How to restore physician autonomy

The sad truth is that many physicians are dissatisfied with their careers. They still enjoy helping their patients, but often feel beaten down by many challenges that overwhelm the reason they went into medicine in the first place. Survey results show that a lack of autonomy often is to blame for their frustration. But what does physician autonomy mean in today’s health care world?

Medical Economics® recently interviewed Wendy Dean, M.D., a psychiatrist and president and co-founder of Moral Injury of Healthcare, to discuss what physicians can do to take back control of their careers. This interview was edited for length and clarity.

Medical Economics®: One of the things we hear about often from our audience is that they lack an autonomy they feel they should have as physicians. Can you talk a little bit about physician autonomy and what that means to you?

Dean: Physicians are trained from the time they go into medical school, and sometimes even before that, to be independent thinkers, to be critically analytical about the problems that they’re looking at that, that they’re investigating for their patients. And they’re also taught not to blindly follow algorithms because that may get them into trouble. And so, after a decade of that sort of training, to go out to practice and have to follow strict algorithms based on reimbursement policies, rather than on clinical best evidence, really goes against the grain of what we believe is good patient care.

ME: In a previous episode, we talked about moral injury. And I’m just wondering how much you feel there’s a relationship between moral injury and a lack of autonomy?

Dean: From my perspective, there’s quite a lot when we are not allowed, for reasons other than good patient care, to get patients what they need. That really goes against some deeply ingrained beliefs on our part and the promises that we made to our patients when we left medical school and went out into training. And the more we are constrained in what we can do for patients, the more frustrated, the more demoralized we become. So I think the two are linked.

ME: One of the things we often hear from our physician audience is that the solution to these systemic issues is just to get rid of the insurance companies, open a direct pay practice or concierge practice. What do you think about direct pay and concierge for simplifying a practice and are they solutions to physician autonomy concerns?

Dean: I think those are great solutions for some physicians. I’m not sure that it is a viable solution across all of health care in the U.S. I have practiced as a direct patient care psychiatrist, and it really did streamline my practice quite a bit. But ultimately, it wasn’t a solution for all of the patients that I wanted to see. So what I would like to get back to is a practice where we don’t have to make those machinations of direct patient care or not, that every patient comes through and can get the same attention, the same one-on-one care, the same undivided attention from their physician ... can walk out and get the prescription they need, the physical therapy they need, the imaging they need, without either the patient or the physician having to go through contortions to make that happen.

ME: What systemic changes do you think need to happen with health care in our country to allow physicians to have more autonomy to spend more time with their patients?

Dean: The biggest change that needs to happen is for the health care system to change the way it supports physicians. So, right now, when physicians are engaged with a patient, they’re reporting to their chief financial officer about how many patients they’ve seen, and this is all indirect, but they’re expected to make metrics on how many patients they see. They’re reporting to the insurer about what they think this patient needs. They’re making a case for why they need the imaging or why they need the medication. So the physician is actually responsible to report to a lot of different people. And really what would be great is if the administrative side of medicine would instead ask how they can support the physician and the physician-patient relationship and change the dynamic so that the physician is facilitated, and how they can get their patients what they need.

ME: The No. 1 reason physicians tell us they are losing autonomy is prior authorization, the insurance companies telling them how to practice medicine. And I’m just wondering, from your experience, what’s the link between the growth of prior authorization and how physicians feel about their careers?

Dean: I think the growth of prior authorization goes along with a lot of the other regulations that have come in and a lot of the other cost-saving measures that have been implemented in health care. So it’s one of a number but it is the most abrasive. The challenge for physicians is we’ve trained for 10 years or 15 years to know what our patient needs. We’re pretty clear that maybe another type of imaging isn’t going to yield us as much as we’d like. It’s going to cost the patient time, it’s going to cost them a copay. And all of that is a challenge, it’s a struggle. We don’t want to have to inflict those things on our patients. When we’re clear we could go right to a particular test, a particular medication, and to be asked to do that based on reimbursement rather than good care, it goes against the grain of our training. And it also doesn’t feel at times as though we’re talking to an equivalent specialist. We’re talking to a nurse who’s trying their best to do what’s right by their company, but not by the patient. We may be talking to a neurosurgeon, may be talking to an OB/GYN to get authorization. And so it just goes against what we believe is good care.

ME: I’m wondering what changes you think need to happen in medical school in the way physicians are trained, to prepare them for the realities of health care and to participate in changing health care?

Dean: Medical students are so fantastic because they are energetic, they’re idealist, which is great. It’s also a double-edged sword. Because if we don’t prepare them for what they’re coming out into as residents or as attendings, then they may become very disillusioned very quickly. So I would love to see us train medical students in what the economic realities are of medicine, how the money flows, how reimbursement works, how policy gets made, how legislation happens. Really train them to be activists in their own interest and in the interest of their patients, because that’s what’s going to be critical in the next 20 years.

ME: What recommendations do you have for physicians to reclaim autonomy in their own careers? Obviously, there are a lot of systemic issues, but I’m wondering what can physicians do for themselves to carve out a space where they feel they’re practicing medicine the best way?

Dean: The best thing that they can do is learn how the incentives are aligned in their own institution. Understand how reimbursement happens, what the incentives are at their entity. And whether they can negotiate to build bridges with the administration, build bridges with other licensees, so that everyone can work together to start fixing things at the local level.

ME: Even for individuals, what this sounds like is they need to talk to their fellow physicians and their fellow health care providers about how to really put the patients front and center and make this better for everybody.

Dean: Correct. In talking to all their fellow clinicians and other physicians, they’ll start to notice what the patterns are, where the stumbling blocks are. Each separate specialty may have its unique challenges, but there will be commonalities that happen. And as you start to look into that more and more, you can quickly become an expert and can have the tools available to you to change what that problem is.