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The continuum of healthcare autonomy – how does it work?

In our last blog, we asked the question about healthcare autonomy – Who Rules?  On first thought, almost everyone agrees ill individuals should make their own health care decisions. Many health systems even promote that concept by touting patient-centricity in almost all of their marketing outreach.  

As a physician – and patient – and understanding how decisions inside health systems get made, the autonomy continuum linking individuals and health systems is often on my mind. In our work with Curadux, the appropriate collaboration with our members moves the individual (our member) along this autonomy scale toward the individual-end of the decision-making continuum. That is important, since it is that part of the continuum where the important values and goals of the unique individual are truly impacting their needed decisions about health.  

Yet, in the everyday work of healthcare decision making it seems that more decisions are made near the health system-end of the continuum. So why is that?  I offer that the movement along the autonomy continuum follows the incentives built into the larger health system; these are facts that may be consciously or unconsciously acted on. Though not exhaustive, it seems to me that the following four incentives push decision-making closer to the health system-end of the autonomy continuum.  

1. Knowledge – in spite of the availability of “Dr. Google” helping patients in learning more about their condition, medicine is facing an information and treatment explosion that often takes physician education and wisdom to sort through symptoms and possible disease course – in short, clinical experience does matter in decision making.

2. Clinical Production Pressure – the advent of revenue targets inside health systems for clinicians and specialty units keeps the care team focused on moving patients through their exam rooms, thus, time for truly listening to individual patients in the exam room is shrinking.  Unique values and goals can easily be missed.

3. Standardizing Care – the movement within healthcare quality circles of “knocking the variability” out of health care processes seems to be often morphing into - there is only one correct way of handling a clinical issue.  Individualizing care is easily overlooked.

4. Bedside or Exam Room Utilitarianism – there are daily discussions by healthcare policy leaders who seek to maximize the resources devoted to healthcare across the largest possible patient population. Without conscious efforts utilitarianism thereby often gets access to bedside or exam room decisions.

When these four factors are considered, each one pushes decisions significantly toward the healthcare system-end, thereby, dominating the healthcare decision-making continuum. A key in that dominance is that the individual’s interests often are left unexplored; the individual is frequently “normalized” into a standardized and interchangeable patient, often framed as a “condition.” The fundamentals that should be impacting decision-making most directly are the values and goals for living held by the ill-individual. These values and goals should be explored and considered more fully and integrated into each of the other decision-making incentive steps to honor individual autonomy.