What I Learned about Physician Autonomy at the ATM Machine
A Message from Shikha Anand, MD, MPH
NICHQ's Director of Strategic Alliances and Initiatives and Obesity Program Director
“Every system is perfectly designed to get the results it gets.” This is a common adage among improvement experts. I heard this phrase for the first time about a year ago, when I was somewhat new to NICHQ. While I considered myself a systems thinker, this only partly resonated with my view of my clinical practice. Like many other primary care providers, I was frustrated with the systems that support my practice, but still believed that I myself was completely responsible for – and in control of – the results of my work with patients.
A few weeks into my work at NICHQ, I went to the Automatic Teller Machine (ATM) at my local bank. I withdrew money, got my card and went on my way. As I walked away, I recalled that in younger years, I very often rushed away from an ATM having left my card in the machine. That hadn’t happened to me in a long time and I wondered why. I am busier now than ever before, and as my mom always reminds me, haste makes waste. So why had I not lost a card in years? As I reflected, I realized that the reason is that the ATM now makes me take my card before giving me my cash. And I would never leave without my cash. The system is designed to prevent this human error, and so I’ve now managed to keep a single ATM card for almost 5 years.
At that moment it dawned on me that my decisions, both inside and outside of clinic, are as much driven by the system that supports me as they are by my personal behavior.
As a medical professional, I have been trained to take pride in autonomy and the art of medicine. Like my peers, I distill large amounts of data and use it to better the lives of others. I use cultural context and health behavior change techniques to help families improve their health. The results I have achieved with underserved families have allowed me to believe that by changing my behavior, as an individual provider, I can change the care I deliver. But the well-worn ATM card in my wallet challenged me to think otherwise. Perhaps the system played a bigger role in my behavior than I had previously thought. While I knew this to be true from my quality improvement work, it remained in direct conflict with my medical school teachings – that, as a physician, I am the primary driver of the care I deliver.
Similarly, we physicians blame ourselves for our mistakes because we feel that we own the care of our patients. As a pediatrician, I order lots of vaccines. Occasionally, I forget to order one. When this happens, I tend to lose sleep. I believe that I own the missed vaccine and had I slept better/ read more/ studied harder in medical school, this would not have happened. What I often neglect to take into account in those moments is the role the system played in the process. In one example, the patient that I was attempting to see in a 15 minute interval was a 13 year old who had immigrated from Haiti two weeks prior after witnessing the unwitnessable and had more physical, mental, oral, and social health needs that could possibly be addressed in the time we had together, even IF we spoke the same language.
But the goal here is not to lament about the system that supports primary care. It is to aspire to a way forward that supports individual autonomy, while preventing human error – say, on a bad day for scheduling or sleep or health reasons – from impacting the lives of patients.
Call me naïve, but I think the team-based care endorsed in the medical home model may be the way forward. Before I came to NICHQ, I led a pediatric department that was undergoing medical home transformation. The change was difficult, as change often is, especially change that impacts every facet of the way we do business as pediatricians. However, by asking the staff we worked with every day to play critical roles in data gathering, decision-making, and double-checking, we as providers were able to preserve our autonomy and also have a safety net for the days in which our processes were challenged by the constraints on the system or by our lives outside of medicine.
Over the past year, I have been privileged to bring this experience to my role as the Project Director for NICHQ's current medical home learning collaborative. I have been helping practices transform their systems to engage their care teams and provide evidence-based care that supports patient and provider autonomy while reducing harm.
In this system, providers’ feelings of isolation as solely responsible for patients is replaced by the knowledge that we are part of a functioning team that is supported by a larger system. Now that is a system that is designed to achieve results.
You can reach Shikha at firstname.lastname@example.org
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