Thursday, April 1, 2010

Government Regulation and Physician Autonomy

Preface: I received the following e-pistle from Richard “Buz” Cooper, MD, Professor of Medicine at the University of Pennsylvania. Dr. Cooper was among the first to draw attention to the looming physician shortage and the link between high costs and poverty. I reprint his letter with his permission.


Berwick is a visionary who, more than anyone, has drawn attention to strategies that can improve quality. But I have real misgivings about his tendency to embrace regulation. His 1996 book, “New Rules,” co-authored by Troy Brennan, is the manifesto for the regulatory philosophy.

I was on a vacation in Spain shortly after “New Rules” was published, and here's what I wrote about it inside the dust cover:

"A sad and enigmatic tale of American medicine at the dawn of the 21st Century, more so than Heller's "Catch-22," Sartre's "The Trial" or Verdi's "Othello." The plight of American medicine caught in an invisible contest between its historic advocates - the bearers of the traditions of Maimonides, and the new self-appointed saviors of medicine - the regulators, the uninvited.

I am in Cordova, Spain opposite the birthplace of Maimonides, the greatest of Jewish physicians, reading again his morning prayer for physicians, exhorting them to "never believe they know enough," reflecting on my own words to a decade of graduates as Dean of the Medical College of Wisconsin: "may you never lose the ability to say, I don't know." This is real "total quality improvement;" the acceptance of professional responsibility - the individual responsibility to be the best one can be in service of one's greatest responsibility - an individual patient.

Now we are told that this ancient axiom, which survived from Hippocrates through Galen to Maimonides and was expressed by Francis Weld Peabody's declaration that "the care of the patient is caring for the patient," has entered a post-modern period of ethical revisionism, where the greatest obstacle to quality is physicians. Regulation now usurps the physician-patient relationship in the name of seeking perfection in an arena that is inherently imperfect but that, through their groping with imperfection, has led physicians to find more perfect solutions."

My colleagues and I expanded on this in the last paragraph of our recent report, “Physicians and Their Practices Under Health Care Reform,” sponsored by the Physicians Foundation. This paragraph addresses the issue of physician autonomy.

“Physicians struggle to improve quality, safety and efficiency in an imperfect world of clinical practice that is overwhelmed with information, laced with ambiguity and plagued by deepening physician shortages. From an organizational perspective, they require sufficient numbers of colleagues, a supportive infrastructure, adequate reimbursement and freedom from administrative and regulatory intrusion. High quality care depends on the autonomous exercise of clinical judgment by competent and empathic physicians who are accountable to their patients and society. No amount of regulation or incentives can substitute. In the last analysis, physician autonomy is the friend of quality.”

Best wishes,


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