More on Physician Autonomy

Last week, inspired by the Independence Day holiday, I wrote about the important distinction between independence and autonomy. I made the case that professional autonomy is not about each doctor doing as he pleases, but about physicians as a group taking responsibility for shaping medical practice.

I was pleasantly surprised over the holiday weekend when I came across a recent paper in Health Affairs that illustrates how effective physician leadership (autonomy) can reduce unnecessary practice variation (independence) and improve clinical care. The paper also reinforced some of my earlier thoughts about the central role that physicians must play in redesigning systems of care.

The authors report on the successful implementation of a standardized care pathway for eligible patients undergoing cardiac surgery at the Mayo Clinic. They devised a way to distinguish “routine” from “complex” patients, and established a “focused factory” model for the former group, which they define as “a uniform approach to delivering a limited set of high quality products.” It included protocol driven de-escalation of care (e.g., transfer of patient from ICU to floor), as well as cohorting of like patients, collection of process and outcome measures, and implementation of appropriate information technology. They were able to demonstrate that patients cared for in the “focused factory” had significant improvements in clinical outcomes and reductions in resource utilization compared with matched, historical controls.

There is a lot to like here. Physician leaders engaged their peers and other members of the care team with the expressed purpose of improving the “value (in terms of outcomes divided by the cost) of cardiac surgical care.” They chose their target well, since cardiac surgery is a high-cost, high-risk, high-profile endeavor. They had a thoughtful strategy, focused on reducing unnecessary practice variation. They designed a system of care sensitive to unforeseen clinical circumstances that would make “routine” care inappropriate. They measured their outcomes.

All of this follows the teachings of Richard Bohmer, who has written an influential book – Designing Care – that provides a framework for how to “better design, manage, and deliver health care.” It is a fascinating book that offers more insights and lessons than I can review here, but I recommend it highly, and will try to summarize some of the key points in future posts.

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