Is Physician Autonomy Dead?

Laurie Scudder, DNP, NP

Disclosures

July 07, 2016

The Call to Disobey

In a recent article on Medscape, Howard Waitzkin, MD, PhD, describes the final employer-imposed mandate that put him over the edge and resulted in his very personal decision to disobey. His obvious frustration and inability to change edicts, regulations, and rules that he perceived as having questionable value and undermining physician autonomy led to an obvious question. To borrow a phrase: Should physicians "just say no"?

We asked our readers what they thought, and although the majority agreed with the position that, at some point, disobedience is required, some disagreed and many left passionate comments.

Most respondents to this question, as well as the majority of readers who joined in the discussion by submitting comments, agreed that at some point enough was enough. That position was well summed up by one internist:

Isn't it enough [that] I have to be an expert on how to take care of a human being? Must I be an expert in all this administrative stuff as well? My degree is in medicine, not billing and coding. When the billers and coders can do my job, I will happily do theirs.

Another internist lamented that medicine "has become all about the almighty dollar and nothing about the care of patients." Numerous comments related to concerns with one-size-fits-all tasks that enforced standardization—think paperwork, bureaucracy, electronic health records, rather than individualization—with a goal of meeting the needs of the corporation rather than those of patients.

And it was not only physicians who voiced concern about the plethora of externally applied mandates and regulations. A pharmacist reader emphasized the importance of placing patients, rather than uniformity, first, noting that "physicians and other healthcare personnel should not be treated as if they were robots. They have an ethical duty to treat their patients professionally and with great care for the patient's overall well-being."

One nurse ironically chimed in: "Now you know what it has always been like to be a nurse."

The Real World of Mandates

We asked our readers about the effects of these mandates and regulations in their own practices.

Although in the minority, a sizeable percentage of physicians agreed that these types of mandates are a necessary reaction to a very complex healthcare environment. An internist conceded that "from a business model, an employer has a right to maintain a financially viable business by setting mandates. It isn't the employer's fault; it is the system." A family physician voiced concerns that healthcare corporations and physicians were inherently at cross-purposes: "A corporation is ethically and legally obligated to make a profit; I get that. The ethical obligation of a physician places the interests of the patient first."

A healthcare administrator agreed, warning that "practicing without any mandated regulations likely would lead to chaos." However, the administrator went on to note that "it goes without saying that those who pass laws and create regulations often know nothing about the intricacies of medical practice; thus, some regulations may be inapplicable to certain situations, or may be irrelevant."

And many readers commented that it was not mandates in and of themselves that were the concern. One anesthesiologist summed up this argument: "Until meaningful regulations/mandates with statistically proven improvements to patient care and outcomes are presented, the rest are just bureaucratic white noise."

In his commentary, Dr Waitzkin expressed his concerns that his own refusal to comply with a mandate that he viewed as non–evidence-based, with the potential for termination from his position, would have deleterious effects on his patients. So we also asked our readers: Should potential harm to patients preclude a physician from making a decision to not to comply with a corporate mandate?

Fully two thirds of physicians responding to our poll agreed that the potential collateral damage of disruptions in patient care and safety was a justified price to pay for physician autonomy. In fact, many Medscape readers emphasized the importance of enlisting patient support in the fight against overregulation. One physician pointed out that "engaging public awareness...will be our collective game changer."

The need for partners was mentioned often. One internist noted, "Making the public aware of what is happening is a must for our survival and quality patient care."

A family physician weighed in strongly about the need to enlist patients and the broader public in the struggle for autonomy:

Medical professionals, in conjunction with our patients, need to take control and demand a shift in priorities that puts the doctor/patient relationship back in the center of this conversation.

Disruptive innovation, such as direct primary care, is one example of how medical professionals along with their patients are taking the control (and responsibility) back and finding alternative ways to stop the madness and refocus the priorities back where they belong!

Of interest, the importance of patient and public support was illustrated in the successful resolution of a recent strike by junior doctors in the United Kingdom. In a discussion on Medscape about the resolution of contract demands made by junior doctors in the United Kingdom, Rajiv Wijesuriya, MBBS, a member of the British Medical Association junior doctors' negotiating committee emphasized the critical role that the public and patient support played in the negotiation of terms of that contract. "We were all incredibly motivated by the support of our patients, who understood the cause for which we were fighting."

Several Medscape readers commented that unity with others in the broader healthcare community was equally essential. One physician assistant summed up this point of view:

The title of Dr. Waitzkin's article was 'Doctor-Workers: Unite'. With due deference, the article might have been better titled "Everyone Who Works in Direct Patient Care, and the Support of Direct Patient Care Services: UNITE!"... A little more empathy and sympathy for those people we work with and over, I believe, would allow for more of the much-needed unity.

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