System Archives - Page 49 of 51

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?

Medical Error: System Solutions vs. Blame

“If you guys can’t think to order pregnancy tests, we’ve got big problems!” the consultant said.

He was a heart expert, but he remembered medical school: women of childbearing age with abdominal pain and/or bleeding must have pregnancy tests.

We forget simple things, make simple cognitive errors, all the time.

Intelligence or experience will not protect you.

Every day brilliant people forget to:

close their zippers,
signal lane changes,
turn off the oven,
feed the cat,
lock the door

Medicine overflows with cognitive traps. It brims with safety-critical activity: you get only one chance to do something right or patients will suffer & die.

For example, a missed ectopic pregnancy can cause a woman to bleed to death. An ectopic exists in 6-16% of women with pain and bleeding in the ED. Every medical student learns early that ordering a pregnancy test can save lives.

But very rarely, blood-work gets ordered without a pregnancy test when providers are left to order lab tests separately.

The consultant believed emergency docs must be even more stupid than he suspected. How could they miss something every medical student knows?

Uninformed individuals still blame people; experts tell us to blame the system.

Errors do not happen for lack of knowledge.

We must improve the system and stop the ‘blame and shame’.

System solutions – 2 examples:

Behaviour-shaping constraints, or forcing functions. For example, you cannot get your bank slip from a bank machine without collecting your bank card first; you cannot start your microwave without closing the door first; you can’t start your car without putting it into park. Constraints prevent medical mistakes.

Opt out vs. opt in: these terms get used in advertising and mailing lists. To capture everyone for a list, advertisers put people on the list until they ask to be taken off. Advertisers assume you want to be on the list, opt in is assumed, until you opt out. (Opt out pops up in discussions about ways to increase organ donation)

Using opt out for lab panels for women of childbearing age with abdominal pain could decrease the chance of forgetting a pregnancy test. Providers could opt out of performing the pregnancy test, but would be forced to think about it first.

Some still resist system solutions and try to blame people for medical errors. What do you think? Can we rely on system design to decrease error?

Physicians Limit Freedom?

A group of doctors discussed gambling.

“You’d never believe the pain some of my patients experience with problem gambling,” one said.

“We should lobby government to stop using revenues from gambling!” said another.

Some listeners nodded.

“Don’t we finance hospitals with lotteries?”

Silence.

“Should physicians dictate morality?” someone asked.

Doctors Limit Freedom?

Regardless of the morality of gambling and casinos, should physicians advocate for laws that limit patient freedom? What is the role of freedom in health and human flourishing?

A physician leader frowned at my defence of patient freedom.

“When do we stop making laws and start supporting individual freedom?” I asked.

“Don’t you agree with seat belts?” he asked. “How about stop signs?”

“Of course I agree with seat belts and stop signs,” I said.

“Well, then you agree with government limiting free choice!”

Now there’s the rub: how much freedom do we give up to live together in a ‘free’ society?

People who conflate stop signs with prohibition confuse mutual limits on individual freedom with imposing personal preference on others.

It’s one thing for us to obey stop signs for the safety of all. It’s something else entirely for intelligentsia to impose restrictions on other people’s behaviour that have little to do with their own freedom.

What do you think? Where do we draw the line between promoting healthy ideas and limiting individual freedom? Who should decide? Do we need more health related laws or do we have too many already?