When the U.S. health care system began, physicians were largely autonomous in selection of medical treatments and their delivery. Patients were treated under a fee for service model. However, over time we began to notice an alarming incline in medical spending which ultimately lead to the development of health maintenance organizations (HMOs). At their inception, HMOs were intended to standardize medical treatment, reduce unnecessary use of resources, and encourage the practice of preventative care. However, these early changes lead to further shifts in health care that ultimately marked the decline of physician autonomy in deciding how health care would be delivered to its patients.
As the modern era of medicine continued to progress (along with medical spending), further organizations became involved in the health care system. Further and further the autonomy in our profession was sacrificed as outside involvement increased.
This loss of autonomy did not come with a decrease in expectations. The role of the physician continued to expand to deliver safe and efficient care while being proficient in the delivery of this care through secondary organizations whose development of which we were not involved in. Physicians were still at the heart of health care without any control over the systems comprising it. I believe this loss of autonomy while still being on the forefront of medical delivery has lead to a decline of health care reform coming from within our own community. How can we change our field when we do not feel we are a self-governing profession?
Here is an example I have seen many times over in residency that demonstrates common frustrations attributable to these limitations. Patient X comes into the clinic with X condition. You want to give her X medication and send her to X doctor because they are the best in the area. X doctor is not in network and X medication is not covered. Now begins the common frustration that stems from the feeling of lack of control over the delivery of what you believe is the most optimal health care for this patient. These constraints seem to be coming from a place where one has little to no understanding of how the day to day health care delivery works. Here we demonstrate the lack of autonomy of the physician. We are expected to be experts in health care treatments and how to deliver them within the boundaries of health care systems, while we are not largely involved in the creation and development of these constraints. We must practice something we have not created, and do not necessarily believe in.
These scenarios are endless and common in our workplace and eventually lead to creating “workarounds” without truly understanding the intricacies of the system and how they can be changed. It starts to seem like an uphill battle unable to be won. So how can we change this — and why should we?
In 2002 the ABIM and ACP came together to give us “Medical Professionalism in the New Millennium: A Physician Charter.” In this charter, there are listed the characteristics and the fundamental components of a physician’s professionalism. These commitments are summarized as follows: professional competence, honesty confidence and appropriate relationships with patients, improving quality of care, improving access to care, just distribution of finite resources, scientific knowledge, maintaining trust by managing conflicts of interest, and professional responsibilities. Now many of these commitments encompass the responsibilities of the health care systems and the continual reform therein. So if we consider these values as part of our professionalism then why does our education and training not reflect this?
In the recent years, there has been a push for medical schools and residency programs to include health policy as part of their curriculum. But this is not a requirement and appears to be the exception instead of the rule. The ACGME accredits the institutions which train our incoming physicians. They have six competencies to deem the proficiency of these new physicians. These include: patient care, medical knowledge, practice-based learning and improvement; interpersonal and communication skills; professionalism, and system based practice. Now on a more in-depth look at this, they do emphasize the practice for cost effective care and delivery of health care across systems. However — I find there is much lacking here. There is no goal to achieve an understanding of health policy to enact change at larger than an institutional level. There is no importance placed to understanding health management organizations, governmental mandates, insurance companies — the list goes on.
On review of the ABIM, we can see this further reiterated. The ABIM provides a list of objectives they base their exam on — which upon passing will certify physicians to practice independently. On the internal medicine certification there is fewer than 2 percent “miscellaneous” topics which include epidemiology, ethics, safety and quality improvement. This shows us lack of focus on training physicians to understand the “system” and simply just practice within the constraints of it.
As my residency comes to an end, I feel compelled and obligated to be involved in health care reform as part of my own professionalism. But I find myself unprepared and lacking the skill set to do so. I believe we need to begin by demanding a change from within our community to train physicians with a skill set to understand and shape health policy. As the delivery of health care in the U.S. has drastically changed, we must change with it.
In our residency, we begin to understand not just about the knowledge of medical treatment but the real world application of it. This is the time we must further our understanding of the health care systems and foster our interest in finding lasting solutions for improvement. Instead of leaving our residents unprepared and in a constant state of playing “catch-up” we can begin to create reform from inside the community of physicians.
We as physicians are a trusted professional community that find ourselves in a position to enact change that has the chance to be long lasting and beneficial and simply “work” in the policy and real-life application of it. And we should feel obligated to do so by educating our future providers — for without knowledge there will be no reform.
Sneha Tella is an internal medicine resident.
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