Physician Autonomy Essential for Good Patient Care

Several years ago, one of my colleagues was having a disagreement with an external health care agency. She’s a very bright young family physician, and is extremely passionate about one part of comprehensive family medicine care. She really felt the external agency was failing in providing a reasonable level of service for one group of marginalized patients. In particular, she felt the agency’s process for accepting referrals was deeply flawed.

After months of advocacy by her, the agency finally reviewed their intake process. They then pronounced that everything was ok, because 90% of the referrals were processed accordingly.

In response, my tenacious colleague sent an email to all the family docs in the area, asking them for feedback on the referral process. She the proceeded to blast said agency for the 90% processing rate. “If a server at McDonald’s got the order wrong 10% of the time, would he still have a job?” was the line in her email that really got everyone’s attention. As a result, my colleagues sent feedback, the external agency’s response was proven inadequate, and changes were made. In her own way, my colleague was following the wisdom of Ruth Bader Ginsburg:

It also shows, in one neat example why physician autonomy is so important to patient care. Because without that autonomy, and independence, we can’t speak out. We can’t advocate for our patients even if it makes bureaucrats uncomfortable. We can’t expose those situations where patient care has been compromised.

This is, of course, exactly what those who want to take autonomy away from us want. For the most part this includes two types of people. First are health care bureaucrats, who feel that because they control the purse strings, everything should be done their way, and no pesky front line physicians should dare question their judgement or expose their flaws. The second group consists of a small number of physicians, who, while well intentioned, feel that physicians autonomy impedes whatever fancy new health program they want to implement.

Suppose you are an employee in the IT department of a corporation. You make a statement like say, “If our legal department worked at McDonald’s they would get fired because they get orders wrong 10% of the time.” What happens then? Human Resources gets involved, you get called out for making derogatory comments, the CEO might even get involved, you get disciplined and basically told to shut up. Even (especially?) if you are right in the first place.

This is exactly what those who oppose physician autonomy want.

The anti-autonomy crowd feels that physicians resist change. Therefore, the thinking goes, physicians will use their autonomy and independence to impede whatever new program/model/team is being promoted. Hence, autonomy must be curtailed so physicians can do what they are told, and accept whatever the powers that be tell them is good for them.

However, this couldn’t be further from the truth. The vast majority of physicians are open to new ways of doing things. If they truly believe a new process will help their patients, and help their lives, they will adapt. This is why we use new medications, new treatment protocols and yes, newer models of health care delivery than we used in the past. Medicine would not have changed so much in the past 25 years, if it wasn’t for the willingness of physicians to explore newer and different methods of delivering health care.

But as my friend’s example shows (and there are many like hers), what is essential to the provision of good patient care, is for physicians to retain their ability to speak out. My friend saw an area where a health care agency was failing a group of patients. Because she didn’t have to fear retribution in the form of being hauled up in front of Human Resources, she was able to effectively advocate for patients (who in this case happened to be too frail to advocate for themselves). Eventually, due to her persistence, the agency recognized their errors and fixed their flawed process.

In much the same way as we explore transforming the health system again (in Ontario these are to be done with the Ontario Health Teams or OHTs), it is fundamentally important to ensure that physician autonomy is protected in these models. This will allow physicians to speak up if the implementation plans are not going the way they should, or if programs promoted by the leaders are not really going to help patients. While painful for those in charge to hear criticisms, it results in better outcomes in the long run because the new programs will be better, stronger and more effective.

Let’s hope that as the new OHTs are developed (full disclosure, I support the concept) the message of the essential nature of physician autonomy is not lost. Physician autonomy has allowed us to be the best possible advocates for patient care in the past. If we can no longer, as Ginsburg urged, fight for the things we care about, it will be the patients who suffer.

We Need to Learn to Live With COVID-19

“All of this has happened before, and will happen again.” – Lt. Kara Thrace, aka Starbuck, from the Battlestar Galactica (2004) TV show.

An advantage of being old is that whatever is happening, you have likely seen it, or something like it before. Every so often, society undergoes an upheaval and people have to change behaviours. For those of us who were around in the 1980s, there are some stark parallels to what happened then, and what society must do now in 2020.

The early 1980s were a different time not only for how we lived as a society, but for how medicine was practiced. This was particularly true with how we handled body fluids. As surprising as it may be to some younger readers, there was no such thing as universal body fluid precautions back them. If you had a known blood born illness like hepatitis, then sure, extra precautions were taken. But not for every body. When I was in medical school, there were multiple stories of a particularly nasty vascular surgeon who would squirt blood on trainees during surgery if they got an answer wrong to his questions. Needle prick injuries were routinely ignored. There was not a robust sharps disposal system. In short, it was very different.

A huge shift in society, and medicine, came when reports of a novel virus (sound familiar?) became publicized. This virus was new, deadly, and little was know about it. At first, this strange new illness seemed to only affect gay men. This led to all sorts of additional discrimination against the gay community, and even more ostracization then they were already experiencing. Mainstream media outlets routinely referred to it as “The Gay Plague” which clearly didn’t help matters. This also led to whack job conspiracy theories about its origins, some of which persist to this day.

This strange new illness was, of course, eventually named “Acquired Immune Deficiency Syndrome” or AIDS and the virus that causes it was identified (Human Immunodeficiency Virus or HIV). It was recognized that body fluid transmission could spread it and that it was not limited by sexual orientation. We learned it was possible to carry the virus and not have symptoms and you could get it from anyone.

And so, the age of universal blood and body fluid precautions began, and policies around this were implemented in hospitals and other health facilities between 1985-1988.

But there was also a shift in how society responded. Until then, most public service announcements around Sexually Transmitted Disease (like this painfully dated one from 1969) focused simply on encouraging people to get treatment after the fact. And accepting that it was possible for you (yes, sweet innocent you) to get an STD.

AIDS changed all that. Suddenly, an STD could be deadly. Suddenly there was no cure or vaccine. Suddenly, just getting treatment wasn’t an option, and education around prevention was mandatory.

With education, the public took precautions. “No glove, no love” was a popular catchphrase used to promote latex condom use as these were proven to significantly reduce the risk of transmission of STDs (including HIV). Public service announcements shifted to openly talking about prevention.

In short, people and society adapted, and changed behaviours to deal with this new virus.

Today of course, we are faced with a novel new virus, that is clearly deadly and is widely publicized. Little was know about it at the start, and we continue to learn about it. The virus seems to have originated out of China, and this has led to all sorts of anti-Asian racism (including from the President of the United States). There are whack job conspiracy theories about it. As we learn more about the virus, we know asymptomatic spread is possible, and that, yet again, anyone can get it. There is no vaccine (and despite Dr. Fauci’s optimism I’m not holding my breath) and no effective cure.

In response, hospitals and other health facilities are implementing new polices around Personal Protective Equipment (PPE). Hospitals are taking extra precautions around elective surgery as the risk of mortality in patients who get COVID19 infections peri-operatively is ridiculously high. In my office I now see patients wearing a mask, eye protection, and surgical scrubs that I immediately remove after my day is done.

And now too, society will be asked to change in response to this most awful virus. The simplest thing to do of course, is to wear masks when you are in an indoor public place, or better yet whenever you leave the house. As mentioned in an earlier blog, one only has to look at Japan where there was poor social distancing, packed public transit and no closure of their famous karaoke bars, but people wore masks, and the number of infections was extremely low. Wearing them also is key to restarting the economy so we can get on with our lives.

Next, we need to accept contact tracing. Aggressive contact tracing in South Korea was largely responsible for their low rates of infection. I was glad to hear that Ontario will be introducing an app to do this. I can already hear the cries of invasion of privacy, but if we are to control this virus, we are going to have to figure out a way to contact trace safely, and protect personal privacy at the same time.

The big difference between the AIDS epidemic of the 1980s and COVID19 now is, of course, the economic costs. The economy was never shut down then, and the kind of wholesale level of job loss we are experiencing now in (hopefully) once in a life time.

But if we are to get the economy running (and we must for a whole bunch of reasons, including the fact a good job improves overall health care), then society will need to adapt again. We did it forty years ago, and I believe we can do it again.

I am however, not looking forward to 2060…….