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As the data supporting the value of evidence-based medicine grows, with its contingent best practices for quality and patient safety, it inevitably comes into conflict with one of medicine's most hallowed traditions-the autonomy of the physician.
As practitioners of both the art and science of medicine, physicians have never wanted to be bound by standards, rules or mandates beyond the Hippocratic oath. How can the new call for clinical protocols, including the increased incorporation of IT, reconcile itself with the age-old perception of the physician as "the captain of the ship"?
"This is an organizational culture and a physician culture issue," explains James E. Orlikoff, president of OrlikofT& Associates, Chicago. "The economic environment that generated physician autonomy until recently [was one in which] inefficiency was rewarded. There were economic incentives to have high degrees of variation in medical staff work."
Traditionally, hospital patients received treatment unique to their doctor's practice methods, which made costs opaque, Orlikoff says. "We didn't need to know what our costs were ... it used to be, the more variation you had, the wider the swings in payment, the greater the reimbursement."
In a moment, however, DRGs changed that system by creating fixed reimbursement. What did not change is physicians' ultimate control over revenue generation, Orlikoff says. But now, inefficiencies are no longer rewarded, they are punished. "The variation that used to generate success now leads to economic failure ... and the only way to control costs is to make sure that physicians [work] in an increasingly narrow way," he says.
"[This is] one of the major challenges in health care-[finding] the balance between physician autonomy and public accountability, or transparency-and the realization that there is so much variation [in care] that not everyone can be correct," agrees David Nash, M.D., chair of the Department of Health Policy at Jefferson Medical College, Philadelphia. "Don't be hoodwinked when physicians say 'My patients are sicker,' 'I've always done it this way' or ? know what I'm doing.'"
The practice of medicine itself is changing, says Tom Russell, executive director of the American College of Surgeons, Chicago. "The old-school type of physician, who may have been in solo practice, is fading away-medicine is getting too complicated." He concedes that "there will always be...