Variation Reduction and Physician Concerns

“Won’t This Interfere with My Autonomy?”

Loss of autonomy is a concern that physicians raise when thinking about variation reduction. For physicians, autonomy is a core issue. Training physicians takes a long time: four years of medical school and then three to five years (or more) of specialty training. All during this time the trainee physician is being told what to do. It’s not surprising after this long apprenticeship that many physicians no longer want to take direction; they want to make decisions for themselves and they think the years of training have given them the right to do so. Now we come along as the variation-reduction team and start questioning their independent decisions.

Many physicians have an idealized vision of how medicine should be practiced. Television gave this vision a face: Marcus Welby, MD, the kindly General Practitioner who worked alone in a small office and was responsible only to himself and his patients. Dr. Welby could spend as much time as he needed during each visit; no group practice and no HMOs got between this doctor and his patients. The reality of practicing medicine today is, of course, much different. As reality takes physicians farther and farther away from the Dr. Welby ideal, physicians experience it as a loss of autonomy.

The solo practitioner is as close to the Dr. Welby ideal as one can get. When I first went into solo practice, I thought I could hang a “Closed” sign on the door any time I wanted to take time off. The reality was that I needed to be in a call group so that my patients would always have someone to turn to if I was not available—my first loss of autonomy but not the last.

When I eventually joined a group practice, my autonomy suffered again: now not only did I have to check with my call group when I wanted time off, I also had people looking over my shoulder making sure I was practicing medicine at a level the group thought was appropriate. When the group joined a larger medical organization, all of our physicians experienced another loss of autonomy. Now our collective fates were no longer directly in our hands but in the hands of an organization based 100 miles from where we practiced medicine.

These days, autonomy for physicians is pretty much an illusion. While some solo practitioners may still exist out in the hinterlands who depend on no one but themselves, the vast majority of physicians in the United States must always make compromises with the ideal of physician autonomy. For physicians working in a multi-specialty medical group, the loss of autonomy is counterbalanced by the benefits of working with a highly skilled team. The positives of working in a team range from the big issues, such as skill of the physician team members, to the more mundane, such as there is always someone to answer the phone even if your receptionist is out sick.

”Isn’t This Just ‘Cookbook Medicine’?”

Another concern is that standard-setting will reduce a physicians’ practice to “cookbook medicine.” What bothers physicians who use this term is that they worry that somehow the training they went through is no longer needed, that the treatment of the patient will be distilled down to a series of steps that anyone can follow. All those years of training and experience for nothing!

But does the use of a cookbook reduce the skill of an excellent cook or the nutrition provided by the food prepared by the recipe? I used to bristle at physicians’ mention of cookbook medicine until I realized that cookbooks were exactly what I wanted to talk about. So our variation-reduction team took the metaphor and used it to our advantage. A good cook uses a cookbook. It’s a starting point. You don’t have to rigorously follow it; in fact, most good cooks vary a recipe depending on what is seasonally available and the people for whom they’re cooking.

A standard is a recipe. It holds for about 80% to 90% of the patients that the physicians see, and the result of all the cooks in the kitchen following the same recipe is a consistent “dish” perfected with practice over time. But, just as a good cook changes a recipe as needed, a good physician matches a general standard of care to a specific patient. For some patients, the standard does not fit, and it would not be good clinical judgment to apply it.
Physicians have valid concerns regarding variation reduction, and the variation-reduction team listens avidly to those concerns. For the most part, we have been able to provide answers to the physicians’ questions and win their engagement. That’s crucial, because it’s the engagement of physicians that powers not only the standard-setting process but its continued use.

Excerpted from Quality Care, Affordable Care: How Physicians Can Reduce Variation and Lower Healthcare Costs by Lawrence Shapiro, MD.