Autonomy vs. accountability: A delicate balance

OK, let's begin with the obvious -- physicians are increasingly unhappy in their medical practices. If you want confirmatory data, you can find them in the Physician Morale Survey conducted by the American College of Physician Executives in July 2006. Among 1,200 physicians across the country who responded to the survey, 46% rated their "overall morale as a physician working in U.S. health care" as five or lower on a scale of one (very low morale) to 10 (very high). When asked to judge the morale of physicians they supervise or work with, 59% gave a score of five or lower.

When asked to identify the single biggest factor in lowering morale, 22% and 21% of physicians responding to the survey highlighted low reimbursement rates and loss of autonomy, respectively, over other causes.

Similarly, a study published in the Jan. 22/29, 2003, issue of JAMA showed that measures related to clinical autonomy were strongly associated with changes in physicians' career satisfaction.

In a speech to the AMA House of Delegates in November 2006, my predecessor as AMA president, William G. Plested III, MD, expressed outrage at how "the prerogatives of our profession are being systematically destroyed." He urged physicians to work together to "take back the profession."

At the AMA's Annual Meeting in June, the House of Delegates debated a resolution introduced by the Georgia delegation (entitled "Taking Back the Profession of Medicine"), asking the Association to pledge that all of its positions "will be driven by an unshakeable and uncompromising commitment to return the rightful prerogatives of the profession to the physicians of America."

The reference committee that heard testimony on that resolution and a few related items of business, such as "pay-for-performance," reported that several physicians argued that "patients will only be protected by taking back our profession and simply saying 'no' to pay-for-performance." But the committee also noted that others "just as fervently believe that it is imperative that physicians maintain a seat at the negotiating table ... [and thus] the opportunity to continue to significantly and materially shape quality programs."

In the end, the House of Delegates adopted compromise language calling on the AMA to actively oppose P4P programs that do not meet all of the AMA's principles regarding P4P; to "strongly oppose the use of tiered and narrow physician networks that deny patient access to, or attempt to steer patients toward, certain physicians primarily based on cost-of-care factors"; and to "pledge an unshakeable and uncompromising commitment to the welfare of our patients, the health of our nation and the primacy of the patient-physician relationship free from intrusion from third parties."

Those statements were firm and forceful, but the emotive and provocative language about "rightful prerogatives" and "taking back the profession" was excluded. Moreover, the house directed the AMA to "continue to work with other medical and specialty associations to develop effective means of maintaining high-quality medical care, which may include physician accountability to robust, effective, fair peer-review programs."

These machinations reflect the tension between physicians' yearning for the unfettered autonomy they enjoyed decades ago, and more recent pressures for more accountability in health care. The persistence of sizable deficits in the quality and safety of health care, coupled with unremitting increases in health care costs, have compelled payers, employers, and regulators to impose more stringent accountability on hospitals, physicians, and other health care entities.

The AMA has recognized the need for accountability through, among other things, its involvement in accreditation of medical schools, residency programs, and health care organizations; and its sponsorship of the Physician Consortium for Performance Improvement, which develops evidence-based clinical performance measures and measurement resources for physicians.

I believe we need to find a carefully titrated balance between the competing needs for physician autonomy and accountability, in order to accomplish two critically important goals: 1) to maintain the professionalism of medicine and the ability of physicians to give patients the best care possible; and 2) to be responsible stewards over finite health care resources.

In regard to responsible stewardship, the House of Delegates, also at the June meeting, adopted an important report on rising health care costs, prepared by the AMA Council on Medical Service. It calls for the AMA to support several broad strategies to address rising health care costs, including making health care delivery more efficient and promoting "value-based decision-making" at all levels. The council defined "value" as "the best balance between benefits and costs," and "better value" as "improved clinical outcomes, quality, and/or patient satisfaction per dollar spent."

These issues were on my mind as I took the Oath of Office as the 162nd president of the AMA on June 26, particularly because the AMA Board of Trustees had revised that oath in November 2006 to reflect the current health care environment.

The original statement that "I shall champion the cause of freedom in medical practice" was changed to "I shall work to preserve and protect the primacy of the patient-physician relationship, and the freedom of physicians to practice medicine without undue impediment."

"Without undue impediment" acknowledges that some autonomy is appropriately sacrificed for the sake of accountability, but the word "undue" stresses that accountability measures must be reasonable. In addition, the new oath emphasizes the primacy of the patient-physician relationship, which was not mentioned in the previous oath. Thus, the new version illuminates that balance mentioned previously, between the competing needs for physician autonomy and accountability.

Isaac Asimov wrote in 1978 that "It is change, continuing change, inevitable change, that is the dominant factor in society today." Three decades later, that statement rings equally true. Our health care system today is better in many ways, but worse in others, compared with the one in which our forefathers practiced. Our challenge is to make our current health care system, in today's reality, perform as well as it can for the benefit of our patients and the public.