By C. Richard Patterson, MD
Surveys of physicians often separate “loss of autonomy” and “loss of respect” as reasons for dissatisfaction among those polled. I think they are complementary and should be combined. Together they represent the leading reasons for declining physician morale. We’ll get to that theme, but first a digression, a bit difficult; please bear with me.
Medical school was actually pretty easy, but surgery residency was intellectually, physically, and emotionally demanding. My program was very traditional, hierarchical, and authoritarian. One entered at the bottom presumed, more or less correctly, to know nothing. The survivors emerged at the top five years later, expected to know everything.
I could say I bought into the idea, but it was more like putting on my own skin. And it wasn’t enough to survive…I had to:
1. Absolutely kill it, and2. Make it look easy.
Whether or not I killed it or made it look easy, I was convinced that I was very well prepared as a surgeon, and I took as impertinent questions from non-surgeons---laypeople and “lesser specialists” alike. This resulted in some behaviors and interactions I shall always regret.
I was fortunate early in my post-residency, academic career to come in contact with modifying, humanizing influences. I also worked very hard to maintain and increase my edge in knowledge and outcomes. As I gained in experience and true confidence rather than chutzpah, I was able to become more open and vulnerable with patients and colleagues. That is where the true joy of medical practice lay for me, and the latter relationships are those that sustain me and make me grateful for the privilege of having been a surgeon.
I’ve taken this confessional digression in order to distinguish between “autocracy”, what I attempted as a newly minted surgeon, and “autonomy”, a trait and value that is essential to effective doctoring.
Autonomy is the latitude to act or recommend actions based on one’s education, training, knowledge and best judgment. In medicine, it should be exercised in collaboration and coordination with the patient’s self-autonomy and always with his or her interests held dearest.
Our society has granted autonomy to physicians based upon those assumptions. That professional autonomy is under assault, but not because it has been abused by the self-aggrandizing few or several, which it most certainly has. The assault is driven by ever-inflating and unsustainable healthcare costs, and the choke point is control of provider, i.e. doctor and hospital, behaviors.
Pretty early in my career, I had to begin seeking “pre-authorization” for surgical procedures I recommended to my patients. Insurors deny they were withholding “permission” to perform those procedures---no, no, no. They wouldn’t dream of interfering in the doctor-patient relationship. They were only determining whether they would pay the surgical fee and the associated and substantial hospital costs associated with the procedures. For the majority of American families, that constitutes “permission”.
I don’t recall ever failing, at least ultimately, in obtaining pre-authorization, and the various schemes employed by the payers have never ameliorated costs. They certainly increased the cost of running medical practices though, some of which had to create one or more staff positions to make the telephone calls. Hospitals had to create entire “utilization review” departments and processes. Medicare regulations made them mandatory.
My late father-in-law, a dentist and a prince, said something prescient to me, before I had even applied to medical school and during the heyday of the unfettered and fully reimbursed physician fee schedule. He predicted that relatively soon those who were writing the checks would begin controlling the party. He was right. Although the efforts so far have been clumsy and ineffectual regarding their goals, the side-effects have proven toxic for physician morale.
I’ll forego a further dissection of how doctors feel over-scrutinized, disrespected and obstructed and instead share a view of our imminent future from the editorial page of the Wall Street Journal, August 6, 2012.
In a piece entitled “RomneyCare 2.0”, the writer reviews the Massachusetts healthcare experience since the “reform”, instituted in 2006:
Health costs---Medicaid, RomneyCare’s subsidies, public-employee compensation---will consume some 54% of the state budget in 2012, up from about 24% in 2001. Over the same period state health spending in real terms has jumped by 59%, while education has fallen 15%, police and firemen by 11% and roads and bridges by 23%.
Several years ago, then-Comptroller General David M. Walker conducted his “Fiscal Wake-Up Tour”, in which he made similarly dire predictions for spiraling healthcare costs across the nation, costs which threaten our country’s financial standing and its physical security.
The Journal editorialist reports that Massachusetts Governor Deval Patrick will soon sign a “cost containment” bill passed by the legislature in response to those fiscal threats:
Under the plan, all Massachusetts doctors, hospitals and other providers must register with a new state bureaucracy as a condition of licensure---that is, permission to practice. They’ll be required to track and report their financial performance, price and cost trends, state-sanctioned quality measures, market share and other metrics.
The law will also create a Health Policy Commission to create and enforce rules that will limit healthcare inflation to no more than 0.5% per year. Healthcare inflation typically runs near or into double digits. The commission has the authority to disapprove any changes in organization or governance and to re-write contracts when it deems it necessary for cost control.
The writer asserts that the Affordable Care Act (“ObamaCare”) parallels the Massachusetts plan and can be expected to produce the same results in costs and similar efforts at control.
So, “loss of autonomy” isn’t likely to slip off the doctor dissatisfier list any time soon. Since we’re still dealing with reasons for doctor grieving at this point, I will not yet delve into the implications for your healthcare relationships, but I think they are profound and worth a future blog.