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Power Shift
When opportunities in a profession change, so does the profession.1
Paul Starr
Traditionally physicians have been honored with high status and respect. Those whose role it is to relieve suffering are valued highly in all cultures, as death and disease are a universal part of human experience. As the 18th Century scientific revolution advanced the tools of care with medical breakthroughs that provided relief of physical suffering previously undreamed of, the healer role became focused less upon the relief of spiritual suffering. The 19th and 20th Centuries saw surgeries performed with anesthesia, a rapid deceleration in death associated with childbirths, and infectious diseases remedied with antibiotics. As the professionals who controlled the means to new treatments and interventions, physicians assumed a prestigious social status that was typically accompanied by a generous level of wealth. However, in the last quarter of the 20th Century a shift in the health care ecosystem has taken place that has impacted the physician’s social status, authority, and prestige.
One of the drivers for this shift has been the advent of information technology. Technological innovations have re-balanced asymmetries of information access between physicians and patients along the continuums of care. In order to operate with maximal efficiency, the highly complex health care delivery system requires integrated knowledge management in a patient-centric context. With this technology-induced change comes a transformation in the culture and a necessarily fresh approach to relationships with peers and teams, new collaborative problem solving, shared leadership, and shared decision-making. This cultural transformation is a shift in power traditionally held by physicians in their professional role from one focused on authority and autonomy to one focused on leadership and collaboration.
There are four areas in which the locus of control in the health care delivery system will alter the medical profession. First, the physician-patient relationship will continue to undergo significant changes. In 1982, Starr identified three claims to be met for the “legitimation of professional authority”:
• Knowledge and competence is validated by peers;
• The validated knowledge and competence rests on a rational and scientific basis; and
• The professional’s judgment and advice are structured around relevant values.2
The exponential expansion and availability of information brought about through the Internet permits direct access by patients to medical information while also permitting the expansion of evidence-based medicine with clinical decision support. As patients and physicians interact in an information-rich world, the peer-validated knowledge and competence of professional authority is challenged by the open, consumerist culture of the Internet. Second, social and structural authority of physicians with peers and clinician team members has been impacted through the use of electronic health records and other health information technology solutions and has shifted the balance of power and responsibilities in the care delivery process.
Third, the authority and autonomy of physicians in their clinical role does not necessarily translate to similar authority in the health care organization in which they work, as the industry continues its transition away from its cottage industry culture to one based in corporate infrastructure. The governance of corporations depends upon boards of directors and professional managers. So the shift in power created by the corporatization of medicine reinforces the need for business acumen and education in management if physicians are to have a seat in the boardroom.
Fourth, economic trends over the past four decades directly contribute to the loss of autonomy by physicians. These trends include changes to the principal-agent relationship, reduction in monopolistic power, and changes in the health care labor market.
In light of the complexity of the U.S. health care system and changing global economic landscape over the past quarter century, these trends have contributed to shifts in the physician’s authority and control over health care services. While health reform initiatives are developed and approved for application at federal and state levels, the implementation of new policy takes place at the micro level in regional integrated delivery systems, multispecialty groups, physician hospital organizations, and clinically integrated networks.
Physicians have less autonomy today in the past, and in many respects their span of control is changing as well. The demographic and economic pressures driving health care reform ensure that these changes will persist. A great deal of status anxiety among physicians is driven by these factors, so transition to a position of leadership within the evolving industry requires physicians to take on new roles and skills tat translates traditional authority in forms that are congruent with the new needs of patients.
Physician and Patient: A Shift in Position
Consumer sovereignty is impacted by the advantage physicians possess in the asymmetries of information and medical knowledge with patients. Internet access has altered but not eliminated this asymmetry. Patients still rely upon their physicians to diagnose and recommend treatments based upon their clinical experience, which necessitates a compact intrinsic in the relationship, based upon trust by the patient in professional judgment and ethical behavior. In 2002, studies in six countries on four continents revealed that the citizens of all countries viewed the patient-physician relationship as second in importance to family relationships. The patient-physician relationship scored higher than spiritual, financial, and co-worker relationships. While the relationship has always been highly valued, it is certainly not static. In all countries studied, the relationship was rapidly evolving. Authoritarian, paternalistic relationships, where “doctor says” and “patient does,” are increasingly in the minority. They have been replaced by collaborative partnerships with 50/50 decision-making, and advisor relationships where the physician serves as resource and guide, but patients take responsibility for decisions on their own health care.3
Since the 1990s, the health care and medically related information available to the general public via the Internet has grown exponentially, bringing about a shift in the balance of information accessible to consumers. Increased transparency of cost and quality information on physician and hospital services is resulting in a stronger base of knowledge possessed by patients. Consumer-directed tools such as Vitals (www.vitals.com), Health Grades (www.healthgrades.com) and the Department of Health and Human Services Hospital Compare website (www.hospitalcompare.hhs.gov) are but a few of the web portals that have emerged in the past ten years to provide consumers with improved information to make more informed choices about the health services they need.
Just as patients have gained access to better information to improve their own decision making, so too have the tools improved for physicians to support clinical diagnosis recommendations and orders for better quality medical care. Using the best knowledge to identify what to do and how to make it part of routine practice may appear obvious, but studies indicate it takes up to 15 years for medical knowledge to become incorporated into routine medical practice. Unexplained variation in clinical practice is prevalent throughout all clinical settings such that the integration of content and context is seldom ideal. Evidence-based medicine provides a bridge between science and bedside application for the practicing physician that can serve as a pathway to transition practice guidelines to a more precision-based and scientifically rigorous methodology. Use of evidence-based medicine should ensure that patient care adheres to clinical best practices and improve the health of communities. However, with evidence-based medicine and evidence-based management there are perceived threats to autonomy and control in clinical decision-making, difficulty in accessing the evidence base, and difficulty differentiating useful and accurate evidence from that which is inaccurate or inapplicable. Integrating evidence-based medicine practices into clinical guidelines requires physicians who are able to draw upon the evidence to improve the quality of care being delivered.4
One of the most important changes to emerge in the past two decades in the physician-patient relationship has been the increase in shared decision-making. The Institute of Medicine’s objective for patient-centered care cannot be achieved without a shift in asymmetries of information. Godolphin notes that there are a number of strategies