Traditionally, physicians have been honored with high status and respect. Death and disease are a universal part of human experience; those whose role it is to relieve suffering are valued highly in all cultures. As the 18th-century scientific revolution advanced the tools of care with medical breakthroughs that relieved physical suffering, the role of the healer focused less on the relief of spiritual suffering. The 19th and 20th centuries saw surgeries performed with anesthesia, a rapid deceleration in deaths associated with childbirth, and infectious diseases combated with antibiotics. As the professionals who controlled the means to new treatments and interventions, physicians assumed a prestigious social status that was typically accompanied by a great level of wealth.
However, by the last quarter of the 20th century, the continuously shifting healthcare ecosystem impacted physicians’ social status, authority, and prestige. Powershifts have included broader income disparities between physicians performing procedures focused on diagnosis and management; loss of professional independence necessitated by being part of integrated health delivery systems to have access to technology and teams; increased regulatory burden; and high business transaction costs caused by payers using managed care techniques to control costs.
Futurist Alvin Toffler understood power to be based on three components: knowledge, wealth, and force. He posited that knowledge is the most potent form of power in our society because we live in a knowledge-based civilization. Within Toffler’s framework, the rise of professional physician power is the result of control of medical knowledge, and the shifts in power result from changes in the span of control of medical knowledge.
To operate with maximum efficiency, the highly complex healthcare delivery system requires integrated knowledge management in a patient-centric context.
One driver of this shift has been the acceleration of information technology in expanding access to medical knowledge and in the exponential growth medical knowledge itself. Technological innovations have rebalanced asymmetries of information access between physicians and patients along the continuums of care.
To operate with maximum efficiency, the highly complex healthcare delivery system requires integrated knowledge management in a patient-centric context. With this technology-induced change comes a transformation in the culture and a necessarily fresh approach to relationships with peers and teams, new collaborative problem solving, shared leadership, and shared decision-making. This cultural transformation is a shift in power traditionally held by physicians in their professional role from one focused on authority and autonomy to one focused on leadership and collaboration.
Four forces affecting the locus of control in the healthcare delivery system will continue to transform the medical profession.
First, the physician–patient relationship will continue to undergo significant changes.
The exponential expansion and availability of information brought about through the Internet permit patients direct access to medical information while also expanding evidence-based medicine with clinical decision support. As patients and physicians interact in an information-rich world, the peer-validated knowledge and competence of professional authority are challenged by the open, consumerist culture of the web.
Second, physicians’ social and structural authority with peers and clinician team members has been impacted by electronic health records and other health information technology solutions. The balance of power and responsibilities in the care delivery process has shifted. One example is the rise of pharmacists’ provision of comprehensive medication management. Integration of pharmacist-led medication management has improved patient care through medication reconciliation, comprehensive medication reviews, medication adherence promotion, and chronic disease management.
Similarly, population health management analytic technology permits non-physician healthcare professionals to identify cohorts of patients in a population with specific medical conditions or risk factors and address them in ways not dependent on traditional clinic interactions. These examples illustrate how a team approach to chronic management is facilitated by the multi-user access of the electronic health record.
Physicians who adapt to team-based care models will be well-positioned to thrive and lead.
Third, the authority and autonomy of physicians in their clinical role does not necessarily translate to similar authority in the healthcare organization in which they work, as the industry continues its transition away from a cottage industry culture to one built upon corporate governance and infrastructure. The governance of corporations depends on boards of directors and professional managers. The shift in power created by the corporatization of medicine reinforces the need for business acumen and education in management if physicians are to have a seat in the executive suite and boardroom.
Fourth, healthcare industry economic trends over the past half-century directly contribute to physicians’ loss of traditional autonomy. These trends include changes to the principal–agent relationship, reduction in monopolistic power, and changes in the healthcare labor market. The principal–agent relationship occurs when one person is allowed to make decisions on behalf of another person.
Historically, the physician–patient relationship had principal–agent components, with physicians making decisions on behalf of their patients, sometimes with little input from the patients themselves. Over the past few decades, legal constructs such as living wills, designated healthcare power of attorney, and informed consent have replaced “doctor knows best” power constructs.
Shared decision-making equalizes the power relationship even more. As other medical professionals expand the scope of their licenses, diagnostic, management, and treatment capabilities are shared with other healthcare professionals. The ongoing expansion of the medical and surgical specialties and the expansion of the healthcare labor market to include new professionals such as advanced practice providers, clinical pharmacists, physical therapists, respiratory therapists, clinical psychologists, licensed clinical social workers, and clinical nurse managers differentiate the healthcare labor force into a highly skilled market with far greater scope and scale.
In light of the complexity of the U.S. healthcare system and changing global economic landscape over the past quarter-century, these trends have contributed to shifts in the physician’s authority and control over healthcare services. While health reform initiatives are developed and approved for application at federal and state levels, the implementation of new policy occurs at the micro level in regional integrated delivery systems, multispecialty groups, physician hospital organizations, and clinically integrated networks.
Consumer-facing models of care enabled by technology, retail clinics, social networking, asynchronous information exchange via patient portals, remote monitoring, and smartphone apps disrupt established healthcare delivery models upon which physician power was historically based.
A great deal of status anxiety among physicians is driven by the impact of these four forces on professional power, so continuation of physician leadership within the evolving industry requires physicians to take on new roles and skills that transcend traditional authority and are consilient with the new needs of patients as empowered and informed consumers.
Healthcare Is Now a Team Sport
Optimal team-based healthcare is associated with improvement in patient outcomes and physician well-being. A healthcare team is a group of individuals who work together interdependently and coordinate their actions to prevent or treat disease and promote health. Team-based models of care endeavor to meet patient needs and preferences with active patient engagement, and encourage all healthcare professionals to function to the full extent of their education, certification, and experience.
Multidisciplinary team-based care is associated with better performance on healthcare quality measures and is cost effective. Teamwork can prevent adverse patient outcomes and is thus an important part of patient safety efforts. Preliminary studies of clinician burnout indicate that high-performing teams can reduce clinician burnout.
Physicians must redesign the profession.
As innovations in delivery models and reimbursement models emerge, the healthcare industry will experience further shifts in the social power structures, levels of autonomy, and control that affect the way healthcare services are delivered in the United States. Physicians who adapt to team-based care models will be well-positioned to thrive and lead in the midst of an escalating pace of change in the industry.
The power physicians hold today has changed from that of the past, but their role is critical to ensuring improvement in quality, access, and cost of care. No longer will leadership derive from a position of autonomous authority. Rather, physician leadership will depend on physicians’ power, knowledge, and skills to influence patient care as part of clinical teams, leadership teams, and governance teams.
The rigors of didactic training and experiential learning position physicians well for the role of ensuring quality of care for the patients and populations they serve. As clinicians, physicians are uniquely suited to leverage their skills to bolster their position as subject-matter experts in shared clinical decision-making with patients and in health system operations. However, the leadership skills that are crucial for teamwork are not always a part of physician training or culture. They must become so.
Physicians must redesign the profession. This professional redesign requires an introspective understanding of training curricula and how the physician culture should be shaped in the future to improve abilities to lead in patient-centric operations, complex healthcare organizations, and at the national social policy level. The transformation will require continued review of the social and environmental forces that are stressing the physician community and the healthcare system.
Regularly examining the current situation from the perspective of various strategic lenses (e.g., health-centric, economic, political, and social) can uncover changing trends in this complex adaptive system and the changes in communication and relationships that affect the effectiveness of higher quality care and improve patient outcomes in the future. Any passive avoidance as a cultural strategy merely increases strain on the system and contributes to victimization and dysfunctional physician behavior. We need a new way to serve our communities and provide optimal care.