Blog | Monday, August 11, 2014

Independence and autonomy


I have been kicking around how the concepts of independence and autonomy relate to one another, since it is often at the top of the list of things that doctors care deeply about.

Webster’s (OK, the on-line Merriam-Webster dictionary) defines “independence” as “freedom from outside control or support” and offers up “self-sufficiency” and “self-reliance” as synonyms. “Autonomy” is defined as “the quality or state of being self-governing” and suggests “self-determination” among the synonyms.

In the context of medical practice, I believe physician autonomy is critically important and independence is over-rated and probably anachronistic. Unfortunately, doctors all too often confuse the 2. Here’s what I mean.

A physician who holds that she should be able to treat every patient as she sees fit, and does so under the banner of physician autonomy, is flying a false flag. That’s not autonomy, it’s independence. True autonomy requires that physicians define the standards by which we practice, and hold each other accountable to practice by those standards. It is not a defense of each of us practicing independently.

We should be rallying around the collective professional autonomy of physician-led standards, and physician-designed care models, not defending “you practice how you want, and I practice how I want.” I also don’t believe we should be advocating for the conceptual model of medical practice that imagines care delivered by a “self-sufficient” physician, who is the only player on the field, when the reality is that modern care requires a team.

Of course, patients and circumstances differ, and I am not saying that all clinical decision-making can be collectivized or dictated. But I am saying that for lots of clinical circumstances, there really are better or worse ways to approach the problem at hand. Some antibiotics are better for community-acquired pneumonia than others; patients with heart failure, absent a contra-indication, ought to be on an ACE inhibitor; patients with ischemic vascular disease ought to be prescribed aspirin.

Physicians are the acknowledged leaders of defining what best practice is, and should also be the leaders of efforts to assure that patients consistently get the best treatment. That is not an infringement on professional autonomy, it is an expressions of professional autonomy.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital. He then held a number of senior positions at Mount Sinai Medical Center prior to joining North Shore-LIJ. He is married with two daughters and enjoys cars, reading biographies and histories, and following his favorite baseball team, the New York Yankees, when not practicing medicine. This post originally appeared at his blog, Ausculation.