Psychological Fitness , SDT Part 1, Autonomy in Medicine

In the past, we have talked about getting back to the self-care basics. Specifically, we focused on three foundational physical needs and implementing those as busy healthcare professionals. This month, we will focus on three foundational psychological needs for mental and emotional fitness. These are based on Self-Determination Theory (SDT) and include autonomy, connectedness, and competence. 

Psychological Fitness.
Psychological Fitness can be defined as optimizing well-being by embracing the whole person – mind, body, spirit – and by integrating mental, emotional, and behavioral abilities and capacities. Developing the core aspects of SDT – autonomy, connectedness, and competence lays the foundation of psychological growth and true mental fitness. Just like sleep, good nutrition, and movement are essential for physical health for all humans, the need for autonomy, connectedness, and competence also crosses cultures, geography, occupations, and socioeconomic status. Richard Ryan, Ph.D., is a key leader in research regarding Self-Determination Theory and is a brilliant resource for a more in-depth understanding of flourishing. True coaching supports all three components.  

External Autonomy and Job Satisfaction. 

I have witnessed my dad who was a family physician for over 40 years in the same town go from full autonomy as business owner, to slightly less when he sold his practice to a physician owned multi-specialty group, to much less when a large non-physician run non-profit healthcare system took over. He experienced a directly proportional decrease in job fulfillment over the decades.   

My husband, has largely been a partner in his own small practices over 20 years. The burden of business decisions and work load were off-set by having a greater amount of autonomy and flexibility. He intentionally kept the practices small to avoid the political burdens that arise with more internal stakeholders. 

I have experienced a range of control over the practice settings I’ve been in. I experienced full autonomy as medical director and clinician for the indigent care clinic even though there were structures outside of my control. I had almost as much as a contracted physician for a private practice where the husband-and-wife physician owners really allowed us to set up most of the details with supportive structure from them (likely to the chagrin of the staff having to remember so many individualized rules). In the community-based residency that I was core faculty in for years – I had a lot of agency within my admin time and how I worked with learners. In the clinic setting, less control. The freedom in the educational role, really offset the office based decrease for me. My loss of job satisfaction was solid based on the degree of agency. My personal burnout had more to do with maladaptive perfectionism, failing to triage important and urgent tasks, and putting my self-care on the back-burner.  

I will say, that I’ve noted a couple of previous graduates that have gone on to work and thrive in very structured settings where they have little to no say about patient load, panel size, staff interactions, or procedures. And they’re good with that – in some cases the mission fulfillment outweighs the need for control. And for others those aspects feel like extra mental load and burdens.  

In summary, I have observed up close the correlation between autonomy and job satisfaction.. First, recognizing that for most individuals, autonomy is correlated with job satisfaction. Second, individuals’ experience agency and autonomy differently, even within the same setting. And third, and possibly most important -  they beauty of family medicine currently is being able to exercise autonomy in what practice type you seek out.  

Healthcare organizations/settings and their role. 

Each practice, no matter if it is physician-owned or healthcare organization-run, can support (or crush) autonomy on a spectrum. The size of the practice, the group's culture, the organization's mission, the number of mid-level and top managers, and the number of experienced physicians in leadership, and the leadership’s understanding of what supports physician well-being all influence the level of autonomy imparted. 

The healthcare system at large and its rising costs, increasing complexity, regulations, reimbursement and insurance barriers, and many other factors make it more challenging to set up private primary care practices – which were once the way family physicians experienced the most autonomy. 2017 was the first year that over half of family physicians were employed instead of owners. The most recent AAFP benchmark data survey shows less than 25 % of family physicians currently either own or work for physician-owned practices.  

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Future of family medicine and autonomy.

There has been a renewed interest in returning to physician-owned practices despite the challenges in doing so.  

Physician entrepreneurs are growing. Newer approaches to building up and sustaining private practices are taking hold (see EntreMD) and the rise of Direct Primary Care are supporting the changes.  

On a broader level, there are individuals working to overhaul the nation’s healthcare system.  I'm glad brilliant people are working on it. I hope that the final product includes more external autonomy for the practicing physician.  

Educational Opportunity in Residencies.

I would love to see more robust practice management training for learners to truly understand various practice settings. This will allow them to choose a practice that more closely aligns.  

Coaching and Autonomy.

I have coached way too many physicians who receive the message from their organization that they should be able to keep up with complex, underserved patients with 15-20 minutes, do it well, get great patient satisfaction scores, meet the metrics, and get their inbox to zero regularly -- and their voices for change are drowned out.  

On the flip side, I’ve coached many physicians who are leading change in these areas to meet the patient care access issues.  

My role at this point, as a physician coach, is to help individual physicians figure out how to live their best life while caring for patients, and finding fulfillment despite circumstances outside of their control. In coaching, they are afforded and supported with autonomy.  They access their internal autonomy. 

I'm convinced that physicians who work from their healthiest mindsets after coaching will be the most effective healthcare industry influencers! 

Stay tuned next week as we add meaning and context to the word "autonomy" and explore ways to regain some agency, no matter your current setting. 

Have a joy-filled week, 

Tonya 

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