Zen and the Art of Physician Autonomy Maintenance

Knowing is not enough. We must apply. Johann Wolfgang von Goethe During the 20th century, physicians achieved an unprecedented level of economic, political, and clinical autonomy (1) as a result of numerous factors, one of which was the extraordinary impact of science on the effectiveness of medical practice (2). Our autonomy has declined during the past two decades, as evidenced by insurers' review of care plans (3); calls for public reporting of physician errors and quality indicators (4); and steadily increasing oversight of documentation, billing, and clinical management (5). The purpose of these activities has been to sanction incompetent or crooked physicians and to influence physicians to practice medicine according to the scientific evidence on which we base our profession. Whatever the purpose, the result has been to decrease the autonomy of medicine as a profession and, even more painful, to erode individual physicians' clinical autonomythe focus of this paper. While the optimal balance between autonomy and regulation is uncertain, some clinical autonomy seems necessary unless society can somehow direct the day-to-day practice of medicine through legislation, regulation, and commercial contracts. To physicians' eyes, the pendulum has already swung far in that direction (6), with considerable harm to the special gift relationships that form bonds with patients (7). Practicing physicians recognize that part of medicine may be regulatable science, but much of it is unregulatable artan art that depends on our ability to build relationships with patients and families; to integrate answers to patients' questions into the context of their lives; and to heal, even when our science cannot cure. If clinical autonomy is good for the art of medicine and we wish to regain it, one part of our strategy is straightforward: We should do a better job of policing our own profession by dealing firmly and effectively with those of our colleagues who do not fulfill their professional obligations of quality and integrity. Kassirer has made this case convincingly (8). Cleaning up our own mess is undoubtedly necessary before some autonomy can be regained, but it would not be sufficient. Certainly, patients also want us to listen to them and spend more time with them (9-11). Patients want us to practice the art of medicine altruistically. Patients also expect us to practice the science of medicine consistently. This task might be framed by the public (if not by our patients, certainly by the regulators and legislators who represent them) as follows: You claim that your profession is based on science. We have given you power because of science's miracles. Now show us that you can use all the science you know, for our benefit. We Are Not Using All the Science We Know The period beginning with Wennberg and Gittleson's studies of practice patterns (12) and ending with the Institute of Medicine's report To Err Is Human (13) marks two decades during which the public learned of our inability to apply all the science we know. The evidence is clear: unexplainable variation in practice and widespread quality and safety problems of overuse, underuse, and misuse (14). These are not problems caused by a few incompetent individuals. These are problems of an entire profession. If medicine is a science-based profession and we know the best way to treat many conditions, why do we fail to implement that knowledge reliably (15, 16)? The answers often cited include uncertainties in the science of medicine, uneven quality of clinical practice guidelines, practitioners' lack of knowledge of the science, variables in the practice setting, lack of incentives, patient factors, and lack of computerized support systems (17-20). These issues are influential and need to be addressed. But within our own culture lies a deeper reason for the gap between what we know and what we doour fierce attachment to individual clinical autonomy. Individual Clinical Autonomy and the Tower of Babel Consider a typical hospital's grand rounds, in which an expert reviews the evidence supporting the current best approach to diagnosis and treatment of a particular condition. After a vigorous period of questioning, the physicians leave the auditorium with the overwhelming consensus that the lecturer has it right. What happens next? In most hospitals, this consensus is not translated into hospital-wide implementation. Rather, the hospital relies on individual physicians to apply the knowledge. Individual actions range from no change whatsoever to major revisions of standing orders. Over time, new evidence is integrated into the practice of individual physicians in a similarly variable fashion. The cumulative effect of this process, repeated for hundreds of conditions, is that clinical practice in the hospital resembles the Tower of Babel more than scientifically grounded activity. Infection control provides an example in contrasting approaches to applying science. It would be unheard of for a surgeon to perform surgery without scrubbing, gowning, and gloving. Whether to use sterile technique is not left to individual physician choice. Recent strong evidence shows that postoperative infections can be substantially reduced by rigorous blood glucose control (21); however, few medical staffs have implemented this practice throughout the hospital. Presuming good evidence for both infection-control practices, why are the patients who are routinely managed in the operating room by a gowned surgeon with scrubbed hands inside sterile gloves not also routinely managed in the intensive care unit with tight blood glucose control? These examples illustrate a pattern in our professional processing of clinical evidence. We regularly discuss the evidence with our colleagues. However, we seldom enter those conversations with the clear understanding that any conclusions we reach will be translated into a system of standing orders and other steps to implement any consensus that emerges from the dialogue. Why? Because to do so would infringe on individual clinical autonomy. This prevalent cultural patterndiscussing knowledge in groups large and small but applying it as individual practitionersis perfectly designed to delay the implementation of new knowledge and to produce wide variation in practice. Variation adds complexitya breeding ground for errors (22)to the work of nurses, pharmacists, and physicians who share in the care of our patients. The result is a wide gap between the science that is known and what we order, as well as a high rate of error between what we order and what is done. Practicing the Science of MedicineTogether In many settings, physicians are practicing clinical science in teams. For example, computerized order entry systems are forcing medical staffs to consider questions such as What should our default order sets for common conditions be? (23). Computers are not a requirement for practicing clinical science as teams. Some hospitals make evidence-based medicine the easiest thing to do by using medical staffapproved, hospital-wide paper standing order sets (Abelson D. Personal communication). Other medical staffs have approved automatic substitution of orders at variance with best practice. In such hospitals, a physician may order meperidine, but the patient will receive a less toxic and more effective pain medication (Dennis B. Personal communication). To support these kinds of activities, medical staffs are establishing structures to govern clinical care as a staff instead of as individual practitioners (24). Rather than being resisted, sharing of individual clinical autonomy with colleagues should be embraced. It produces better outcomes of care (25-27). Organized processes for considering and implementing new evidence drive more rapid adoption of effective innovations and discarding of old, ineffective practices. Creating evidence-supported order sets for the care of common conditions frees up time for physicians to do the difficult custom crafting of care (the art) that every patient needs. It simplifies the work of nurses and pharmacists and reduces errors. Regarding professional autonomy, it clearly feels better to be deciding the science for ourselves rather than having it done for us. The implications of this idea for our professional culture and for our organizations are profound. Medical schools and academic health centers would lead the design of curricula, programs, and health care systems that would generate new knowledge and apply the knowledge we already have. Medical staff organizations, physician groups, and specialty societies would adopt processes to govern the science of clinical care, maintain and update best practices, and take accountability for performance (28). Most important, we as individual physicians would recognize that sharing clinical autonomy with our colleagues, at least for the science-based aspects of medicine, would be a big step toward returning pride and satisfaction in our daily work. Yes, But Physicians resist evidence-based guidelines and protocols, even when using them would improve care and free up precious time for the art of medicine. Some of the common objections and their counterarguments are listed here: We can't agree on all the science. Of course we can't, and we never will. The evidence base for many practices is not firm; it is always changing. The question is, What science can we agree on? Given the imperfections and uncertainties of the evidence base, it might be argued that, rather than waiting for perfect evidence, we should make good judgments using the evidence we have, implement those choices together, measure the results, and thereby use our practices to extend our knowledge base of what works and what doesn't. Specialties will make self-serving judgments about the science. Transparency and accountability for resultscombined with systematic, cross-disciplinary evidence reviewswould be the best antidotes for thi