Pushed to Abandon Clinical Judgment
Dr. Shelley said insurers and other corporate interests have too much control of healthcare, and the result is that "the physician becomes accountable for what other people have decided." A key example of this, he said, is forcing doctors to give up their medical intuition in favor of clinical practice guidelines, which are often used to determine prior authorizations, are embedded in electronic medical records, and are the basis of many pay-for-performance standards.
Rather than resort to guidelines, Dr. Shelley said he primarily relies on his intuition when diagnosing patients. If he is not satisfied with that, he said he reverts to analytic methods, such as ordering tests and consulting guidelines. But he sees this as an awkward and time-consuming way to approach clinical problems, "like having your car in 4-wheel drive all the time," he said.
Moreover, he said practice guidelines have to be interpreted because they are often off the mark. Several studies[9,10] have questioned the validity of guidelines, and close to half of doctors in a 2012 Medscape survey said quality measures and guidelines would have a negative impact on care.
Dr. Forman, on the other hand, supports guidelines and is skeptical of intuition. "There was a time when we allowed physicians to act like artists," he said, but in the future, "practice styles will be more equal. Everybody will be expected to have basically the same diagnosis and treatment."
Dr. Kennett, the Missouri cardiologist, said he supports voluntary use of clinical guidelines. "I'm a fan of appropriate use of clinical criteria -- not for every single thing you do, but mainly for high-cost, advanced treatments," he said.
Under Hospitals' Thumb
In a 2011 survey of final-year medical residents, conducted by the recruitment firm Merritt Hawkins, 60% wanted to be employed and only 1% wanted to go into solo practice. Hospitals, in particular, have been a magnet for these young physicians. In 2012, almost 30% of physicians worked in practices partly or wholly owned by a hospital, according to the AMA.
Dr. Shelly thinks employed physicians are at risk of being co-opted by the hospital's interests. "Their actions have to reflect the will of the organization," he said, adding that an employed primary care doctor is expected to refer to the hospital's own specialists.
Dr. Kennett said he is concerned that young employed physicians "expect predictable hours and outpatient practice only" and gravitate to "shift work." Rather than following patients through treatment, they are happy to hand them off to the next physician, and that's "a bit disappointing," he said. Many physicians share these views.
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Cite this: Are Doctors Being Exploited? - Medscape - Feb 13, 2014.