Independence and Autonomy

With the approach of the 4th of July, I have had “independence” on my mind. In my professional role, I always have “autonomy” on my mind, since it is often at the top of the list of things that doctors care deeply about, and I have been kicking around how the two relate to one another.
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 two. 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.
Happy Independence Day.

2 thoughts on “Independence and Autonomy

  1. I understand what you say..I think. I had a really good doctor that I liked. She has a solo practice. Actually she was wonderful. It was self-pay, until I fell off a ladder. 2 sprained knees, and one sprained ankle on a Sunday. For the first time in my life, I was in an ambulance. I wasn’t on Medicare yet, and the hospital charity fund paid for almost everything. I already paid for the ambulance and most of the X-rays, and that cleaned me out. They have a Medicare Advantage plan, 3 ERs, lab work is free, 3 hospitals in this area, An MD Anderson radiation clinic, one of the best oncology clinics in the state. The HMO-Advantage plan handles the paperwork, and most of the imaging is free.

    I still regret that finances caused me to leave this great practitioner. I ended up being diagnosed with cancer a few years after I left her. I was able to get into the cancer clinic quicker, because I was in the system.

    As you say, “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.”

    I said the same thing when I contacted my really “self-sufficient” physician and told her that I had really great regrets in leaving her practice, but

    There’s give and take no matter what a person or a doctor does. Some people say that you can have a ‘win-win’ situation, but I don’t have the finances for that.

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