In Defense of Physician Autonomy

By SAUL GREENFIELD
September 7, 2010


The auditorium was filled with young, newly minted physicians sitting nervously in white jackets. When the chairman of surgery mounted the stage to address me and my fellow surgical interns, we immediately hushed and gave him our attention. I don't now recall most of what he said, but one remark has stayed with me through my 25 years of surgical practice: "You can't practice medicine by committee."

He didn't mean that we shouldn't listen to associates or seek their advice, or that we shouldn't be aware of scientific literature conveying the opinions and research of others. He meant that every physician must, at some point in the patient-care process, make decisions and take responsibility for them. And unless the doctor does so, the outcomes will be compromised. He was warning against groupthink and telling us that patients often present challenges that cannot be solved by easily consulted algorithms.
The chairman's admonition was a succinct definition of the parameters of the doctor-patient relationship. And in the eyes of many contemporary medical thinkers—those who seek to reorder the universe of medical care in this country—it would be heretical.
In recent political debates, the autonomous physician has been portrayed as a problem to be solved, an out-of-control actor motivated by greed—and a major cause of rising health-care costs. Insurance companies and the federal government have sought to control physician behavior with the dual aim of decreasing costs and improving care. In their view, individual and regional disparities in rates of medical testing, hospitalization and surgical procedures are ipso-facto demonstrations of physician autonomy run amok.
In the United Kingdom, the National Institute for Clinical Effectiveness (NICE) provides guidelines for clinical care in order to ensure greater uniformity of practice and, it claims, better care. In this country, the recent health-care reform law established a Comparative Effectiveness Institute with the same aims.
Such institutions are illegitimate and undesirable. My field of pediatric urology is only a small subset of medicine, but recent experience demonstrates the dangers of bureaucratic, committee-based practice.

In 2007, NICE published guidelines for the care of children with urinary tract infections. A committee of diverse specialists reviewed the literature and voted on the final recommendations. Without going into great detail, these guidelines enacted a significant departure from then-current practice by recommending against thorough radiographic evaluation in many instances.

One member of the committee who was out-voted on the final guidelines publicly castigated NICE and accused the committee of misusing statistics, failing to involve the proper specialists, and seeking mainly to decrease costs. The criticisms were correct.

Since the NICE recommendations were promulgated, publications in peer-reviewed journals have shown that many children with significant underlying conditions—some leading to serious kidney disease—would go undiagnosed if the NICE guidelines were followed.

Over a decade ago, researchers at Dartmouth College documented disparities in rates of tonsillectomy in children. They famously asserted that certain high rates of tonsillectomy were inappropriate and did not improve health outcomes. To do this, they relied only on insurance claims and hospitalization rates; they had no data on the prevalence of recurrent tonsillitis or long-term cardiovascular morbidity from obstructive sleep apnea. In fact, they had no data comparing the quality of life of individuals denied the procedure with that of individuals who underwent surgery. Their broad statistical overview was simply unable to answer many important questions.

Physician autonomy is a major defense against those who comfortably sit in remote offices and make calculations based on concerns other than an individual patient's welfare. Uniformity of practice is a nonsensical goal that fails to allow for differing expression of disease states.

This is not to say that clinical research, randomized controlled trials, literature meta-analyses and guidelines are not necessary and useful. They are all essential. It is also not an argument against rigorous oversight of physician behavior, licensure and training. But we must recognize that many physicians will often make decisions that deliberately do not conform to "community standards"—and that patients will be better for it.

Dr. Greenfield is director of pediatric urology at the Women and Children's Hospital of Buffalo and a professor at the State University of New York at Buffalo School of Medicine and Biomedical Sciences.