Jean Lawrence
Contributing Editor
MANAGED CARE September 1997. ©1997 MediMedia USA

For physicians, reclaiming a measure of clinical autonomy can be a matter of health itself. But alas, there's no one blueprint to follow.

Jean Lawrence

Contributing Editor

Burnout can be subtle," says John Henry Pfifferling, Ph.D. "It is a slow, aggregating erosion of energy. It's not something that happens overnight. You no longer look forward to working. You no longer see the day as an opportunity to do what you do best."

Pfifferling is the director of the Center for Professional Well-Being, a nonprofit organization in Durham, N.C., that counsels doctors on stress, practice cohesion and morale.

"All I hear these days are complaints from doctors," he says. "And a large blame component is managed care."

Doctors differ, of course. But it is characteristic of a certain stereotype of physicians that when it comes to their own well-being, they need reminders themselves of the very things they routinely counsel patients about: the importance of minimizing stress and maximizing self-care, for example, and each individual's need to choose the work environment that suits her or him best.

That's why no discussion of physicians "taking back the power" in health care would be complete without consideration of just what that power's presence or absence does — not too clinically speaking — to your gut.

As an anthropologist, Pfifferling looks at American physicians today and diagnoses culture shock. Drastic shifts in medicine's economic organization are challenging doctors' personal tendencies, reinforced by training, toward autonomy and independent action.

"Everywhere physicians turn, they see managed care intruding into their relationships with patients," Pfifferling continues. "And it's easier to blame the single entity of 'managed care' than to look at what managed care actually is: a diversity of organizations, rules and structures."

The four groups described on the preceding pages have reduced the intrusion of managed care organizations into their clinical lives by accepting full risk and taking over some functions — such as physician credentialing — that HMOs previously performed. Does following such a course mean stress reduced, burnout avoided, happiness assured?

Not necessarily.

If physicians take it upon themselves to learn what the market requires, and proceed with a coherent vision of what they wish to accomplish in that market — a vision supported by colleagues and flexible enough not to be shattered by unexpected bumps in the road — then by taking on new responsibilities they can do much to create a "new world view" to supplant the old autonomy for which they're grieving, Pfifferling suggests.

But there are pitfalls. Time spent learning about the market or capitation is time taken away from clinical learning, for one. And by their very nature, greater risk and greater accountability create greater vulnerability to financial reverses — including "unfair" reverses, such as a population of covered lives turning out to be sicker than it was supposed to be.

More work, you lucky doc

Sometimes, too, adds Pfifferling, "the reward for being a good doctor is more work. In the old days, you know, some physicians joined large groups so they could work less.

"Also, to keep the risk you've assumed from biting you, you may need to make greater use of nonphysicians doing things physicians formerly did. That, too, can create tensions."

Pfifferling recommends that physician groups address these problems head-on. Hold workshops on frustrations with managed care. Let physicians share their lists of stressors. Pinpoint the specific cause of a problem, looking beyond the abstraction "managed care" to the organization or system responsible for the troubling intrusion. Discuss frankly what certain steps toward greater autonomy might do to address these concerns — and perhaps to create new ones.

While taking a clear-eyed look at the stress factor in one's business relationships and what can be done about it may be good advice for all physicians, there is, unfortunately, no "one-size-fits-all" solution. Both the urgency of "taking back the power" and the appropriateness of methods for doing so will differ from one physician to another. One may be contented with the security of a salaried position at a staff-model HMO (a security growing harder to find these days), while another will crave the chance to be rewarded for managing care aggressively. Business decisions should take into account each doctor's preferred work style, openness to change and receptivity to the managed care ideals of prevention, cost-effectiveness and population-based care.

Anthropologist John Henry Pfifferling, Ph.D., holds workshops on dealing with the frustrations of managed care.

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