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Psychological Fitness Foundations, SDT Part 4 - Autonomy of Tasks/Techniques

We continue to explore the foundational needs for psychological fitness – autonomy, connectedness, and competence. Autonomy has four important domains: time, tasks, techniques, and team. We covered time last week. This week, we will reflect on the tasks and techniques.


Tasks/Techniques. Depending on the setting practiced in (academic, hospital, rural full-spectrum, community outpatient, etc.), there are numerous tasks we each perform. I'm sure there are places where the medical culture limits tasks or techniques, but most organizations give physicians the autonomy of what a physician does and how. In other words, it's easier for us to find evidence that we do have agency in these arenas. And yes, residents and fellows likely feel differently. (I'll attempt to dissect autonomy in trainees in two weeks). The most common way task-related control is limited within a practice or organization is in the standardization of various tasks - EHR's, staff utilization, etc.


Because, for most of us, it's not a realistic expectation to have full autonomy unless we own our own practice, I like to offer examples of how we can utilize shared goals with the organization to find pockets in which to take back agency. I offer this just to get your creative juices flowing.


An example of how the practice can set up reasonable standardization while also supporting task-related autonomy: In the small private-practice setting I worked in, they set up standardization around referrals. We needed to communicate with our MA that a referral had been initiated and they needed to complete the process. This was very reasonable. Since we shared a pool of MA's, it ensured that referrals were completed with appropriate documentation and closed loops on the back end that I didn't need to learn. The autonomy came in how we communicated with the MA and how we handled the referral. Some of us used the generic order entry tab to write a quick note. Some of us used the letter template. Some of us used a customizable template. We decided what other documentation should be sent. And we chose the priority level.


An example of how reasonable guidelines and autonomy can co-exist at the location level: In the large organization, our local office decided what instruments and supplies we stocked in our office's procedure room. We looked at where duplication made sense and how we might all adapt to one way. For example, do we need to stock Derma-blades, scalpels, and double-edged straight blades? Again - it's shared decision making. 


As an example of balancing the vast amount of items to be accomplished in academics while supporting autonomy, I'll offer up another experience. During one of our faculty retreats, we had a giant whiteboard with all of our names, and under each name - a sticky note for each hat we wore. We then moved the ones we wanted to keep to the left slightly, the ones we really wanted to offload to the right slightly, and the "meh, I can keep it, but if someone wants it, it's fine" stayed in the middle. What unfolded was two-fold. 1. It was a wonderful time tailoring our work life to things that brought us fulfillment. 2. It also led to a rich discussion about the most popular and most unwanted items. It enhanced the sense of team: sharing/rotating some fun tasks and accepting our share of the unpleasant ones. 


Most of the time, physicians' task-oriented autonomy is infringed upon by external individuals/systems.  It can be hindered by insurers/CMS's control of reimbursement, which can indeed dictate how we practice, prescribe, etc. Perhaps once we overhaul healthcare, we won't be at the mercy of their profits. Certainly, insurers will hold many strings for the foreseeable future (unless you are in direct primary care.) So, while awaiting brilliant minds to heal our healthcare system, the immediate solution I offer is – you guessed it - focused on mindset.


Task thought-work: (I will use insurance barriers as an example - but this can be applied to any area that feels like a lack of task autonomy. 

-Focus. Draw attention to areas you do control how you deliver healthcare. By appreciating what we can control, rather than focusing only on what we don't, we can lessen unnecessary suffering. I like my approach to shoulder injections. Someone else may prefer a different approach. I control that.


-Acceptance. Stop being surprised or outraged by the new heights insurance companies will go to put barriers in our ways to preserve their bottom line. They are going to cost us and our staff time and energy. Period. I'm done using my emotional capital on being shocked, venting, ruminating, etc. It doesn't actually change anything (proof- I've done it at increasing levels for over 20 years and insurances have more control now than ever). As Cy Wakeman often says, "If you argue with reality, you're going to lose, but only 100% of the time." Acceptance is not an endorsement. And, it leads to a bit more ease.


-Decide. Do you want to be a part of real change in this arena? Then, do the research, talk to other leaders, look at other groups who are making headway, and collaborate to make meaningful change. It may be rewarding to channel some energy in this way. But, on the other hand, if you don't want to be directly involved, look to how you can support others working in the space. Or permit yourself to forego the burden. And therein lies choice.


-Discover. Look for your reason to overcome the barriers insurers or organizations put up. Usually, it is because we care about the patient and know what is best. You then can discover you actually do get to choose to advocate. It's a minor tweak, but it can feel a bit less frustrating. For example, in a recent coaching session with an attending –she was frustrated with the organization's roll out of a new turn-around-time mandate of particular inbox messages (prescription refills and patient messages). When we worked through her reasons that she did and did not want to address those messages in the mandated time, she discovered a couple of things for herself. 1. She likes to get patients their medicine refills quickly, so they don't have a gap in treatment. 2. She likes patients to get quick reassurance or instructions, so they don't worry or delay care longer than necessary. 3. The inbox items she didn't want to do were complex issues best-done face-to-face. Those often felt burdensome and were delayed. Then, she was able to see that the organization's expectations were actually reasonable in most cases. She would choose to do many within the mandated time because they aligned with her goals and values. She could choose others to be converted to visits, in-person or virtual. And the rare ones that the mandate didn't align with her priorities or make sense, she took back her agency. She would do those on her own timeline. The volume of that category was too low to cause a negative impact. Her frustration level dropped. 


-Brainstorm. Ask yourself and brainstorm with your team what systems can be implemented. Perhaps, if a doc-to-doc call is required to gain approval, designated staff can get through the insurance company's phone tree, provide the appeal number/insurance info, and grab you when their doc is on the phone. Or, depending on your patient population, perhaps you choose not to participate in prior authorizations for metformin as it's on most pharmacies' discount lists as long as the Rx is written properly. You and your team will find the ones that are right for you. It can be a PDSA cycle. Implement what can be changed, re-evaluate and pivot if needed. 


-Ask. Are there areas within the practice/organization where task-oriented autonomy is a significant issue for most physicians? How can you take a collaborative approach to make small incremental change forward with your leadership?

Next week, we will look at teams through the autonomy lens. 

Have a joy-filled week! Tonya

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