How do we motivate physicians and other health professionals to work at their best? How do we create systems of high performance? Is it by a series of top-down highly specific mandates or by setting up general guidelines and providing tools?

I believe it comes down to one’s vision of physicians. Are physicians knights to be empowered in their service of patients or knaves not to be trusted or pawns to be manipulated?

Consider the goal of reducing inappropriate use of antibiotics. A policy aimed at physicians as pawns or knaves would be based on micromanagement at the point of care. Create a system of hard stops and drop-down boxes. Make the doctor justify each prescription. Limit options based on the diagnosis and duration of symptoms. Force the doctor to document in discrete data every element of the clinical encounter (date of onset of symptoms, fever or not, x-ray findings etc.) and only if the tick boxes align with the algorithm can the order be completed. Create a system where there will be many real-life circumstances that fall outside of the algorithm, and put physicians in a bind of trying to fit a square peg in a round hole. Results: workarounds and cynicism, and ultimately despair at another straight-jacket.

Alternatively a policy aimed at physicians as knights might be based on empowering physicians to act professionally in the best interest of their patients. Create a higher level expectation: for example, that each hospital or clinic have an appropriate use of antibiotics committee. Give guidance as to how that committee could be structured and work, with sample measures that could be tracked and sample communications to use with patients and providers. This approach treats physicians as knights, who want to do the best for their patients and community, and will do so when given support and guidance.

Much of the burnout of physicians can be traced back to an external environment that increasingly treats physicians more as knaves and pawns, and less as knights. And I believe the more physicians are approached as knaves and pawns, the more knave and pawn-like behavior there will be.

Conversely, when the external environment approaches physicians more as knights, and gives the tools to help improve, this will draw on physicians’ desire to provide the best care possible for their patients, and we will provide better care, not just in antibiotic usage but across the entire spectrum of illnesses managed.

Do you have any experiences, pro or con, with either the top-down or the bottom-up approach to improvement?

Christine Sinsky is an internal medicine physician who blogs at Sinsky Healthcare Innovations.