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Patient Well-being Requires Doctor Autonomy

If America is experiencing a Medical Care Crisis where patient well-being has become subordinate to the corporate well-being of its functional components (hospitals, doctors, payors and universities/industry), what will it take to remedy the situation? We have suggested that the medical care environment will need to be re-balanced. Each functional component must stand autonomously to help support patient well-being. This is especially true for the doctors.

Doctors must be aligned, organized and capable of standing toe-to-toe with the hospitals, the payors, the universities and the medical industrial complex on behalf of their patients. It has been suggested that doctor employment by either the hospital or the payors is the reason we have a Medical Care Crisis. Doctors are the direct interface with patients. Anything that conflicts with the well-being of the patient such as the corporate well-being of the doctor’s employer is destined to undermine the primary objective of medical care.

Perhaps true. But is that always the case?

Some weeks ago, we outlined the history of the medical group at the Greenville Health System (GHS) – a system that I had the privilege serving as President for nearly four years. In retrospect, the GHS medical group, known as the University Medical Group (UMG) was a scalable model that deserves closer attention. As the 15th largest employed medical group in America at the time, it was unique because while it was technically a hospital employed group, it was also autonomous. This means that while the doctors were employed -- answering to the same Board of Trustees as the hospital – they were afforded self-governance and were expected to act in accordance with moral duty rather than self-interest.

How was this accomplished?

As it turns out, the medical group was a corporation separate from the hospital. It had a physician-led operations board and a senior physician who answered to a CEO committed to physician self-governance. That CEO led both the medical group and the hospital. He reported to a single Board of Trustees. UMG had a separate financial bottom-line to which the doctors were held accountable, going at risk for meeting (or failing to meet) financial targets. None of the doctors had restrictive covenants. They managed their own HR staffing needs. They transactionally negotiated with the hospital each year for funds to support teaching, medical directorships and call coverage. Once the dollars were agreed on and transferred to UMG, there was no further hospital subsidy.

UMG was mission-based. It existed to set the standard of care for South Carolina’s Upstate; to care for everyone regardless of complexity or ability to pay; to teach the future workforce; and to make the dollars work. Its mission was its moral duty. It gave its leaders a sense of purpose. It challenged its doctors to be responsible. To be “owners” of the medical care environment. To place mission above self-interest. While it is easy to remember the past through rose-colored glasses, clinical burnout was never a crippling issue at UMG. We were seemingly too busy to be burned out, starting transformational academic projects (like a new medical school) or clinically integrated networks. Likewise, we were committed to leadership development – conscious leadership, self-awareness, Enneagram typing -- and meaningful partnerships with our hospital colleagues. GHS and UMG became a highly integrated healthcare delivery system devoted to physician-administrator dyads, physician leadership and patient well-being.

Notice the paradox. Autonomy resulted in integration. Trans-actionality yielded transformation. More responsibility (i.e., work) resulted in less clinical burn-out. Relinquishing control yielded greater compliance. More independence created a greater sense of ownership. Less effort resulted in more productivity.

There is a great lesson here. When we look around the country (and around the state) hospital employment of doctors generally means that doctors fall in line like all other hospital employees. Doctors are expected to do their job like everyone else and be good employees. The corporate bottom line prevails and lives in the C-suite. Doctors are controlled. They are hired, evaluated and fired according to corporate rules. Clinical decisions must align with corporate philosophy. Doctors rarely feel like “owners.” The hospital-doctor relationship can sometimes become rigid. A relationship that competes with the doctor-patient relationship.

Of course, this is occurring at the same time we are experiencing unprecedented clinical burnout rates, a lack of availability to basic medical services, computer generated text messages to patients (often delivering bad news), non-clinicians being asked to make clinical decisions, a system of communication that is woefully inadequate and a state of wide-scale patient dissatisfaction. In other words, it is occurring during the Medical Care Crisis where patient well-being is no longer the priority.

A coincidence? Not a chance.

Fixing the crisis – making patient well-being the “North Star” – starts with restoring doctor autonomy. Whether it is with independent practice or a separately budgeted or incorporated hospital employed medical group like UMG, autonomy – self-governance and practice in accordance with moral duty rather than personal or corporate self-interest -- is the first step necessary to achieve doctor engagement. And without doctor engagement, there is no hope for a resolution to our current situation.

Stated differently, doctor autonomy is essential for patient well-being. To think differently is imprudent. In fact, it is folly.


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