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Autonomy and accountability

Section Editor(s): Bushardt, Reamer L. PharmD, PA-C

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Journal of the American Academy of PAs: January 2015 - Volume 28 - Issue 1 - p 16-17
doi: 10.1097/01.JAA.0000458862.55688.e9
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I have embarked on a professional journey that is as idealistic as it is necessary. I have begun to spend part of my time on a health system clinical operations team, helping our organization adapt to changes required by the Affordable Care Act (ACA), with particular emphasis on optimizing our human capital investment. I piece together stories from colleagues at other health systems, read myriad literature (which is heavy on theory and light on real outcomes), and contemplate the various points where I will undoubtedly encounter barriers. To be successful, this journey will require the engagement of many, openness to new ways of delivering care, and a willingness of current teams to value the talent and capacity of others, sometimes at the expense of their own autonomy and job security. One truth is not disputable: the ACA is requiring us to deliver care in a more affordable way. Providing excellent care is not enough. The cost of delivering care must decrease. It must exist in a culture where the financial risks of illness and the financial benefits of health are harmonized and recalibrated under this new paradigm. Sir William Osler said, “The practice of medicine is not a business and can never be one.”1 Maybe we can preserve such a noble sentiment in our hearts, but today I know Osler could not be more wrong. Medicine is not just a business. It's big business.

I talked recently with a PA colleague who was frustrated with her practice environment. Over her 10-year career, she has been a highly autonomous provider. She not only delivered care but also helped to innovate the ways her team provided that care. Then, she and her family moved to North Carolina. Her new job is in the same specialty but does not challenge her. Collaborating physicians do not understand her capacity. She performs work that is duplicative, less than what she is trained to deliver. She sees other professionals doing work they are overqualified to perform. Her suggestions for improving the efficiency and quality of her team are ignored. Her persistent efforts to effect positive change, despite repeated frustration, reveal her deep commitment. I think to myself, this commitment must be inherent because her current work certainly doesn't justify it. I don't know whether she has ever had to negotiate for opportunities to flex her clinical skills. I coach her as best I can, and in the week that follows, I attempt to leverage relationships with her supervisors so that her ideas might be heard. A comment she made stays fixed in my mind: “I didn't realize how important autonomy was to me until it was gone.”

The healthcare workforce of the future will require radical innovation as we shift to value-based care. As the complex provisions of the ACA continue to be rolled out, we find ourselves straddling a financial pressure to increase our revenue captures in current fee-for-service to create subsidy to build care models that are more accountable to the health of a population. We are asked to do more with less. Tools that promised to help us cross this chasm from volume to value, such as the electronic health record, at times feel more like torture devices than the life preservers they were conceived to be.

Returning to the professional journey I described earlier, I know the destination, but that's really all I know. The destination is a place where the healthcare professionals working in our hospitals, clinics, and communities practice to the full extent of their training. Teams are configured for maximal return on value for patients and their families. Accountability is shared, and teams embrace it. The overall costs of our clinical and nonclinical personnel are substantially lower than they are today. Maybe new types of jobs are created. Maybe some current jobs are gone or reduced in number. We are sustainable once again. My PA colleague is once again challenged and heard, in her current job or a new one. Medicine is still a business, but an emphasis on creating value and the opportunity to practice to a fuller extent of our training makes Osler's vision seem a bit more attainable.

We will ruffle feathers to optimize this workforce. We will drive some capable providers, from all professions, away from satisfying work. If we choose to care about the personal fulfillment of colleagues and lobby for their greater autonomy, we will be more successful. As a profession, PAs have been waiting for nearly 50 years for a moment when healthcare is submerged in disruptive innovation. As the most flexible members of any healthcare team, PAs can seize the opportunity to reinvent ourselves in a way that fosters excellent care but makes it more affordable. If we believe this evolution will happen without taking risks, sharing our creativity, and helping to redesign our teams, we are wrong. Together, let's step up and do something.


1. Osler W. On the educational value of the medical society. In: Osler W, ed. Aequanimitas, with Other Addresses to Medical Students, Nurses and Practitioners of Medicine. 3rd ed. Philadelphia, PA: P. Blakiston's Son & Co.; 1932:395–423.
© 2015 American Academy of Physician Assistants.