• Understanding the patient’s preferences, values, beliefs, and expectations;
• Establishing partnership approaches / philosophies to relationships with patients that position themselves as a mentor and advisor when needed in the patient’s clinical decision-making process;
• Helping patients develop and recognize choices in meeting their medical care needs. (while the gap in asymmetries of information has closed, the physician’s clinical training and experience will always hold value beyond that which can be absorbed by the lay members of society);
• Planning to devote more time to shared decision-making processes with patients; and
• Recognizing and respecting the patient’s decisions. 5
For the physician leader this shift in power in the physician’s relationship with patients is one that has organizational and managerial implications. Following practice guidelines or meeting requirements for administering services at hospitals may require certain physician behavior ad communications to adhere to established risk management, quality, or safety policies. Integrating shared decision making into practice policies will be a cultural shift for every organization.
Information Technology and Autonomy
One of the single most important elements that has impacted the shift in the power for physicians in the past half century has been the influx of technologies in the health care industry. Robotic surgical instruments, diagnostic devices and systems, electronic medical records, health information exchange, data analytics, and new coding languages, have given rise to new capabilities and power to the physician community while simultaneously reducing their control in the social structure of medicine held for so much of the 20th century. Starr notes:
…the most influential explanation for the structure of American medicine gives primary emphasis to scientific and technological change and specifically attributes the rise of medical authority to the improved therapeutic competence of physicians.6
The advancements made through technological change have enabled many of the industry’s breakthroughs and life-saving accomplishments, but also challenge physicians’ professional control. Just as robotic surgery changed the capital requirements of hospitals, decreased recovery time for patients, and required new technical skills for surgeons, so too do populations management strategies dependent upon health care information technology in the community setting alter the role of physicians. The introduction of new technology within the clinical work environment always alters processes and has unintended consequences.
A study by Campbell, Sittig, Ash and colleagues identified a set of nine unintended adverse consequences that result from the introduction of computerized physician order entry systems. Of note, the unintended power structure shift from physicians to others is based upon their loss of control over information.7
The shift in control of information has led to an increase in leadership roles held by nurses in the care delivery process and administration of health care organizations. Nurses make up the largest segment of the health care workforce and, as their responsibilities have grown to accommodate the needs of delivering patient-centered care, academic initiatives are focused on strengthening the education level of the national nursing workforce. This is resulting in a growing number of nursing leaders working in partnership with physicians to redesign the health care delivery system and processes.8 A number of factors are driving this change:
• The social architecture and fabric of health care organizations has changed. Nurses are increasingly being called upon to shape health policy, implement new systems, and to serve as change agents throughout the health care ecosystem.
• Health information technology tools have increased the need for shared responsibilities in managing health information at the patient and population level.
• The patient population continues to increase through demographic and socioeconomic changes that will drive the need for additional collaborative clinical leadership in managing care delivery programs and organizations.9
While some will view these changes and structural shifts in power as threatening, physicians will maintain a position of leadership within the shifting organizational culture by leveraging their professional training and fiduciary duties in a contextualized manner appropriate for the new working environment.
A concept that helps provide a deeper understanding of the complexity of power shifts is the interactive sociotechnical analysis (ISTA) introduced by Harrison and Koppel in 2007.10 Computerized provider order entry and other health information technology systems all involve transforming the clinical workflow processes within organizations as they are implemented. Throughout the process of design, test, implementation, and eventual future-state use of a new application, clinician-ancillary-administrative team members are engaged with physicians to ensure that benefits are realized from the new tools to meet goals for improving outcomes, cost, quality, and safety of patient care. Harrison and Koppel indicate that, throughout this process, relationships and communication are impacted by the dynamics involved with changes in workflow and the new systems. New triggers, alerts, and in some cases workarounds11 can emerge that inadvertently result in shifts of roles and actions that can impact quality and safety in patient care operations. Application of Harrison’s and Koppel’s ISTA model can be used to understand the requisite policy changes that are necessary to accommodate new workflows, approvals, communication patterns, and roles of various professionals in the health care system.
Physicians in the Boardroom
Even into the 20th Century physicians have operated in a cottage industry environment, but economic necessity is bringing to a close the era of smaller independent physician practices. With this industry transition, the importance of having physicians operating in the governance and leadership of the new health care corporate institutions has become a priority. Most recently CMS’s proposed rule for the new Medicare Shared Savings Program12 calls for physicians to be engaged in leadership within the governance structure of accountable care organizations.
In academic medicine the traditional positions of power continue to be held by physicians. The physician’s knowledge, skills, and ethical responsibilities have emerged as essential needs for the spectrum of other organizational types that operate in the health care ecosystem. Companies ranging from biotechnology start-ups to managed care organizations and government agencies are calling upon physicians to take leadership in order to create sustainable health care institutions.
Health Economics of the Shift
In 2011 the Medicare Payment Advisory Commission’s (MedPAC) Report to Congress provided an updated picture on the restated long-term outlook for cost growth of Medicare spending first through 2019 and then through 2035.
Given these projections, it is noteworthy that MedPAC’s top reason for the growth in health care spending over the past four decades is advances in technology. In that dynamic, the physician’s role as an autonomous decision-maker for utilization of such technologies will continue to be challenged. The exorbitantly high growth in costs will continue to push a regulatory response and a reform agenda such as value-based purchasing, bundled payment systems, and across-the-board cuts in fees. As the rapid backpedaling on the Ryan Plan by the Republican-controlled House of Representatives illustrates, a focus on the consumer-side of the equation is far less politically palatable than that focused upon the providers. Thus, physician leadership must understand the impact that economic trends will have upon the profession from a comprehensive standpoint.
Changes to the principal-agent relationship. Agency theory formulates the concept of the principal (patient) and agent (physician) relationship that should be the foundation of patient-centered decisions and programs. The economics of health insurance benefits structure, and