Achieving Physician Autonomy

The American Medical Association and the American Association of Medical Colleges reported recently that increasing numbers of medical students are seeking dual degrees. The most popular combination was the MD/PhD for physician-scientists, followed by MD/MPH for physicians with public health interests, MD/MBA for physician-entrepreneurs, and lastly MD/JD for physician-lawyers. Despite the extra time and money, MD candidates believed that additional training would lead to a more sustainable, and perhaps, more productive career.

Interestingly, my dual degree, the MD/MPP was not discussed in this article. MPP stands for Master’s in public policy, a hybrid between an MPH and an MBA with a dash of public administration. My fellow MPP classmates included healthcare providers, state officials, presidents of foreign countries, military leaders, and directors of nonprofit organizations. I was drawn to the program because it allowed me to learn from my classmates, as well as experts who taught in the law, education, public health, and business schools of the university. When a number of my teachers and classmates left abruptly to return to government service after the 9/11 tragedy, I felt even more thankful for the richness of knowledge and influence that was expanding my view of the world.

Many people over the years have asked me why I chose to take this detour. Being a nontraditional candidate doesn’t win you many points in what remains a conservative application process for medical school. I was frequently asked during residency and fellowship interviews why an aspiring doctor would waste time dabbling in public policy. I told the truth: I wanted to learn how to protect my patients from the system. I never wanted to feel helpless in the face of laws, regulations, and bureaucratic red tape. My interviewers liked how I emphasized the primacy of physician autonomy.

Sit down with any group of doctors and you will hear that we want people to stop getting in our way of taking care of patients. Just last week, Dr. James Breeden, the president of the American College of Obstetricians and Gynecologists, wrote an impassioned letter to the editor of the New York Times, demanding that politicians “get out of our exam rooms.” The letter struck a deep chord within the physician community. Throughout 7+ years of education, we were preparing to combat disease and to hold the doctor-patient relationship as sacred. Then, we graduate into the world of clinical practice, and realize that the U.S. health care infrastructure was not created to support our mission. Doctors lose hours on the phone trying to convince insurance agents to approve indicated treatments. Scheduled surgeries are cancelled last minute due to nurse under-staffing. Uninsurable patients with pre-existing conditions go to emergency rooms for routine care. Hospital financial managers tell families that their unconscious loved ones in the intensive care unit have to go elsewhere because they have the wrong insurance.

In pursuing a dual degree, my colleagues and I wanted to guarantee our independence in an often-dysfunctional system. Autonomy should naturally develop from greater self-sufficiency and competence, and we would have more letters after our name to confirm it. Yet, 12 years into my pursuit for autonomy, I find myself going back to a lesson learned early on during my public policy years -- team players get better results than lone wolves. When faced with serious problems, professional collaboration usually trumps single expert opinions in getting things done.

I especially remember the Spring Exercise in graduate school, a class-wide activity in which 130 of us were expected to organize and produce a detailed solution to the issue of HIV/AIDS in Africa, using real-time data. We had one week to prepare the report and presentation for faculty members. I still recall the stunned pause in the auditorium when my classmates and I wondered how we could possibly complete this massive assignment, not knowing each other’s names, much less worked together. Then, we rose to the occasion. We formulated objectives and assigned them to committees based on our majors and interests. We made contact lists and set up a strict schedule of meetings. We had daily check-in times when every committee shared their progress with the entire class. We debated, negotiated, walked away from the table, came back to the table, and ultimately drew up an extensive policy brief with graphs and figures, a budget, and a political strategy for execution. Who knew a ragtag collection of people from all over the world with various backgrounds could pull together and accomplish a common goal in 7 days? During our final presentation, we found out that our work would be given to the Secretary of State for review. It was exciting to hear echoes of our efforts in subsequent government briefings.

I didn’t appreciate the true power of the Spring Exercise until years later, after I have stayed up nights wondering why our health care system is so inadequate. It was a success that continues to remind me of what’s possible. Medical training encourages lone wolf behavior, but health care reform needs team players. Doctors want to be left alone to do our work, but sustainable autonomy won’t happen until we let go of our siege mentality and look for solutions outside our comfort zone. I had originally set out to equip myself for independence, but instead, I’ve learned that our problems are too big and too complicated to tackle alone. I hope that what our country is experiencing now is that pause in the auditorium before the action gets underway.