The Importance of Medical Autonomy
by Patricia N. Reams, MD, MPH, CCHP
In April, I proudly participated in my daughter’s graduation from medical school. There was a bit of nostalgia as I remembered 40 years ago when her dad and I did the same thing. That led to some thinking about what has changed in medicine in the past 40 years. It occurs to me that practice in the free world has come to resemble correctional medicine of the 1970s in many ways.
An example of this is the practice of medical autonomy, which in the parlance of the National Commission means the freedom of a health care provider to act in a patient’s interest without interference from another authority. This is related to the physician–patient relationship, where two people and perhaps some family members make health care decisions. In corrections, interference can come from administrators, courts, etc. In the free world, we now see it from third-party payers and government regulators.
Early in my career as a corrections physician I was told by a facility superintendent to stop sending so many teens for X-rays after injuries. He said it was too expensive and he did not have the staff to accompany them. I was surprised. It was the first time my authority had been questioned so it never occurred to me to take it as an order. I went back to the superintendent for a discussion. This led to some discoveries that improved the system and the safety of the youth. We discovered that most injuries happened during basketball games with staff who were playing too competitively for the uncoordinated teens. The superintendent agreed to stop that practice and the injuries decreased significantly. We also contracted to have X-rays done in-house, saving the costs of hospital outpatient studies and staff time.
The Value of Discussion
The discussion was valuable. The result was that everyone involved was served, including the juveniles, the individual patients, the physicians, the administration and the taxpayers. It is my perception that in the free world this discussion is happening less frequently now. Insurance companies have become more aggressive with denial of care. Health care providers are too likely to acquiesce to the demands of the payers without argument.
I have seen this happening in corrections facilities, even those that are accredited. Examples include a physician who has been told that it is too expensive to do chlamydia testing on intake for people recommended for testing by the CDC guidelines; a nurse who is told that she cannot see an inmate in administrative segregation; a physician’s assistant who is told that he must participate in punitive measures for an unruly inmate. There are many instances where health care providers are asked to cross professional ethical boundaries. If they do it without question, they are not serving themselves, their patients or their profession.
NCCHC standards require administrative meetings to bring these issues to the forefront. I think the free world would be better served if such discussions were also required. I have found that when an insurance company medical director tries to interfere with care of my hospital patients, I can better serve the patient by bringing the medical director into treatment decisions.
It is certainly not wrong for administrators or insurance companies to question practices that interfere with their mission, such as controlling a budget. However, I submit that it is wrong for them to have the authority to dictate medical practices. There needs to be some balance to the power. Health care providers must align themselves with patients to serve their needs and desires.
Patricia N. Reams, MD, MPH, CCHP, is 2014-2015 chair of the NCCHC board of directors and serves on the board as the liaison of the American Academy of Pediatrics. She also is a pediatrician at Cumberland Hospital, New Kent, VA.