Quality Rounds
Physician Autonomy in the Age of Accountability
By Scott D. Smith
Doctors are rethinking what professional autonomy means as they increasingly are urged to follow evidenced-based guidelines and protocols.
The lone physician bucking bureaucracy and convention to save a patient is a popular plot in television medical dramas. In real life, that’s how the average patient might have viewed physicians and how the average physician might have viewed himself 20 years ago.
Indeed, autonomy—having the freedom to treat patients according to their best judgment—has been a huge part of how doctors have traditionally defined themselves as professionals.
But in recent years, their autonomy has been challenged as physicians have come to be viewed as fallible human beings and not so much as heroes wielding the sword of science.
In his 2003 article “Zen and the Art of Physician Autonomy Maintenance,” published in the Annals of Internal Medicine, former Park Nicollet Clinic head James Reinertsen, M.D., points out that this change in the public’s perception of physicians is fallout from the widespread media coverage of the Institute of Medicine’s “To Err is Human” report in 2000. The report revealed that physicians did not always know everything, nor did they apply all of the science they knew. And the news that 100,000 patients a year died because of medical errors not only shocked the public but spawned the modern quality and evidence-based medicine movements. Increased oversight, public reporting, treatment guidelines, and practice benchmarks are by-products of the report, and physicians must figure out how to preserve their autonomy in this culture of increasing accountability.
Reinertsen says the tension for physicians arises when a practice group, health plan, or outside agency seeks to eliminate practice variation by enforcing standards, guidelines, and order protocols. “Physicians get concerned about that because it is a directive from someone else saying this is how you should make a decision. And they say, No, I as an individual should make that decision,” says Reinertsen, who now lives in Wyoming and works as a consultant. He suggests the way through this is a Zen-like paradox: To regain control of patient-care decisions, physicians need to relinquish it to their colleagues. To preserve their autonomy, they must first give it up to systems they create and science and evidence they endorse.
When scientific evidence points to a clear course of action, physicians need to form teams inside hospitals, clinics, and medical groups that determine protocols and order sets. And they need to make a concerted effort to get their colleagues to follow certain approaches. “If we give up autonomy to each other as physicians, we gain it as a profession,” he says.
Reinertsen says a good example of this occurred at Beth Israel Deaconess Medical Center in Boston. The cardiac surgeons there instituted an insulin protocol between 2002 and 2004 to achieve tight glucose control of cardiac surgery patients in the operating room and intensive care unit that resulted in decreased rates of mediastinitis.
Reinertsen says other cardiac surgeons should take it upon themselves to institute similar protocols before a health insurer or someone else makes them.
Local physicians interviewed for this article agree that in order to improve the quality and safety of patient care, they need to submit to protocols and order sets created by colleagues. However, they also believe that systems, whether created by doctors or others, must allow for justifiable deviations when necessary.
Pseudo versus Real Autonomy
At Mayo Clinic, teams of nurses, physicians, and pharmacists devise standardized order sets and protocols that are based on the latest scientific evidence. Internist Mark Liebow, M.D., makes the point that hip surgery post-op orders, for example, aren’t likely to change much from case to case, so providing a basic template is beneficial. In his view, such templates, along with computerized reminders, allow physicians to devote more time to practicing the art of medicine, rather than dealing with mundane details. “If you have to remember ‘What did I do last time?’ every time, there’s a chance you will screw it up,” Liebow says.
If physicians need to deviate from the protocols, he says, they should note the reasons in the chart.
Safety First
Gary Oftedahl, M.D., medical director for the Institute for Clinical Systems Improvement, a Minnesota organization that enlists physicians to draft health care recommendations based on the best available evidence, agrees with Reinertsen’s thesis.
If doctors don’t heed this advice, Oftedahl warns, they’ll lose more even autonomy. “The buyers of health care that I speak with are becoming highly impatient with our unwillingness and inability as an industry to provide higher levels of care,” he says.
Basically, physicians need to standardize protocols where they can, he says, if they are to provide predictably reliable care. For example, he notes that research indicates that it’s important to control the blood sugar levels of patients in intensive care. The only way to do this reliably, he says, is for all physicians to use one set of orders, developed with the help of physicians and selected by the hospital’s physician leaders, as a baseline.
Relinquishing individual autonomy in this case is the only way to increase the reliability of outcomes, he says, because nurses presented with a variety of protocols from different doctors are more likely to make mistakes as they try to understand the nuances of each one.
Trust is a Must
Some doctors question the wisdom of implementing systems that would force them to uniformly comply with protocols, even those determined by other doctors.
Terence Cahill, M.D., a family physician in Blue Earth, Minnesota, says feedback loops and benchmarks for physicians are positive developments, but he’s uncomfortable with mandates or punitive measures tied to quality or use of guidelines.
Cahill agrees that physicians need to operate within accepted parameters defined by evidence, but he says physicians sometimes need to deviate from standard practice to care for a unique patient For example, he might discontinue a beta blocker if it doesn’t work for a heart failure patient. When treating patients for depression, he sometimes tries a third- or fourth-line drug. Would a payer or administrator think he doesn’t follow guidelines?
“That’s the real problem with most of this stuff.” Cahill says. “How can someone tell if I deviated from guidelines for a good reason or because I don’t know any better?”
Cahill believes doctors must be able to make the final call regarding their patients’ treatment. Physicians clearly need to be able to justify why they deviate from standard practice, he acknowledges. But he maintains that they also should be trusted because they’re the ones who actually see patients and are trained in the art of medicine.
Reinertsen acknowledges that physicians won’t be able to standardize all of medical practice. But he says they should move toward consensus on practice standards when they can.
“My fear,” he says, “is that if we, as doctors, hang on to our individual autonomy and don’t standardize what is standardizable, society will watch us make all these mistakes and say, ‘They had the autonomy to self-regulate and didn’t do it very well.’” MM
Scott Smith is a staff writer for the Minnesota Medical Association.