The Changing Faces of the Doctors, Part II

In our last blog we explored the New Guard of medicine analyzed in the 2014 Survey of America’s Physicians. One of the more interesting findings of the survey is that this New Guard, which tends to be younger, female and employed, has a more positive attitude toward medicine than the old guard:

‘’Physicians are not uniform in their perspectives. Younger physicians, female physicians, employed physicians and primary care physicians are somewhat more positive about the current medical practice environment than are older physicians, male physicians, medical specialists and practice owners, though the majority of almost all groups suffer from low morale and express doubts about the direction of the healthcare system (emphasis added).” (page 9)

The following chart breaks down morale by group:

Professional Morale By Physician Type

	Very/somewhat positive			Very/somewhat negative
45 or <		54.2%	45.8%
46 or >		38.9%	61.1%
male		42.4%	57.6%
female		48.6%	51.4%
employed		50.5%	49.5%
owner		33.1%	66.9%
PC		50.2%	49.8%
specialists		40.7%	59.3%

Yet it is the intersection of morale and clinical autonomy that deserves the most attention:

 

Lack of Clinical Autonomy By Physician Type

Decisions sometimes/Often compromised
45 or <	68.9%
46 or >	69.1%
male	68.7%
female	69.7%
employed	68.2%
owner	70.6%
PC	70.1%
specialists	68.6%

 

While woman and primary care doctors feel their autonomy is challenged slightly more than their male and specialist colleagues, the more surprising result is that employed doctors report their autonomy is challenged slightly less than their owner colleagues. Of course, not unlike pain scales, specialists and primary care doctors may have a different sense of what it means to be compromised.

The authors of the report comment on these findings:

“This contradicts the widely perceived notion that physicians sacrifice their clinical autonomy to become employees in exchange for security, while practice owners sacrifice security to preserve clinical autonomy. In fact, the survey suggests that many employed physicians and practice owners feel their clinical autonomy is limited, in close to equal numbers. This may in part be a result of more robust clinical analytics than existed in the past, which, by outlining treatment protocols for various medical conditions, have taken some of the subjectivity out of medicine.”

This suggests a far more complex relationship between big data, treatment protocols and doctor autonomy. The authors of the survey point to what is in fact an ongoing critique of evidence based medicine (EBM), namely that it removes the craft or art of medicine. Timmermans and Mauck summarize this particular critique in The Promises And Pitfalls Of Evidence-Based Medicine:

“By discouraging idiosyncrasies in clinical technique, standards introduce disincentives for individual innovations in care and healthy competition among practitioners. Instead of revolutionizing care, EBM therefore threatens to bring about stagnation and bland uniformity, derogatorily characterized as ‘cookbook medicine.’”

What is so interesting in the survey is the suggestion , and it is only a suggestion, that analytics and protocols may be changing how doctors understand autonomy, and that this changing sense of autonomy might be reflected in the experience of doctors and the survey. In short, perhaps the changing nature of the health care delivery system is changing both what autonomy means and the doctor experience of that autonomy being challenged.

If this is the case it might be useful to remember that Timmermans and Mauck conclude their article by calling for a democratization of standards. The questions moves from a binary sense of autonomy to a larger concern over how the standards are created:

“The construction and implementation of clinical practice guidelines tend to remain the exclusive purview of leading experts and thereby regularly fail to take into account available resources and opinions of allied professionals, support staff, and patients who will be directly affected by the guidelines.”

It is precisely that failure to utilize the best resources, such as the front line doctors who take care of our patients, that is one of the central messages of our Doctors Council White Paper. Doctors’ input and voices must be heard on patient care and quality improvements. This would improve provider satisfaction and in turn enhance patient satisfaction.