________________________
19. Since you assumed a role as a physician manager, whom do you consider to be your
PRIMARY peer group (check one)?
1______ _____________ practicing physicians in general
2 _____________ practicing physicians in this Health Maintenance
Organization
3 _____________ practicing physicians in your specialty area
4 _____________ other physicians in management positions
5 _____________ non-physician health care managers
6 _____________ other (specify)_______________________________________
20. Is your desire to remain in a physician management position?
1______ _____________ yes, in same position as now hold
2 ' _________ yes, but in a different management position
3 _____________ not sure desire is to remain in physician management
position
4 _____________ do not desire to remain in medical management
132
Please complete these sentences by checking the one among the six alternatives that best
expresses your real feelings. Try to do every one.
My family doctor... 8 . Wearing a tailored suit...
o is a good doctor o is uncomfortable in hot weather
o is a very important person in my life o does not bother me at all
o is someone I see when necessary o is a status symbol
o could show more interest in patients o doesn’t do a thing for me
o is always available when needed o makes me feel that I am well dressed
o is a quack and does not know much o makes me feel important
Sitting behind a desk, I... 9. Decisions...
o do a lot of work 0 are fun to make
o become bored o are sometimes good, sometimes bad
o often wonder if I will get the work done o should be made and stuck to
o feel confined o should be carefullythought out
0 feel obligated to do my job effectively 0 must be made
o feel comfortable o sometimes hurt, when they’ re wrong
Shooting a rifle... 1 0. Running for political office...
o takes skill and accuracy o would be interesting and challenging
o is relaxing o is not for me
o , I try to be careful o , you should be an honest person
0 is a sport I enjoy o requires a lot of hard work
o doesn’t appeal to me o would be exciting
o can be very dangerous o could be nerve wracking
Being interviewed for a job... 1 1. When one of my subordinates asks for advii
o is necessary o I try to be helpful
o is a pain in the neck o I feel good
o you should tell the truth o I give it freely
o is very interesting o I listen, but do not give advice
o makes me nervous o I always listen with sincerity
o , I am confident o I try to help the individual make the
decision by remaining neutral
5. Giving orders...
o is something I am not very good at 12. Country club dances...
o is not always a pleasant task o are fine for those who belong to a
o should be done in a tactful manner country club
o is better than receivingthem o are very formal
o is sometimes necessary o can be relaxing
o gives me a good feeling o bore me
o are fun
Brothers and sisters... o are a waste of time
o have the same mother and father
o are nice to grow up with 13. Conductinga meeting...
o should help each other o makes me nervous
o sometimes fight o is something I like to do
o can mean a lot to each other o does not necessarily produce the
o can be very difficult to understand intended result
o is good experience
Athletic contests o is not difficult
o are something I like to participate in o takes planning
o are not my cup of tea
o are exciting
o are very competitive
o have questionable value
o should always be played to win
133
Federaljudges... 2 1 . Top management...
o make questionable decisions at times o can make mistakes
o are enlightened individuals o I respect
o make important decisions o seems to be o.k. most of the time
o are relatively fair and impartial o are people doing a good job
0 are dull o isn’t involved with the lower levels enoug
o are o.k. I guess o sometimes has a difficult task
Getting ahead... 2 2 . Teaching a class...
o is my main objective o interests me
o means many things to many people o you must be prepared and able to get
o is impossible to achieve your viewpoint across
o is not the most important thing to me o is not a job I want to do
o is gratifying o is a very rewarding experience
0 means a lot of hard work o requires patience and understanding
o makes me nervous
Dictating letters...
0 , you should express yourself clearly 23. Making long distance telephone calls...
o can be a bore o should be kept to a minimum
o makes me feel important o saves a lot of time
0 saves a great deal of time o is o.k. when needed
o doesn’t bother me o is easy today
o is time consuming o is a good way to stay in touch
o costs a lot of money
Punishing children...
o is necessary at times 24. Playing golf...
o requires some thought o is very relaxing and enjoyable
o when they’re wrong, is best for everyone o attracts an older crowd
concerned o is a time consuming hobby
o is not the best way to correct behavior o is for those who enjoy it
0 is a depressing task o is not my game
o now will have its rewards later o is one thing I would like to do more
If I were running my own business... 25. My education...
o I would make it a success o will never be complete
o I would really enjoy it o is very important to me
o I would do my best to make a profit o hasn’t helped me much
0 I would probably not enjoy it o is not what it should have been
0 I would be my own boss o is something I am very proud of
o I would probably go bankrupt o has required hard work
Marriage... 26. Getting my shoes shined...
0 has its ups and downs o is not something I do often
0 is a serious thing o improves my appearance
o serves no useful purpose o doesn’t do anything for me
0 is a two-way partnership o makes me feel important
o is wonderful o is a bore
o can be satisfying and rewarding o is routine
If I were physically disabled... 27. If I am promoted...
o I would try to make the best of my o I would be proud
remaining capabilities o I would lose many friends
o I would need a lot of help o I will try to do my best
o it would be quite a blow o it will be based on what I know, not who
o I don’t know for sure what I would do I know
0 I would try to get involved in something o I’ll faint
o I would become very depressed o I will get a raise in pay
134
When playing cards, I... 35. Writing memos...
o usually lose o is a means of expression and
o like to win communication
O get bored easily o is a necessary evil
o have a good time o can be boring
o concentrate on what I am doing o is a good habit to get into
o do not cheat o
o
should be done carefully and complete!
helps me to remember things
Getting other people to do what I want...
o is not always easy 36. Making introductions...
o gives me a feeling of accomplishment o helps to put people at ease
o doesn’t always seem that important o should be done properly
o is one of my ideals o is awkward at times
o is sometimes necessary o gives me pleasure
o if they don’t want to, is hard for me o
o
does not present a problem
can sometimes become a bore
My father...
o has disappointed me 37. Final examinations...
o is (was) a wonderful person o take a lot of study
o is (was) the head of his household o give me anxiety
o is (was) a man I admire(d) very much o help to show what you have learned
o has had a great effect on me o are a challenge I enjoy
o is best forgotten o
o
are a poor way to measure knowledge
are not difficult, if you are prepared
Arguing for a point of view...
o is exciting 38. Policemen...
o
I stand up for what I feel is right o have a difficult job to do
o can cause ill feelings o are brave
o is alright if you know what you’re talking
about
o are underpaid and not appreciated
enough
o sometimes seems pointless o represent authority
o I listen to all that is said o generally think they are superior to
everyone else
When driving a car, I... o sometimes misuse the law
o drive defensively
o try to observe the law 39. Yacht racing...
o feel good o is expensive
o remind myself to be alert o is beautiful
o feel at ease o is exciting
o tend to tighten up o
o
is something I know nothing about
doesn’t really interest me
Presenting a report at a staff meeting... o looks like it would be fun
o requires preparation
o makes me nervous 40. Going to Sunday school...
o is o.k. o is a good place to meet people
o can be satisfying o is a source of peace
o would be a pain in the neck o generally isn’t very rewarding
o is the kind of thing I like o
o
helps in making a well rounded person
is a chore
When running a race, I... o is an individual matter
o usually don’t do too well
o hold my own
o try to pace myself
o get out of breath
o try to win
o enjoy the competition
135
In the following section, please consider your job and indicate the 1 =
degree of your agreement or disagreement by writing the 2 =
appropriate number on the line provided. 3 =
4 =
5 =
1. I have to do things that should be done differently.
2. I receive an assignment without adequate resources and materials to
execute it.
3. I work with two or more groups who operate quite differently.
4. I have too much work to do to do everything well.
5. I work on unnecessary things.
6. My job requires me to do things against my better judgment.
7. I have to buck a rule or policy in order to carry out an assignment.
8. I receive incompatible requests from two or more people.
9. I have enough time to complete my work.
10. I do things that are apt to be accepted by one person and not accepted by
others.
11. I feel certain about how much authority I have.
12. My job has clear, planned goals and objectives.
13. I know that I have divided my time properly.
14. I know what my responsibilities are.
15. I know what is expected of me.
16. Explanation of what has to be done is clear.
17. The amount of work I am asked to do is fair.
Almost always
Often
A s often as not
Occasionally
Almost never
136
Think of your present work. What is it like most of the time? In the blank beside each word
given below, write
Y for "Yes"if it describes your work
N for "No"if it does NOT describe it
? if you cannot decide
WORK ON PRESENT JOB
1 . Fascinating 9. Useful
2. Routine 10. Tiresome
3. Satisfying 11. Healthful
4. Boring 12. Challenging
5. Good 13. Frustrating
6. Creative 14. Simple
7. Respected 15. Endless
8. Pleasant 16. Gives sense of
accomplishment
137
This final section is in a somewhat different format. But it is a very important aspect of the
questionnaire. Please try to respond to each of the questions. Express your real feelings. All
that is required is a few words to complete the sentences. Please write or print clearly.
1. I prefer my friends to be...
2. A sense of calling...
3. Having an important job...
] 4. Contributing to a charity...
6. Scientific theory.....
7. Working as a reporter...
8. After I do what I think is right.....
9. Teaching at a university...
10. If my boss turns down my ideas...
11. A lifelong career...
12. Carrying out research...
13. When I have a certain amount of faith in my decisions...
14. Counseling others...
15. Freedom...
5. Bringing up children...
138
16. The respect of others...
17. When an answer seems needed...
18. When I have a problem, I...
19. Possessing a doctor’s degree...
20. When I must choose my own projects...
21. Religious doctrines...
22. My work...
23. Working for a widely respected organization...
24. Knowing the right answers...
25. If I become my own boss...
26. Professional ethics...
27. Attending Harvard...
28. Child development work...
29. Having a large office...
30. Being elected...
31. Learning to spell...
32. Bringing work home from the office...
33. Loyalty...
34. Doing detective work...
35. Giving a lecture to students...
36. When a person needs advice, I...
37. Working to get an education...
38. Having a private practice...
39. When people seek help from me...
40. Attending a training program...
140
Appendix B
Correlation Matrix of Variables Used for
Hypothesis Testing by Subject Group
Administrators
Role Role Professional
Conflict Ambiguity Motivation
-.28*
.1 2 -.18
.01 -.11 .31**
p < .05*
p < .01**
p < .001***
Satisfaction
With Work
Satisfaction
with Work
Role Conflict .31**
Role
Ambiguity -.41***
Professional
Motivation .29*
Hierarchic
Motivation .07
Hierarchic
Motivation
141
Physicians
Satisfaction Role Role Professional
With Work Conflict Ambiguity Motivation
Satisfaction
With Work
Role Conflict .31**
Role
Ambiguity -.32** -.35**
Professional
Motivation .14 .16 -.15
Hierarchic
Motivation .24* .07 -.06 .45*
p < .05*
p < .01**
p < .001***
Hierarchic
Motivation
142
Chiefs-of-Service
Satisfaction Role Role Professional Hierarchic Over
With Work Conflict Ambiguity Motivation Motivation Choice 40 Years
Satisfaction
With Work
Role Conflict -.10
Role
Ambiguity -.18 ..4 7 ***
Professional
Motivation .17 -.06 .01
Hierarchic
Motivation .35** -.19 -.02 .36**
Choice .11 -.22 -.11 -.18 .17
Over 40
Years .07 .21 -.23 .05 -.04 -.13
Desire to
Remain in
Management -.04 .25 .01 .12 -.22 -.30* .14
p< .05*
p < .0 1 **
p < .0 0 1 ***
Desire to
Remain in
Management
M
-ft.

Asset Metadata

Creator Newman, Honore Lynn (author)

Core Title Motivational patterns of administrators, physicians, and chiefs-of-service in a variably structured health maintenance organization

Contributor Digitized by ProQuest (provenance)

Degree Doctor of Philosophy

Degree Program Education

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag health sciences, health care management,OAI-PMH Harvest

Language English

Advisor Von Glinow, Mary Ann (committee chair), Hocevar, Dennis (committee member), McCall, Morgan W. (committee member)

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c20-283450

Unique identifier UC11260177

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Legacy Identifier DP23468.pdf

Dmrecord 283450

Document Type Dissertation

Rights Newman, Honore Lynn

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...

Repository Name University of Southern California Digital Library

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