How Physicians Can Take Back Control: Agency vs. Autonomy in Modern Medicine | Ep28

Michael Hersh, MD

[00:00:00] 

Physician Agency. It's kind of this new buzzword making its way around medicine. Maybe you've seen it in a recruiter email. Maybe you've heard it at a leadership conference. Maybe you've noticed it sitting next to other familiar words like autonomy, empowerment, engagement. It sounds good.

Modern. Collaborative. But here's the problem. If someone's trying to give you agency, you've already lost it. Because real agency isn't something you get handed. It's something you claim. Ready to learn more? Stick around because that's what we're talking about today.

Well, hey everyone and welcome back to the Better Physician Life Podcast. Thank you so much for being here today. So today, we are digging into a phrase I've been seeing more and more, which is physician agency. It's showing up in emails, leadership meetings, and social [00:01:00] media posts, and on the surface it sounds empowering, like maybe things are finally shifting in the right direction, but when you look a little closer, something about it just doesn't sit right.

Because before everyone started talking about agency, the word we kept hearing was autonomy. And the difference between the two isn't just semantics, it's the difference between control and compliance, between being the decision maker and being managed. So let's start there. Let's talk about what autonomy actually meant and why it mattered.

So, autonomy used to be the cornerstone of being a physician. It wasn't about ego or control, it was about responsibility, about having the professional freedom to make independent decisions for your [00:02:00] patients, guided by our training, medical ethics, and experience, not by administrative checklists or payer algorithms.

Autonomy meant you could look a patient in the eye and know that the buck stopped with you. You could advocate for what was right without worrying about how it would play out on a dashboard. It also meant you carried the weight of those choices. When things went well, it was on you, and when they didn't, that was yours too.

But that's what made the work meaningful. Responsibility and authority side by side, and that balance gave medicine its integrity. Somewhere along the way, though, that balance started to shift layers of oversight, policies and efficiency metrics crept in, and slowly what used to be a professional calling started to [00:03:00] feel more like a managed role.

And that's when this new word agency started to appear. Now, on the surface, physician agency sounds empowering again. It's often paired with words like engagement, alignment, and collaboration. But here's the catch. Agency does not mean the same thing as autonomy. It's not even close. Autonomy is about control.

The ability to make decisions based on what's best for your patients. Agency, at least the way it's being used right now, is really about influence. It's about how much room you have to move within the system, not your ability to change the system itself. It comes from the world of behavioral economics and human resources, and basically, it describes how much someone can act inside a structure they don't actually control [00:04:00]. In plain language. You can maneuver, but only inside the box you've been given. So when hospitals or recruiters start talking about increasing physician agency, yes, it sounds empowering. A hundred percent. What they're really saying is something closer to, we'll give you a little more room to make choices as long as you stay inside the lines.

And that's not empowerment. That's management. And here's the real danger. The more we use the word agency instead of autonomy, the easier it is to forget we ever had a say in the first place. And that confusion, that slide from autonomy to agency, isn't just a vocabulary issue. It changes how medicine feels.

When clinical decisions move from physicians to systems, something essential starts to [00:05:00] disappear. Care slows down, conversations shrink, and the space for judgment and nuance gets squeezed out. We end up practicing to protect metrics instead of patients, checking boxes instead of using judgment. And it's not just the system that suffers; we do too, because when you are responsible for outcomes but stripped of real authority, it wears on you, it chips away at your purpose.

And that's one of the quiet drivers of physician burnout and moral injury. It's that gap between what you know is right and what you're allowed to do. And let's be clear, autonomy isn't nostalgia. It's not about the good old days or how things used to be. It's about accountability and trust.

When physicians have autonomy, patients get better care because the decisions happen in the [00:06:00] exam room, not in a boardroom, not on a dashboard, not in a policy manual. And when accountability stays close to the bedside, ownership follows it. You don't just care more, you can care more because you're trusted to do what's right.

That's the part we can't afford to lose. Now, it's also important to remember that agency itself isn't the enemy. The word isn't the problem; it's how it's being used. Real agency isn't something you wait for someone to hand you. It's how you act on what's still yours to control. Your job might limit your autonomy, but agency? 

Agency is how you decide who you're going to be inside that structure. You still get to control your standards, how you show up., what kind of a colleague, leader, or [00:07:00] physician you choose to be. You can't rewrite every policy, but you can decide how you practice within it. You can choose to see the person behind the patient, even when the schedule is packed.

You can choose to advocate and to speak up even when it's uncomfortable, especially when it's uncomfortable. That's agency. Not compliance dressed up as empowerment, but choice exercised with integrity. And the more you practice it, the more space you start to create. Not because the system suddenly shifts, but because you stopped waiting for permission to lead.

That's how real change starts. One physician at a time, choosing not to give their purpose away. And here's the thing, this isn't theoretical. It's already happening. I am seeing more physicians, especially [00:08:00] younger ones, push back against the idea that autonomy is gone for good and they're saying it out loud.

Autonomy isn't some throwback idea. It is a hundred percent necessary. These are doctors figuring out their own way forward. Building micro practices, creating direct care and concierge clinics, joining practice in a box platforms, taking on locums, not as a backup plan, but as a way to practice on their own terms.

Some are working with physician coaches to get clear on their next step and cut through the noise. Some are starting consulting businesses, others are moving into nonclinical roles where their voice matters. Things like health tech or other areas where physicians can have real impact, and they all have one thing in common.

They've stopped waiting for someone else to fix it because if the system won't hand back autonomy. [00:09:00] They're gonna build it themselves. One decision, one risk, one small act of ownership at a time. That's not rebellion. That's leadership. Real leadership. And I wanna make something abundantly clear. You don't have to quit your job or reinvent your career to feel this again.

You can rebuild agency right where you are by calling out what doesn't make sense and choosing to lead from the seat you already have. Sometimes it starts with something as simple as deciding to stop accepting things that clearly aren't working. It is the return of physicians leading the work, not as a business trend, but as a course correction because medicine only works when doctors actually lead it.

So here's how I think about it. Autonomy is the why, agency is the how. [00:10:00] Autonomy is about having control over the system. Agency is about having control over yourself inside that system. And if you've lost some autonomy, that doesn't mean you're powerless. You can still practice agency in how you respond, in what you tolerate, and in where you put your time and energy.

And if you are in a position to help bring autonomy back. Through leadership, ownership, or something new you're building, then do it not just for yourself, but for the physicians and patients who come after you. Because autonomy protects something much bigger than our professional pride.

It protects the relationship medicine is built on: trust. When accountability and decision-making stay close to the bedside, care gets better. And when doctors lead from that place, from [00:11:00] integrity, not control, everybody wins. So here's my question for you. Where in your life have you been waiting for permission to act?

Maybe it's in your practice? Speaking up? Delegating or finally stopping the things that don't make sense? Maybe it's at home unplugging at the end of the day, not dragging work into every conversation actually being present. Again, because agency, the real kind isn't granted by a title or a system. It's built one decision at a time.

And every time you make a choice that reflects your values instead of your fear, you take back a small piece of what autonomy was meant to protect, and one of the best places to start rebuilding that sense of control is the line between work and home. Because if you are, like most physicians, you don't just walk through the door at the end of the day.[00:12:00] 

Your body's home, but your mind is still running the list, replaying conversations, thinking about tomorrow, carrying the whole day with you. That transition doesn't happen automatically. It takes intention. And so that's why I created the Five Minute Commute Reset for Physicians. It's a short guided audio and worksheet that help you leave work at work, clear your head and walk through the door ready to connect with the people who matter most, and you can download it for free at betterphysicianlife.com/commute-reset. And I'll link it in the show notes because autonomy, agency, and boundaries all start in the same place with awareness and a decision. You don't need to wait for permission. You already have the agency to start. 

Thank you so much for listening, and I'll see you next time on the Better Physician Life [00:13:00] Podcast.