How to reclaim physician autonomy

March 24, 2020

Wendy Dean, MD, the founder of Fix Moral Injury, discusses how physicians have lost autonomy, and what can be done to restore it.

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. Surveys show that many physicians blame a lack of autonomy for their frustration. But what does physician autonomy mean in today's healthcare world?

Today, we are joined by Wendy Dean, MD, to discuss what physicians can do to take back control of their careers.

Medical Economics: Can you can you talk a little bit about why physicians go into medicine.

Wendy Dean: I think physicians go into medicine primarily because they can't think of anything else that they would rather do. They love the science of it. They love the patient care aspects of it. And it's almost more of a calling than it is a career.

Medical Economics: One of the things we hear about often from our readers and our audience is that they lack an autonomy that they feel like 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 to not 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 to 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.

Medical Economics: In the 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: There's, 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, are linked.

Medical Economics: 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 get rid of the insurance companies open a direct pay practice open a direct pay or concierge practice. What do you think about direct pay and concierge in sort of these ways to simplify the practice and whether they're a solution 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 healthcare in the US, I 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, 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 can get the same one on one care, the same undecide undivided attention from their physician and can walk out and get the prescription that they need the physical therapy that they need the imaging that they need, without either the patient or the physician having to go through contortions to make that happen.

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

Dean: The biggest change that needs to happen is for, for the healthcare system to change the way it supports physicians. So, right now, when physicians are engaged with the patient, they're reporting to their chief financial officer about how many patients they've seen, and this is all indirect, but they're, they're expected to make metrics on how many patients they see. They're reporting to the insurer about why 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 out to a lot of different people. And really what would be great is if the 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 get their patient what they need.

Medical Economics: The number one reason physicians tell us they are losing autonomy is prior authorization, the insurance companies telling us 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, 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 healthcare. So it's, it's one of a number but it is the most abrasive. The challenge for physicians is that what we face is we've trained for 10 years or 15 years to know what our patient needs. We're pretty clear that, you know, 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 for 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 goes against the grain of our training. And it also feels as though in reality, it doesn't feel as though oftentimes, we're not 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, you know, a neurosurgeon may be talking to an OB GYN to get authorization. And so it it just goes against what we believe is good care.

Medical Economics: I'm wondering what changes do you think needs to happen in medical school the way physicians are trained to either prepare them for the realities of healthcare or also sort of participate in changing healthcare, the way that many physicians feel we need?

Dean: Medical students are so fantastic because they are energetic, 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 become They may become very disillusioned very quickly. So I would love to see us trained some medical students in what the economic realities are of medicine, of how the money flows of how reimbursement works of how policy gets made, of how legislation happens to to really train them to be activists in their own 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.

Medical Economics: What recommendations do you have for physicians to reclaim autonomy in their own career? Obviously, there's a lot of systemic issues, but I'm wondering what can physicians do for themselves to carve out a space for themselves where they feel like 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, understand what the incentives are of their own entity. illustrators and how they may align with with the physicians incentives or how they may miss a line. And whether or not they can negotiate with the administrators to try to bring those two closer together, build bridges with the administration, build bridges with other licensees, so that everyone can work together to start fixing things at the local level.

Medical Economics: What it sounds like is that even for individuals, what this really means is they need to talk to their fellow physicians and their fellow healthcare providers about how to make to really put the patients front and center and make this better for everybody.

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

Medical Economics: Physicians are always thinking about the impact on patients. I'm wondering what you think reclaiming physician autonomy will do for patient care and for patient outcomes?

Dean: It will help patients get what they need more quickly. It may reduce their economic burden. It will, it will help to solidify the relationship between physicians and patients. And I think patients will end up getting better care as a whole.