Page 13 - Delaware Medical Journal - January 2018

THE MEDICAL PROFESSION
Table 1: Movement of Physicians to Employment
Effect on Physician Autonomy, Patients and Physicians
CONSEQUENCES OF TREND
EFFECT ON PHYSICIAN AUTONOMY
EFFECT ON PATIENTS
EFFECT ON PHYSICIANS
Physician relinquishes role as independent practitioner and assumes role of an employee.
Reduced:
Physician becomes accountable to an employer, in addition to her patient.
Favorable: When health system holds physician accountable for high-quality care.
Unfavorable: When health system accountability infringes on patients’ best interest (e.g. by requiring adherence to health system financial goals in preference to patient interests.)
Favorable: Elimination of the burden of business ownership.
Functions
of practice personnel become formalized.
Reduced:
Generally physician relinquishes control over support staff.
Favorable: When well-managed, patient sees greater service consistency and reliability of clinical care.
Favorable: Physician can rely upon system of accountability within the office.
Unfavorable: Physician loses ability to individualize practice style.
Standard protocols guide clinical practice and referrals.
Reduced:
Physician loses unrestricted ability to choose care.
Favorable: If well designed, protocols and referral systems lead to more appropriate patient care.
Favorable: Easier to practice in accord with the best evidence.
Unfavorable: When over-reliance on protocol obscures unique aspects of a patient’s individual needs.
self-employed. They work in groups, or for hospitals, most often as employees, rather than owners. Daily medical practice is a team effort rather than an individual endeavor. Practice guidelines and electronic health records guide
and standardize care. Individual effort and productivity are eroding as prime determinants of payment, being replaced by measured benchmarks and standards of value. The skills and processes of an entire health system often matter, at least in reimbursement, more than professional prowess. This type of environment diminishes physician autonomy. Since professional autonomy is associated important to examine medical trends
that might diminish physician autonomy for their effect on the physician’s ability to care for patients. This is especially important in areas such as acting as a patient’s advocate, assuring professional expertise, monitoring quality and safety, and having the ability to introduce important medical innovations. Physician autonomy traditionally has been highly valued by physicians. Its loss is seen by many as weakening the profession. How do the trends that diminish autonomy affect physicians and their work?
We analyzed four prominent medical trends for their effects, both positive
and negative, on physician autonomy,
on the care received by patients, and
on the professional lives of physicians themselves. The trends we evaluated
are: the movement of physicians from independent practice to health system employment; the movement away from fee-for-service and toward value-based revenue; the use of the electronic health records; and the movement to team-based care (e.g. patient-centered medical home). Additionally, we consider the potential effects of these trends on elements of physician autonomy — advocacy for an individual patient, clinical expertise,
TABLE LEGEND
Effects on Patient Benefits Associated with Physician Autonomy
EFFECT ON PATIENT ADVOCACY
EFFECT ON CLINICAL EXPERTISE
EFFECT ON QUALITY AND SAFETY
EFFECT ON CLINICAL INNOVATION
Reduced: If physician is (or feels) constrained by employer’s influence on her ability to act as a patient advocate.
Enhanced: If physician is encouraged by employer to be a patient advocate and supplied with resources to do so.
Enhanced: Group practice and organizational resources likely to increase
each individual physician’s expertise.
Enhanced:
Systemization of care and group norms likely to improve quality and safety.
Reduced: If organization does not support clinical innovation.
Enhanced: If organization supports clinical innovation.
Reduced/Unfavorable
Enhanced/Favorable
Mixed
Del Med J | January 2018 | Vol. 90 | No. 1
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