How Psychiatry Led Me to Management and Ethics

It was easy for me to choose psychiatry when I graduated from medical school in 1964. Medical students saw psychiatry as a way to help individuals, improve the world, and learn about the mind and soul. Fifteen to 20 percent of my graduating class followed that path.

Psychoanalysis was at its heyday during my residency, but I wanted to work with a wider range of patients, so I opted for community psychiatry and population health. In 1980, after 10 years of combining private practice, teaching, and part-time work at the not-for-profit Harvard Community Health Plan HMO, I was summoned to the HMO medical director’s office. I’d never met him and wondered if I’d done something wrong.

To my surprise, he asked if I’d be interested in being medical director of a new facility we were opening, a general management role that involved overseeing all the medical specialties but also the administrative infrastructure and even the parking garage. I was happily engaged with developing outpatient programs for patients with chronic mental illness, and my first answer was “No, thank you.” But when I asked myself the question “What are the generic characteristics of what you like so much about the work you are doing?,” I realized that they coincided with what the medical director role called for. Outpatient care for patients with schizophrenia, bipolar disorder, substance disorders, and more required (1) dealing with complex problems that (2) required a multidisciplinary approach and (3) working with teams, while (4) being able to tolerate less-than-perfect results.

I changed my mind and took the medical director role. Directing a medical center that served a community appealed to my commitment to population health. I found that the human skills I’d developed in psychiatry—especially from group and family therapy—could be adapted to the human leadership requirements of the medical director job.

After seven years I still believed in the work I was doing as medical director, but I wanted to go back to patient care and teaching. The HMO had started a small teaching unit. I joined it half time with the other half of my time going to clinical practice.

Since college days I’d been interested in philosophy and ethics. I thought an HMO-based teaching unit should address the ethics of caring for patients under a budget—in other words, managed care. In the course of “networking” in the ethics community, I met Norman Daniels, a distinguished philosopher. Norman knew how to apply for grants, and we got support for an international study of the ethics of setting limits, which we wrote up in many articles and a book, Setting Limits Fairly: Learning to Share Resources for Health.

In 1999, I was asked to take responsibility for the ethics program at Harvard Pilgrim Health Care, a New England not-for-profit health plan. 1999 was my 60th birthday, and I’d decided I wanted to concentrate on ethics and health policy as long as health and opportunity allowed, so I took on the ethics program role and stopped taking new patient referrals to create the needed time.

Since then I’ve developed policy cases for more than 100 meetings of the Ethics Advisory Group of Harvard Pilgrim Health Care. Participants include health plan staff, employers, physicians who practice in the network, consumers, and policy experts. I’m often told “you do a great job facilitating the discussions.” At first, I thought this was simply polite fluff because the role felt very easy, but I eventually realized that I was using listening and facilitating skills I’d developed over decades in psychiatric practice.

The incoming president of the AMA gets to nominate one member for the AMA Council on Ethical and Judicial Affairs. In 2012, Jeremy Lazarus, M.D., who shares my passion for ethics, nominated me. I’m now in the sixth year of my seven-year term. Working with physicians from every specialty and region on behalf of the ethics of medicine has been a highlight of my career.

It’s what I learned practicing and teaching psychiatry that made this varied career possible! ■

“Confronting Trade-Offs in Health Care: Harvard Pilgrim Health Care’s Organizational Ethics Program” can be accessed here.