Physician Autonomy: an Historic Relic?

Physician autonomy was sacrosanct; even enshrined in the Warsaw declaration.

Lately, it’s negotiable.

Ballooning costs of care and medico-legal risk make more doctors call for clinical practice guidelines (CPGs) to protect them, simplify complex decision making, and justify not ordering unnecessary tests and treatment when patients demand them.

Looking for something solid on which to make clinical decisions, physicians elevate evidence based medicine as a weapon against bureaucrats’ cost cutting and so-called expert opinions. But, the weapon also slices off physician autonomy.

Battle-lines form, with cost on one side, autonomy on the other, and evidence held hostage by whoever can show it best supports them. Patient centeredness, another hostage, usually hangs from physician banners. National associations weigh in; things get nasty.

When physicians call for CPGs, are they calling for limits to their autonomy?

Doctors usually say, “No. We can ignore the CPGs when indicated.”

If so, it seems CPGs afford little protection from lawsuit. If standard care is to ignore CPGs when indicated, how can doctors rely on CPGs to decrease medico-legal risk?

Having CPGs, but ignoring them at will, seems to be the worst of both worlds: loss of autonomy without decreased risk.

While the aroma of clinical autonomy lingers, any trace of operational autonomy in hospitals or large groups disappeared long ago. Even so, some physicians discussing system decisions still say:

Every physician should be involved in every decision

Every change idea should be shared at the earliest possible moment with every MD

Consensus with all physicians should be reached before any change

Are we in a post-physician-autonomy age? How does this impact professionalism? Is autonomy something that’s earned or protected? Is autonomy the wrong question?

Responsibility, accountability, and autonomy are inseparable. Some want to remove physician responsibility as a way to decrease physician influence; others want to remove responsibility as a way to decrease risk. Some insist on keeping accountability, but work to remove responsibility and autonomy.

Should we forget about physician autonomy and only ask what’s best for patients?

5 Ways to Reduce Healthcare Spending on Emergency Departments

ED visits are growing.

ED costs are growing.

If the ED was a bakery, we could send customers away at the front door when the pastries were gone. Some still suggest this dangerous practice. Here are 5 better ideas that will work.

5 Ways to Save $$ on EDs

1. Increase access to imaging and labs. A patient can’t wait weeks to find out whether the lump in her breast is a cancer or headache is a tumour. Patients come to the ED even though they’d often rather go anywhere else.

2. Provide clinics for ‘in-between’ patients (CTAS 3). On a scale of 1 to 5, CTAS 3 patients aren’t dying but have more than a sunburn. These patients needs tones of care and investigations. A few are acutely ill, but most suffer from chronic issues. Either give them direct access to clinics, or let emergency physicians send patients directly to specialty clinics (same day appointments).

3. Get admitted patients out of the ED. Admitted patients get horrible care in the ED and cost the most, by a very wide margin. ED care costs more than ward care. Get admitted patients were they can get the care they need: up to the wards!

4. Don’t transfer dying patients to the ED who never wanted to come to the hospital in the first place (signed advanced directive).

5. Close EDs. In Canada, we close rural EDs and refuse to expand the size or number of EDs to keep pace with population. It’s a terrible option for customer service, but it does save money. 🙁

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See How Patient Flow Improved: Mini-Trial of RN-MD Triage

Early Success!

We tried a nurse-physician team with 3 stretchers in our old (empty) waiting room. We did not change our old process; just added a parallel process out front.

An RN met all ambulatory arrivals at the front door for a quick look as before (pre-triage). Ambulance patients came in through a separate process. We ran the parallel RN-MD trial from 10:00 – 13:00.

Process

Patient arrives to see an RN screener/sorter/pre-triage.

Patient directed to an RN-MD team with 3 beds in the waiting room.

Patient sent to registration.

Patient sent home or to appropriate clinical area.

If RN-MD process overwhelmed, patient sent to traditional triage.

At any point, patient sent to acute room as indicated.

Results for 3 hour trial:

30 ambulatory patients seen (less than average volumes?)

Time to see MD = 0 minutes for 27 patients (< 3 minutes from RN screener).

3 patients direct to acute room by RN screener.

5 patients (17%) seen and discharged home by the MD-RN team

3 exam spots added (6% additional capacity) at ZERO cost.

0 left without being seen

0 patients required traditional triage

Reflection

We identified a number of things to improve for our relaunch next week.

Staff who had strongly opposed the trial turned optimistic.

As a team, we had become overly anxious to try new things after a major change ‘failed’ in 2012 (we tried something for 2 1/2 days that didn’t work as hoped). We got a boost today.

We’ll share process detail and performance data as we gain more experience.

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