Physicians have an obligation to put patients' interests first. With diminished autonomy, this is increasingly difficult. Some physicians can no longer deliver what they believe to be appropriate care in their current positions. When faced with this in the past, they had choices, including working independently. This is no longer possible for family doctors without seeking additional support that can be arbitrarily denied. For the first time, they no longer have the option to say "enough!" without extreme consequences. Without this "safety valve", doctors and patients face an unacceptable existential risk.
Dear Dr. Dosanjh et. al.,
I am writing today as a concerned patient, pleading with you to vigorously defend physician autonomy.
I'd always thought about autonomy in medicine primarily in the context of patients, and still do. But I'm also seeing the rapid erosion of physician autonomy, which now threatens patient autonomy.
I'd better back up. I'm not a doctor, though my wife is (a psychiatrist). I've had a front-row seat as she's worked across Ontario, Alberta, and BC, in large and small public hospitals and cancer centres, for various health authorities, on salary in a private psychiatric hospital, in physician-led primary care networks, and in private practice. I've had the privilege of assisting her in various ways at various times, along with many of her patients and colleagues. I've been driven to advocate on behalf of patients and have focused on the threats to healthcare delivery, mainly in mental health but more recently in primary care.
I don't need to remind you that healthcare is a multidisciplinary team sport. We've all benefited from increased collaboration and maximizing everyone's contributions. The system couldn't function otherwise. Yet, physicians have a unique and vital role on the healthcare team as the final arbiter of patients' interests. We recognize this professional responsibility every time the shit hits the fan. Others have professional and moral obligations, but in a very real sense, the buck stops with physicians. I also recognize that physicians frequently fall short of this standard, often without consequences, which is a separate problem.
Today, physicians are losing their ability to fight for their patients. That's bad for them, but it's worse for their patients. Increasingly, decisions about how they practice and the care they provide are outside their control. Often in the hands of administrators and bureaucrats more removed from patient care and whose primary responsibilities lie elsewhere. Yet, for the sake of the patient, the physician is responsible for acting in their patients' best interests. And when they don't...
We all know of situations where competing priorities push physicians to act in ways they recognize are not optimal for patients. In our system, this frequently comes down to adequate resources. As professionals, they are obligated to work with others to bridge this gap to the best of their ability. Ultimately, if the conflict cannot be resolved and the consequences on patients are severe enough, they have to draw a line. Often, they have to walk away. In less dire circumstances, they may still feel that the interests of their patients would be better served if they practiced in a different way elsewhere. I've witnessed both many times. As have you.
The vast majority of specialists have always had the option of working independently in private practice, though some rely more on facilities directed by others, e.g., radiation oncologists, surgeons fighting for OR time. As long as they comply with the rules and standards of the profession (manifested by licensing, etc.), they don't need to get anyone's permission to practice independently. They can still provide care for all patients supported by our public health insurance system. They maintain the autonomy to act in ways they feel best defend their patients' interests.
It's been shocking to realize recently that most family doctors — who should represent the last line of defence for patients' interests — no longer have that autonomy in BC.
Increasingly, many family doctors practice in ways that we all recognize are suboptimal for patients. The root cause for many is the (easily-correctable) flaws in the fee schedule, leading to too short appointments, inadequate follow-up, etc. The huge disconnect between expectations for physicians from CPSBC, the physician compensation model, and the primary care access situation on the ground is an open secret. There's no possible way to balance the three of them at this time. It's a sign of clear structural flaws in the system.
The response has been funding initiatives: physician contracts to work in health authority facilities or targeted support of individual physician-owned clinics. These have been a lifeline. But they also come with conditions that sometimes limit physicians' ability to act in their patients' best interests or even to speak out to advocate for those interests.
Critically, each and every individual funding decision is at the sole discretion of health authorities (and hence the government). In the past, a family doctor who felt unable to best serve their patients' interests in those environments had the option of practicing independently, as specialists can.
This is no longer an option. Family doctors can no longer provide longitudinal care through the public health insurance system without seeking approval and securing additional individual funding, which may be arbitrarily denied. Family doctors are left with the untenable situation of choosing between their own families' livelihood or their patients' best interests.
This absolute loss of physician autonomy is not theoretical. It's happening now. The consequences on patients are clear. And it's unlikely to stop at family doctors. I cannot imagine a more pressing existential threat to the profession.
I urge Doctors of BC to recognize the full gravity of this threat and to vigorously fight to preserve physician autonomy before it disappears altogether. Do it for physicians. But mainly, do it for patients.
Within our public health system, there must always be an option for physicians to practice in a manner they feel best serves their patients' best interests. An option that doesn't require them to seek permission to do so, permission that can be arbitrarily denied.
Most physicians may choose to practice supported partially or fully by alternative payment models. They have many advantages. But we must recognize the tradeoffs.
The option to practice supported solely by a rules-based funding model like MSP is critical. Where seeking approval is not needed. Where the main requirement and obligation is adhering to the standards of the profession.
This autonomy, this independence, is a necessary "safety valve" should alternatives fail. Alternatives outside of physician and patient control.
Patients need to know that their interests always come first.
We're counting on doctors to fight for us.
Please don't let us down.
Mark Roseman, Victoria BC