We talked about getting back to the self-care basics a few months back. Specifically, we focused on three basic physical needs and implementing those as busy healthcare professionals. This month, we will focus on three basic psychological needs for mental and emotional fitness. These are autonomy, connectedness, and competence.
Developing these assets leads to psychological growth and true mental fitness. We know sleep, good nutrition, and movement are essential for physical health for all humans. And the need for autonomy, connectedness, and confidence 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.
We will focus on autonomy, since it is key, and how it plays out in medicine, just like sleep is key for physical health. Having restorative sleep makes it easier to engage in movement and good nutrition. Having that sense of agency improves the mindset for connection and growth in competence. I will offer my perspective of autonomy in medicine from various experiences - from physician-owned practices to physician-employed practices.
My dad, a general practice physician (before family medicine became a specialty), spent 20 years in a 2-physician office with total autonomy. The business aspect was a burden, but he enjoyed making those decisions. In the '80s, he took an offer from a large healthcare organization to buy the practice. And for at least ten years, he had complete freedom to make decisions for his local office. In the final ten years, there was a slow creep into the number of patients seen, proper documentation methods, and the type of medicine the office should provide.
My husband, a surgeon, chose to be the owner/partner in both of his practices over these past 20 years. He also decided to have small practices to avoid the politics of larger practices. He, too, thrived in making the business decisions and creating the environment and systems he enjoyed. The times he feels an infringement on his autonomy are primarily due to insurance companies and occasionally hospital systems, but he and his team navigate those reasonably well.
Then there's me. I knew I didn't want the burden of running a business (though I did love to be included in major decisions). In my 22 years of practicing, I've been in various roles. First, I was an employee for a large health care organization. I had a lot of choice and decision-making capability to begin with (not near as much as my dad had), but that began to erode about the time I left to help start an indigent care clinic. As medical director, I felt a lot of agency and more responsibility, though reasonable. When we moved to Alaska 14 years ago, I entered the world of academics. There was a lot of freedom in our program. We could shuffle curricula around, use our admin time as desired, and practice medicine in the way we saw fit. Of course, there were occasionally Best Practices set up to keep a reasonable standard of care. I was mainly in agreement with those, so I never felt forced to practice in a way that didn't align. The biggest rub for me was not fully controlling the time allotted to each patient. The pressures that led to burnout in that setting for me had nothing really to do with lacking autonomy. Finally, after burning out and transitioning to be on-call faculty, I became an employed physician by a small private practice owned by a physician couple who set it up to enjoy the practice of medicine rather than maximize the profits. There, I had the most autonomy out of the four. They were incredibly supportive of us practicing medicine the way that worked best – almost to a fault as our medical assistants and front office staff had to keep lists of individual preferences that I'm sure became challenging.
Adding in my reflection of the various practices our graduates and my friends have gone into, I feel I have a somewhat accurate assessment. Each individual experiences agency and autonomy differently, even within the same setting. Each practice, no matter if it is physician-owned or healthcare organization-owned, can offer autonomy, or it can crush it. 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 influence the level of autonomy given. I would say that there are benefits to smaller, physician-owned practices – but the healthcare system at large-- rising costs, increasing complexity, regulations, how reimbursement works, and many other factors make it more challenging to set up practices in that manner. That is why direct primary care has become so attractive to so many.
Now keep in mind – I'm not passing judgment one way or another on the regulations, or who owns/runs a practice or what model. I'm just making observations regarding autonomy from my perspective. However, I would love to see more robust practice management training for learners to choose their best style of practice. I'm glad brilliant people are working on repairing/overhauling our healthcare system. I hope that the final product includes autonomy for the practicing physician.
My role at this point, as a physician coach, is to help individual physicians figure out how to live their best life and find fulfillment despite circumstances outside of their control. And, again, 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 dive into ways to take back some agency no matter your current setting.
Have a joy-filled week,
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