From Cedar Street to Capitol Hill

Some med school alumni effect change not one-on-one, but through health policy, and on a grand scale.

Brenda M. Ritson, M.D. ’06, was only a few weeks into her fellowship in Washington, D.C., in the early spring of 2005 when Sen. Hillary Rodham Clinton invited her into her office.

“Come up with a progressive alternative to hard-cap tort reform,” the New York Democrat told her. “Here’s my Rolodex. You have three months.”

“I started sweating,” Ritson recalled. “I called my mom. And then I got down to business.”

Ritson was working in Clinton’s office as a fellow of the Women’s Research and Education Institute, an independent nonprofit organization, after her third year in medical school. After Clinton’s challenge, Ritson spent weeks educating herself at the Library of Congress and on the Internet. Eventually she chanced upon an article about a hospital in Michigan that had decided to apologize to patients who had been harmed by medical errors. By avoiding lawsuits the hospital was able to save millions of dollars, and used the money to hire more physicians and invest in innovative patient safety systems. Intrigued, Ritson met the hospital’s CEO and shaped the idea into a national proposal. Clinton, along with then-Sen. Barack Obama, introduced the idea as part of a bill in Congress in September 2005, calling it medic, for National Medical Error Disclosure and Compensation. Though the bill “died in committee,” Ritson said, the concept continues to pop up in new bills; a New England Journal of Medicine article; and the Sorry Works! Coalition, an advocacy group that urges full disclosure, apologies (when appropriate), and compensation (when necessary) following adverse medical events. And the concept of apologizing for medical errors is catching on among hospitals, including Yale-New Haven Hospital, which began a similar program last year. “It makes me proud to know that my ideas have somehow contributed to or influenced a discussion of a very challenging problem, and it excites me to watch the ideas grow and evolve,” says Ritson, now a practicing pediatrician.

Making a career in health policy

Ritson’s turn at working with lawmakers is something of a tradition among Yale physicians, many of whom have applied their medical training and experience to public policy. For some it is a sideline. But others hang up their stethoscopes and make policy a full-time career. A doctor’s journey into government often starts with an epiphany. One saw the light in the Amazon rain forest, another took up a challenge to go to Washington, and a third grew frustrated by the prevalence of preventable ailments. But what they all have in common is an interest in helping many people at once and a willingness to pursue their goals over years, if not decades. They often work behind the scenes, rarely getting credit for their achievements. Some work in government, others in advocacy groups, and some in academia. But all moved from treating people one on one to treating the public at large. They are among many alumni who choose careers beyond the clinic or the laboratory and find innovative and sometimes unusual ways to promote health.

William L. Kissick, M.D. ’57, M.P.H. ’59, Dr.Ph. ’61, developed an interest in public health during medical school while accompanying his wife, Priscilla, a nurse with the Visiting Nurse Association, on home visits. “There was a certain clash of cultures,” he said, recalling that her patients would often refuse to go to the hospital because they viewed it as a place to die. Later, as one of the first residents in a unique social medicine program at Montefiore Hospital in the Bronx, he decided that he wanted to rebuild the American medical system from the ground up. William H. Stewart, M.D., who would serve as surgeon general from 1965 to 1969, heard Kissick express his ambition at a public health conference in Detroit in 1963, and asked, “Why don’t you come to Washington and learn something first?” Kissick was soon assigned to the 11-person task force that developed Medicare. He spent seven years in Washington, contributing to some 13 legislative efforts in health policy including Medicare, which became law in 1965.

Working with the underserved during medical school helped turn Larry C. Horowitz, M.D. ’69, toward policy-making, a career that later brought him national prominence as chief of staff and personal physician to the late Sen. Edward M. Kennedy, the Massachusetts Democrat. In medical school Horowitz was inspired by such mentors as then-Dean Fritz Redlich, M.D., and Yale’s charismatic President Kingman Brewster Jr. to join the Student Health Project, which assessed the health needs of the underserved populations in New Haven and New London, and migrant communities in Riverhead, Long Island. During Horowitz’s residency the Vietnam War nudged him into a two-year commitment to the public health sector as an alternative to the draft. He worked in Washington at the Health Services and Mental Health Administration, an umbrella organization that oversaw a number of national health programs. It was then that he caught the eye of Kennedy, whom he had invited to give a talk to his co-workers. Horowitz began that practice in Harkness Dormitory, inviting such luminaries as author William Styron and Walter and Eugene Rostow, brothers who held posts in Democratic administrations in the 1960s. After joining Kennedy’s team Horowitz finished his residency while traveling between Palo Alto, Calif., and Washington as a Robert Wood Johnson fellow handling the Senate’s oversight of the pharmaceutical industry. He decided to continue in government, he said, because he loved working on Capitol Hill. He served as Kennedy’s chief of staff from 1981 until 1986.

“It’s not like I decided, ‘That’s it for clinical medicine,’ ” said Horowitz, who is now a consultant to pharmaceutical companies and runs an investment and entertainment company of his own. “It’s just that each step was so exciting and fulfilling and gave you a sense that you were contributing to something larger than yourself in a meaningful way. … Working for Sen. Kennedy was great fun. You had the opportunity to meet all the best minds that existed in the United States and elsewhere on the issues you cared about.”

A passion for prevention

Scott A. Berkowitz, M.D. ’03, M.B.A. ’03, is taking time off from a cardiology fellowship at Johns Hopkins to spend a year as a fellow on the Senate Finance Committee. His fellowship is part of an NIH training grant in geriatrics investigating Medicare policy. “It’s been fascinating to see the political dynamics, and to realize that this is the center of the next generation of health care. To do whatever I can, however small, to help in that process has been very rewarding,” he says of his front-row seat on health care reform. “There are definitely times when the physician background helps.” During the summer between his fourth and fifth years of graduate school, he too worked for Kennedy, and between his first and second years of internal medicine residency at Johns Hopkins, he worked in the office of former Illinois Gov. Rod Blagojevich.

Indeed, it is the big picture that pushes many doctors into policy. It happened to Donald O. Lyman, M.D. ’68, in the Brazilian Amazon, where he spent a summer as a medical student working with the Yale Arbovirus Research Unit. He arrived to find villagers waiting to see “the doctor.” Nervous at the prospect of treating rare tropical diseases, he nonetheless agreed to see them. The terrible banality of what he saw changed his career. “After about the 12th patient, I said to myself, ‘The things I am seeing are no-brainers. Malaria, malnutrition, things like that. You can go into prevention and you could do a lot more good, both in places like this and at home, instead of treating people who are sick one-on-one.’ ” Before long, Lyman had signed on with the Epidemic Intelligence Service at the Centers for Disease Control. That led him to full-time public health work in California, where he is chief of the state’s Division of Chronic Disease and Injury Control and where he oversaw a statewide anti-tobacco campaign that is credited with saving tens of thousands of lives.

A passion for prevention also drives Howard K. Koh, M.D. ’77, M.P.H., who in June became the assistant secretary for health in the U.S. Department of Health and Human Services. In that position Koh serves as senior public health advisor to the secretary and oversees the Office of Public Health and Science, the Commissioned Corps of the U.S. Public Health Service, and the Office of the Surgeon General. (His brother, Harold H. Koh, J.D., former dean of the Yale Law School, is legal advisor to the U.S. Department of State.) “I’ve seen too many patients suffer preventable suffering and die preventable deaths. The only answer to that challenge is promoting prevention through public health.” After finishing residency, Koh taught cancer prevention and got his first taste of satisfying policy work in 1992 while heading a coalition that successfully advocated a tobacco tax in Massachusetts. Later, as that state’s public health commissioner, he guided his state from 10th- to third-healthiest in the nation, in part because of a high quitting rate among smokers. Like Horowitz and Kissick, Koh also honed an interest in the needy while at Yale. Though he said his parents impressed upon their children the importance of both education and service to others, he names the Reverend William Sloane Coffin Jr., the civil rights leader and Yale chaplain between 1958 and 1975, as a strong influence. “He always preached about the broader perspective on life and serving the underserved—caring for those in society who are counted least and put last,” said Koh of Coffin Jr., who died in 2006. “I think of him often and miss him tremendously.”

How to make policy work

“Fresh-faced shiny kids” in their late 20s and early 30s—which might describe the speaker herself—are the people doing much of the work in Washington, D.C., said Ritson. Many arrive with little or no experience in the jobs they’re about to undertake. No one taught Ritson how to research a policy proposal; she was expected to figure it out herself. The system seeks the self-motivated and the adaptable.

For example, after a surgical internship and a lab research year, Michael D. Miller, M.D. ’86, wound up dissecting the federal budget. Seeking to work in health care at the “ultimate macro level” after leaving an orthopaedics residency, he entered the policy arena as a fellow with the American Association for the Advancement of Science (AAAS). He worked on funding for biomedical research at the Office of Management and Budget—a plum location where no AAAS fellows had landed before. There, he says, he got a bird’s-eye view of the entire federal government by studying the flow of funds. “It’s crucial to understand how money flows,” he said. “I was—and still am—astounded by the number of people at senior levels who don’t understand the budget process.”

The relationship between money and policy is complex and not always healthy. Policy, Lyman believes, should drive funding. “You start with the policy; you start with the social justice, and the dollars follow.” But sometimes money appears to lead. “There were a number of legislative hearings when the advocates thought they had the votes,” Lyman said. “In comes the Assembly speaker and he walks around the room and he talks to each and every member of the legislative committee individually, and they either turn red with rage or they walk out. Then they vote down the bill. The advocates lament that they could just hear tobacco money passing hands.”

For Lyman, the words he uses are as important as money. He credits the Hollywood advertising industry for the success of the phrase “secondhand smoke” during his anti-tobacco campaign. And he is careful to make his public health messages culturally appropriate. But the fading prominence of the phrase “social justice,” a concept that underlies everything he does, saddens him.

“It is just astounding that the vocabulary, the metaphors, the mindset are very geared to money,” he said. “What happened to social justice? What happened to the quality of care? What happened to outcomes?”

Keeping a hand in medicine

In 1969, Kissick left Washington for the Wharton School of the University of Pennsylvania, where he taught for decades and helped found several combined-degree programs. He is now adjunct professor of political science at Yale, and teaches undergraduates about the evolution of American health care policy. He is decidedly skeptical about current health care proposals. “I’ve been in the racket for a half-century,” he said, “and I’ve learned just about everything that won’t work.”

Despite those years spent crafting and teaching policy, Kissick’s heart has always remained in medicine. His last clinical experience was in 1963, when he was called to a home delivery at 3 a.m. during a snowstorm. But his identity as a physician is tenacious. Although a great many lawyers who pass the bar never practice law, said Kissick, “when you go to medical school, you’re hooked. You can’t get out.”

Berkowitz, who plans to pursue clinical cardiology alongside a policy career, believes that medicine opens more doors to more career paths than it did in the past. “I think it’s really important for people going in and starting medical school to recognize that the opportunities with a medical degree, both in terms of taking care of patients and impacting policy on a broader level, are really great and really exciting,” he said.

Koh, who is board-certified in four specialties, practiced clinical medicine for more than 30 years until his Washington post began. But he is thrilled to be on the front lines of policy, and relishes the interdisciplinary nature of his job. “I really enjoy it when the worlds of medicine and law and business and community and advocacy all interconnect in the form of public health,” he said.

Ritson is building up clinical pediatric experience and plans to return to Washington within a few years. Miller did volunteer clinical work but spent the bulk of his time outside the hospital. After working with the NIH on HIV/AIDS policy, he joined the team of Rep. Sander M. Levin of Michigan, where he worked on Medicare a generation after Kissick. He also worked with then-First Lady Hillary Rodham Clinton’s health care task force in its first incarnation in the 1990s. Miller now blogs and runs a consulting company. And Horowitz, though he later played a prominent role in Sen. Kennedy’s health care plan, remembers that he “looked up one day and I hadn’t practiced in many, many years.” He hadn’t made a conscious decision about it, he said. “My interests had changed. What I wanted to do in life had evolved.”

Lyman cautions that giving up one’s patients and the one-on-one relationship is not for everyone. “There is never a person—not a soul—that will ever see me on the street and say, ‘Oh, thank you that I never got lung cancer!’ You have to have that same satisfaction from looking at a graph with a line going down.”

After decades in government, Lyman has seen governors and legislators come and go while he and his team maintain stability behind the scenes. That continuity, the ability to continue to contribute, is part of the satisfaction. “You don’t see us; we are very quiet. We can’t stick our heads out very far. But we are the ones who stay.” YM

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