Expectations, particularly when unmet, can be a source of disappointment. Anticipating something to happen a certain way and having it not come to fruition can leave us wanting, waiting, wondering. It can be particularly challenging when we feel responsible for a result but have incomplete, little, or even no control over it in the first place.

In medicine, there is a movement toward outcomes-based care with a valiant mission of prioritizing and elevating the benefits to the patient. In considering outcomes and appropriate ownership, there remains room for interpretation and opportunity to reframe reasonable expectations.

If we are measuring success based on outcomes, who is deciding what they should be?

What defines the best possible outcome for a given diagnosis or procedure in medicine?

What happens when the ideal outcome is different for the patient, the physician, the hospital, the health care system, and the insurance company?

Who is ultimately responsible for this expectation, and how is blame assigned when it is unmet?

Does the power of determination rest with the same entity who bears ultimate responsibility?

When the answer to this last question is “no,” dissonance arises for those delivering care and those receiving it.

Consider for a moment that the detailed final result is actually outside of everyone’s direct control. Examining the number of variables involved and the unique combination of factors that conglomerate to yield a result – exposure, sleep, nutrition, technique, genetics, access, environment, stress, knowledge, skill, behavior, ability, to name a few – it is quite possible that no one is ultimately responsible for the specific outcome. It is equally plausible that all have degrees of influence, contributing to the likelihood of achieving the desired outcome. Perhaps it is also conceivable for this collective approach to be de-stressing rather than distressing.

Physicians can feel, and in many cases are directly told in the way of liability and means of compensation, they are responsible for the ultimate outcome. Infection rate, readmissions, patient satisfaction scores, cure, resolution, avoidance of death. Are any of these actually within the sphere of control of an individual physician? Is this where dissonance that leads to burnout begins?

When assigning expectations for the result of another without access to the power over so many factors, we create an impossible loop. Acknowledging this as power that cannot be assigned because it simply exists outside of individual control is the first step. Admitting it is incongruous to allocate responsibility disengaged from power is the next. Accepting that responsibility must be otherwise delegated is the next and is more of a leap.

Imagine if physicians were responsible for delivering high-quality care, in their specialty. For staying up to date with the information available in their field. For implementing proven protocols. For caring for themselves with sleep and nutrition. For listening and leading patients and team. For responding to feedback from a place of constructive growth rather than protection against liability. For contributing to the effort from their experience and expertise as part of the collective rather than the sole source of the outcome.

Imagine if patients were responsible for the aspects of their health they could control. For understanding and inquiry. For participation in the process. If they do not have the resources to uphold these responsibilities, for this to be acknowledged, with efforts made to fill those gaps through policy and process.

Imagine if the hospital was responsible for the factors that offer the greatest chance for success – smoothly operating procedures and protocols, up-to-date resources, support for staff, and responsiveness to patients. For balancing the bottom line with best practices.

Imagine if the health care system was responsible for acknowledging the whole picture of health. For filling those gaps identified. For creating policy that supported permission over punishment, prevention over reaction, possibility over limitation.

Imagine if the insurance companies were responsible for appropriate compensation for services rendered. For encouraging health or, if serving as originally intended to actually ensure access to and coverage of care for catastrophic events, making way for a new system that could serve the health.

Consider the individualization of these various responsibilities not as a division but as a thoughtfully crafted collective synergy, returning power to its fullest capacity by intertwining it directly with appropriate responsibility.

Imagine if each entity came together in awareness of that which they could control, accepted that responsibility, and the portion of the expectation accordingly influenced. Imagine the relief in relinquishing the stress that accompanies liability for something outside of one’s jurisdiction. Consider how each would show up in a different way, freed from the pressure of performance outside one’s zone of genius and capacity. Envision each entity engaged in ownership of that which could be controlled and the ensuing release of shame and blame.

How much more likely would it be to achieve the expected result, and, in those cases when it was not achieved, how might the levying of responsibility shift the repercussions and reform?

Liability transforms into accountability through the appropriate allocation of power with responsibility.

Would outcome measures shift from quantity to quality based on the various contributions of individual achievements combined? Questions of subjectivity and reproducibility arise, perhaps appropriately challenging the system toward personalization. Even if the same outcome measures as presently used remain in place, viewing them through this new lens of ownership allocation reframes their purpose and possibility.

Consider infection rates, falls, readmissions, length of stay, medication use, and survey scores. If these are the expectations, how might they be evaluated differently, knowing what each entity should, could and did contribute? Perhaps this could lead to realistic assessment, greater understanding, systems updates, and practical reform.

Dissonance comes when we are expected to control that which we cannot. Congruence happens when there is reunification of power and responsibility.   Outcomes and value-based care are infinitely enhanced when we stand together in full ownership of our own spheres of influence. Let’s step out of imagination and into reality.

Amelia L. Bueche is an osteopathic physician and founder, This Osteopathic Life.

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