Autonomy

Perhaps more than any other trait, physicians deeply value their autonomy. They want to be in direct control of decision-making when it comes to the care of their patients. Every physician will tell you that being overruled by an insurance company is only made worse when you have to do a peer-to-peer review and the reviewing physician, who isn’t even in your own specialty, rejects coverage. All due respect to my colleagues in other specialties but is it really reasonable to expect a retired (fill in the blank with any subspecialty EXCEPT IR) to understand the indications, treatment options, and intricacies of yttrium-90 radioembolization or pelvic venous insufficiency? The answer: perhaps no more than a knuckle-dragging IR like me could manage the patients in their respective practices.

In emergency departments everywhere, patients are often treated based on algorithms for specific diseases. For example, if you come in complaining of crushing chest pain that radiates down your arm and have a history of cardiovascular disease, there is a whole battery of tests that are automatically ordered to determine whether you’re having a heart attack before an MD even knows you’re there. While this fairly obvious scenario might facilitate care and ultimately save lives, some physicians (maybe old, gray-haired ones like me) resist the broader adoption of algorithms because it removes the diagnostic challenge that was so central to the practice of medicine. After all, medicine has a lot of gray areas (unlike the scenario I’ve given) and there’s a lot of satisfaction to be had in those murky places.

I realize that sounds crotchety- you’re probably wondering when am I going to start yelling for the hot water basin and towels, or some leeches.

But as the autonomy of medicine is slowly eroded away on so many fronts, what will be the ultimate role of physicians? My point is, I think that as autonomy is slowly stripped away, physicians become more egocentric as a psychological defense mechanism. We become more protective of our historical-but-diminishing turf, which is decision making and patient management. So when an entity like an insurance company or a colleague or a social media pundit decides to second guess us, our increasingly thin skin is pierced relatively easily. I witness this on social media with some regularity. It also shows up in Morbidity and Mortality conferences. It is the rare physician who can intuitively and truly remove their ego from their own devastating complications. 

No one doubts the merits of multidisciplinary coordinated care, especially in complex pathways like organ transplantation. But as IRs, we’ve all died that small death when the perfect y90 patient is shunted into a phase 1 clinical trial for a new immunotherapy, or gets rejected because state Medicaid won’t cover radioembolization. These scenarios erode autonomy and can lead to moral injury. After all, autonomy is a fundamental ethical principle, whether you are a patient or physician.

Trying to maintain our desired autonomy (which must be balanced with humble and authentic transparency) is what we all strive for, but it is an increasingly difficult task as autonomy is slowly stripped away by institutional and technological “advances.” Once again, the crotchety me feels like there will be less and less of the art of medicine and more protocols and algorithms. Outcomes may improve, which is the most important part, but tomorrow’s physicians will have a different sense of gratification, one that I’m trying hard to imagine and relate to.

Continued erosion of our autonomy as physicians seems inevitable and that makes me sad. With multibillion dollar investments and high financial stakes, physician satisfaction seems pretty low (if not completely irrelevant) on the priority list. Metrics like productivity, turn around time, Press Ganey surveys, length of stay, ROI, and hospital margins get a lot more attention. In this environment, how do we try to maintain that autonomy, from which we derive so much professional satisfaction? Or is this a fool’s errand? Maybe we need to think of other parts of our practice that will fulfill us in the fast approaching future.