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Psychological Fitness Foundations, SDT Part 2 - Autonomy

This month, we focus on the three basics of psychological well-being that improve vitality, motivation, and performance – Autonomy, Relatedness, and Competence.

Last week, I gave an overview of my perspective and experiences of autonomy in medicine. Today we will take a deeper look.


The psychological definition of autonomy is the capacity to make an "informed, uncoerced decision." It involves the individual's ability to participate in an aligning manner willingly. From a social science viewpoint, autonomy means individuals can do their work at a higher level of their own discretion. We can see how autonomy fits hand-in-hand with agency – the sense of control over one's actions and consequences.


We emphasize the importance of patient autonomy at greater levels now than in the past. It's a core ethical principle of medicine. As much as we highlight it for patients, somewhere along the line, both physicians' autonomy, and in turn, their agency, has decreased. The growing number of stakeholders and their power and the increasing size of healthcare organizations are major driving forces from my vantage point.


It's important to realize that the word "autonomy" doesn't automatically mean complete independence - the absence of requirements or constraints. Instead, it means the individual can get behind the boundaries and expectations and have genuine buy-in. There must be some internal or intrinsic motivation to view the requirements, at the very least, as reasonable.


Medical practices, no matter who is running them, must reconcile a variety of issues including competing priorities: physician needs and preferences, accessible hours for the most utilized days and times, staffing adequacy, revenue and overhead, the population size served by the location, and equipping staff with practical protocols to name a few.


Physician-owners have a built-in intrinsic motivation to make the office fiscally viable. Routinely, however, employed physicians are kept disconnected from the running of a practice. They become disengaged, siloed, and only have an external motivation to comply with solutions they had no part in designing. This adds to further lack of agency and increased frustration. It can quickly become adversarial. Physicians feel powerless and believe the organization hasn't held up its end of the social contract or mission.


So often, I hear in coaching sessions, "This isn't what I signed up for!" The last-ditch effort of changing large systems rarely rewards the individual(s). Often frank moral injury ensues. And, once fully disengaged, the cognitive flexibility to understand or care about the competing interests of the business and creative solutions to gain improvement are lost. It becomes "us" against "them." In each case, the physician either becomes defeatedly compliant, biding their time, and fanaticizing of a future day when they can leave the organization or medicine in general, or they grow in resentment and frustration until they burnout or worse.


Likewise, when those running the business side of things become so focused on growth and maximizing the profit margin, hiring more executives and middle management, and giving preference to other entities/outcomes over the physicians' needs and concerns, they forget the complexity of primary care. They try to use carrots and sticks as motivators. (Such low-level external motivators have been proven Ineffective in complex situations). As a result, leaders disengage from the shared humanity with the physicians. Physicians then are seen as "difficult" and adversarial when advocating for themselves to make the work sustainable in a way that feels like it truly serves the patients. Then it's a small step to viewing physicians as necessary but replaceable, cogs in a wheel. And the cycle continues.


Leaders should be encouraged to tap into their curiosity and creativity to tailor increased autonomy. Snacks are kind, yoga classes are nice, but they are not tangible solutions to the plethora of issues. Mandating wellness courses, though well-intended, further removes freedom of time utilization. Leaders/Owners/Boards need to listen to hear and understand, not to find placations or to say empty words such as, "You've been heard" with a symbolic pat on the back.


Individual physicians or groups and leaders, those with the bandwidth left, can tap into the same curiosity and creativity and offer up ideas collaboratively to break down the adversarial interactions.


Let's get back to a shared vision and mission. Consider others' perspectives, experiences, and humanity. Let's start with what is working and where we all (hopefully) want to see the future of medicine: excellent, accessible, sustainable, and fulfilling for all involved. We need to get back to the table, drop the armor, and have a good old-fashioned Brené Brown-style productive rumble. Physicians who haven't forgotten the challenges of being on the front-lines MUST be at the table AND be empowered. Autonomy MUST be prioritized. I'm not saying it will be easy, but it will be worth it for the future of healthcare.


Next week, we will delve into the four domains of autonomy: Time, Tasks, Team, and Techniques. I'll add in a fifth "T" – Thoughts/Mindset. We will look at taking back some agency even before changing the circumstances.

Have a joy-filled week, 


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Originally written 2/2022, revised 5/2024


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