Do doctors have autonomy?
27 June 2022
Paediatric and Adult Otolaryngologist, Ear Nose and Throat, Head and Neck Surgeon Dr Eric Levi reflects on the concept of ‘autonomy’ in medicine - how much autonomy is enough for doctors to thrive?
Autonomy is something we give to our patients. That’s the bedrock of medical ethics – respect for patient autonomy over their health and their choice of treatment. As doctors we make diagnosis and we offer our recommendations, but the ultimate decision on treatment is in the hands of our patients (except in very few select situations where the patient is unable to do so).
Let’s put the mirror up to ourselves now. Do we offer ourselves autonomy? Are we given autonomy in our day to day practice as clinicians? Does your department head or supervisor of training allow you some autonomy in your work?
All through medical school and surgical training, I have been trained to think in a certain way and act in a certain way. All of our training is about principles, rules, regulations, protocols, policies, and they’re all good – to a certain dogmatic degree – for the sake of our patients. As a surgical trainee years ago, I felt my life ruled by my pager and on-call roster. I had loss of autonomy. I did not see my family much due to relentless call backs. I lost my social network due to frequent relocations through training. I lost my hobbies as they are displaced by the time demands of training, work and study. This rigorous training is necessary to a degree, but is also erosive to the individual personal autonomy.
As consultants, many of us have better control over our days, but we are also merely cogs in the wheels of the complex healthcare system with many jurisdictions and administrators determining our day to day work. As we spend our days chained to computers on wheels click-click-clicking the EMR, the song “I want to break free” by Queen sometimes echoes in our heads, or maybe just in my head (sorry if you are not from that awesome generation).
Autonomy is not absolute freedom. Autonomy is the freedom to decide what is good for us. Yes, there is a sprinkle of selfishness in there if autonomy is taken to an extreme and intrude on others’ autonomy. We are clinicians and of course we have to abide by rules and principles when we treat patients and work in teams. But perhaps the lack of freedom to do what we really want to do because of the numerous mundane non-clinical work displacing the essentials is what is causing personal distress in us. Multiple studies have shown that bureaucracy and non-clinical tasks are the things that cause emotional distress and burnout in many of us.
How much autonomy is enough autonomy for us as doctors? As it turns out, there is a number. And that number is 20%. From Dr Tait Shanafelt : Evidence suggests that doctors who spend at least 20% of their time focused on the dimension of work they find most meaningful are at dramatically lower risk for burnout. Although each 1% reduction below this threshold increases the risk of burnout, there is a ceiling effect to this benefit at 20% (eg, spending 50% of your time in the most meaningful area is associated with similar rates of burnout as 20%). This suggests that doctors will spend 80% of their time doing what leadership needs them to do provided that they are spending at least 20% of their time in the professional activity that motivates them. This activity could involve caring for specific types of patients (eg, immigrant health) or patients with a given health condition (eg, becoming a disease expert) or activities such as patient education, quality improvement work, community outreach, mentorship, teaching students/residents, or leadership/administration.”
Interestingly, high performance organisations such as Google and Apple recognise this and apply this principle of allowing staff members to have a degree of flexibility in their work. What about us? We trained to be clinicians and that privilege comes with certain responsibilities such as teaching, research, leadership, administration, and other non-clinical duties. Let’s be honest, some of us are better at one thing than another, and in reality that’s probably because some of us prefer one thing over the other and find one particular thing to be more meaningful than another. What if we gave each other the gift of autonomy and allow each other some freedom within the boundaries of our responsibilities to do work which we uniquely find most meaningful. Just 20%! How will that affect our job satisfaction, job effectiveness and patient care?
Dr Eric Levi
Paediatric and Adult Otolaryngologist Head and Neck Surgeon
Thank you to AMA Vic member Dr Eric Levi for writing this article for our #WellbeingWednesday series. Any member who is interested in writing a 500 to 750 word article on a wellbeing topic, please contact email@example.com.
-  Shanafelt, Tait D, MD; Noseworthy, John H, MD, CEO. Executive Leadership and Physician Well-being: Nine Organizational Strategies to Promote Engagement and Reduce Burnout. Mayo Clinic Proceedings, Vol. 92, Iss. 1 (Jan 2017): 129-146.