The revolution is here.

YES, THERE ARE POCKETS OF PRACTICE WHERE physicians still have expectations of life-time job security, guaranteed income, autonomy, increasing benefits, minimal accountability, growing resources, and physician-oriented work environments. However, the trend paints a different picture of practice reality. When traditional expectations clash with a changing reality, most people feel stressed. Physicians are no exception. Right now, most physicians are enculturated in the old world order: the paradigm that gave them the feeling of control, prestige, specialness, and clinical autonomy. That is being lost to the evolving paradigm of a different medicine (and a different world view with a different belief system). Partly because of a lingering attachment and sense of entitlement, many physicians are anxious and unprepared to function effectively in the evolving medical setting.

What follows is a list of belief clashes. When an individual understands the changing context of beliefs and expectations, he or she can better manage the inherent stress. The notion that physicians are the only appropriate judge of medical care is no longer accepted. The purchasers of medical care are asserting a judicial role. They are demanding better outcomes, better interactions with the treating physicians, lower costs, and more equity. Increasingly aggressive plaintiffs no longer tolerate medical iatogenesis. In an alarming fashion, the territory of medical care is populated by players with non-patient advocacy agendas. In this context caregivers, including physicians, are less and less satisfied.

Well-being is predicated on clear and realistic expectations and can be attained. The only realistic expectation in the medical profession is increasing uncertainty. The good news is that people can be coached in coping better with uncertainty.

Belief Clashes

1. Positions no longer guaranteed for life

Job security will be associated with proof of success in an increasingly competitive environment. Lack of an appropriate or expected medical contribution may cost one his or her job.

2. Physician income based on group practice success

Income will be based on the financial success of the practice or corporation in the overall health care market and not necessarily on the physician's individual contribution. Income could certainly decline and is predictably uncertain. Greater numbers of variables will be associated with net income. Many of these variables will not be under the control of the physician. Many physicians in surgical fields have already seen a decrease in income. Skills in strategic and financial planning and marketing will be rewarded.

3. Population-based decision-making system

The upcoming decision-making system will become more population-based (i.e., what contributes to the health outcomes of a population), thereby lessening the needs for consultation with physicians. The autonomy of the physician will decline, perhaps dramatically. In this situation, physicians' individual skills will be subordinate to the team with whom they work. Using skills in team-building and team direction will foster successful adaptation.

4. No guarantee of generous benefits

Benefit decisions will be allocated among all staff without regard to professional status. Already, bonuses are commonly tied to meeting a managed care plan's profit or utilization targets that reward physicians for stinting on extensive care. Bonuses are also tied to results of patient satisfaction surveys that measure service perceptions and not overall quality. Many managed care entities encourage physicians to see more patients in order to keep remuneration higher, but the very fact that they see more patients leads to less time available to see the individual patient, which will undoubtedly produce a lower patient satisfaction rating and therefore make the management executives "believe" the doctor is not doing a good job (from the patient's perspective). This may harm the doctor's standing with the payer.

5. Sanctions and rewards based on accountability and politics

Some guidelines, if not most, will be drawn from regional or national pools of practice parameters. Specific outcome or process parameters will be expected and will be included in the quality review process. Skills in the science of clinical quality evaluation will be rewarded. This can be an advantage to all--but if this process is tainted by politics neither side will gain.

6. Involved in creating success

Physicians will be expected to be involved in creating overall competitive success. Skills in non-clinical domains, such as marketing, public relations, and creativity will be rewarded.

7. Limited resources will be allocated

Limited resources will be allocated, taking all requests into account. Persuasive communication skills to legitimize resource requests will be rewarded. Skills in cost-benefit analysis will be particularly useful.

8. Lost autonomy

Physicians may have to work where they are needed based on management and population-based outcome criteria. Physician hours, expected pace, and availability will be operationally determined. If there is an oversupply or an easily co-opted physician group, expectations of autonomy will suffer. Physicians will lose captaincy status and may move into unions. The Physician Organizations can, in fact, be viewed as insipient unions.

9. Physicians will hurt more, ultimately initiating constructive responses

Physicians can expect to hurt more, reframing the pain to the point where they initiate constructive responses. These can include using physician well-being and support/ assistance programs so that trust and inter-professional cohesion is enhanced. Pain is inevitable for all of us. Suffering, on the other hand is optional. Suffering can be relieved by interpreting the pain differently and changing the environment. Physician self-care support groups are one constructive response.

10. Focus on prevention-based medicine

The unspoken covenant of meeting physician requests unquestionably by administration is over. The pecking order rewarding high-tech, specialist practice will change. Physicians who practice more frugally and focus on prevention, education, low tech, and low cost interventions will earn more. The day may occur when those who recommend cheap ("alternative") treatments will earn more than those who recommend orthodox zmethods. For physicians to be well-respected in this new world order, they will have to espouse a prevention-based medicine.

This powerful reversal of world views--raising public health and diminishing episodic, curative practices--carries another clash of expectations. Culture clash survivors will have to adjust to new ways of practicing medicine and treating team members, and will need to educate patients differently.

Not only will we tend to focus on prevention for patients, but also the preventable complications of physician dissatisfaction--for example, stress syndromes, inter-professional conflict, and inefficiency. In the new order, we must attend to both patient and provider satisfaction. Physician well-being must be addressed in reforming and creating a viable system of health care. Triage is here for patients and now for physicians. We can moderate the new medical world order's ill effects.