AAMC Reporter: May 2006

A Look Inside the RWJF Health Policy Fellowships

"Dean Smith" Goes to Washington

Howard Rabinowitz, M.D., had barely had time to find his desk in the office of Sen. Jay Rockefeller (D-W.Va.) as a Robert Wood Johnson Foundation (RWJF) Health Policy Fellow, when the senator asked him for a briefing paper on health issues in New Mexico for a visit he was making to the state. "I asked him when he wanted it," recalled Rabinowitz, professor of family medicine at Jefferson Medical College of Thomas Jefferson University. "He looked at his watch and said, 'My plane's leaving in a couple of hours.'"

Research that would have taken Rabinowitz six months in the academic world had to be completed in about an hour.

Howard Rabinowitz, M.D., professor of family medicine at Jefferson Medical College of Thomas Jefferson University

"I got on the phone, called experts, read things — it probably was not dissimilar to the way reporters gather information very quickly. And I put something together that was pretty good — not 100 percent of what it would have been in six months, but probably 95 percent."

The frenzied pace of Capitol Hill is just one of the many eye-opening experiences that outstanding mid-career health professionals encounter when they become RWJF Health Policy Fellows.

Since 1973, this unique program has provided the opportunity for leaders in academic medicine and related fields to engage in 12 months of total-immersion exposure to real-world health care policymaking.

So far, more than 200 fellows have rotated through the halls of power on Capitol Hill, working for Senators, members of Congress, and executive branch officials. If you ask any fellow how they view the program, the typical response is: "It changed my life."

"They go back with a whole new set of skills and ways of looking at things, and a big perspective change. I tell them: you'll never look at a newspaper in the same way again," said Marie Michnich, who directs the program and is a former fellow.

Upon their arrival in Washington in early September, fellows are put through an in-depth three-month orientation process that many consider to be the crown jewel of the program.

This very hectic period, where fellows often visit five congressional offices per day, ends a couple of weeks after Thanksgiving, when the fellows meet with the staff of the Hill offices they have been assigned to and begin to learn their way around their new workplaces. In January, when the Senate goes into session, they begin their new positions.

"Once they're in those offices, they're fully consumed by activities and events of that Congress. Hearings pop up, bills go to the floor, speeches have to be done, committees have to be staffed — there's an awful lot of work that becomes part of their portfolio," Michnich said.

During congressional recesses, fellows do not take a break — they head out to the member's home districts to learn about health policy issues on the local level.

"We don't just keep them inside the Beltway — we try to put things in perspective," said Michnich.

An Eventful Year

Like many former fellows, University of Colorado School of Medicine Dean Richard Krugman, M.D., compares the transformation of his understanding of the public policy process to the difference between being a medical student and a third-year resident. In 1981, Krugman spent his fellowship year in the offices of former Sen. David Durenberger (R-Minn.), just after the Republicans gained control of the Senate for the first time in 40 years. Because Durenberger had no legislative assistant for health, Krugman assumed that role, and spent the year working closely with him, then-Sen. Bob Dole (R-Kan.), and Dole's powerful health aide, Sheila Burke.

"I knew a lot about workforce issues, but I knew nothing about health care financing, so I deliberately wanted to work with the Finance Committee as much as possible. I learned a lot that year — and since I'm now, among other things, president of our practice plan for the last 16 years, understanding Medicare, Medicaid, and other health care financing issues has been very useful," Krugman said.

Krugman looks back with particular pride on the passage of a maternal child health block grant, in a year in which Ronald Reagan's budget cut everything by 30 percent.

"We realized that mothers and children would get buried under the political strength of the elderly in most states, so Dole and Durenberger asked us to arrange a hearing, and we got the block grant through," Krugman said.

At the end of his fellowship, Krugman had several Washington job offers — from the AAMC, Durenberger's office, and Blue Cross and Blue Shield — and he says he might still be in Washington had he not promised his mentor, C. Henry Kempe, M.D., that he would return and run the university's child abuse prevention center.

"During the first 10 years back, when I did child abuse work at the center, having the experience of understanding the federal bureaucracy was very helpful," Krugman said.

Krugman feels as if he benefited from being in Washington during a very eventful year. But when you talk with most former fellows, it becomes clear that all of them have pretty eventful years.

For instance, Rabinowitz worked for Rockefeller during the period when President Bill Clinton put forth his Health Security Act, a piece of legislation of enormous size and scope. Mark Carlson, M.D., associate vice president for government relations and associate dean and professor of medicine at Case Western University School of Medicine, worked for Sen. Orrin Hatch (R-Utah) in 2002-2003, as Congress worked to pass the Medicare Modernization Act.

Susan Goelzer, M.D., chair of anesthesiology at the University of Wisconsin Medical School

Susan Goelzer, M.D., chair of anesthesiology at the University of Wisconsin Medical School, joined the office of Sen. Bill Frist (R-Tenn.) in the same year. One week after her arrival, Frist became Senate Majority Leader.

"The fellowship was, as I expected, a kind of graduate-level education in health policy. But you also get first-hand experience in forming new policies and transforming health care in this country," said Goelzer. But perhaps the best thing about the experience, she added, is the network that fellows build. "You get to know hundreds of people who are involved with the public policy process, and you develop a list of contacts that is exceptionally helpful if you return to academic medicine."

A "Sabbatical with No Publication"

There are no specific jobs waiting at the end of these fellowships, and some view taking a year out of the academic fray in the middle of one's career as a dicey maneuver.

"That's a risky business at any point in time, but today it's even more risky with the insecurities surrounding academic institutions," Michnich said. "It's a sabbatical with no publication at the end of it, which is not easy when you're dealing with some of the constraints that academia imposes."

But former fellows report that their experiences opened doors that would never have been open to them before.

"I returned to Case Western with the opportunity to head government relations, which would not have happened without the fellowship," Carlson said.

"I've also had the opportunity to work closely with the AAMC on advocacy efforts that are coordinated there. I chair the health policy committee for the Heart Rhythm Society, and I'm currently leading a task force that is writing our recommendations and guidelines for post-market surveillance analysis and reporting of implantable defibrillator and pacemaker performance. As you can imagine, my experience in D.C. has been absolutely critical to our efforts so far," Carlson said.

Rabinowitz concurred. "I've done a number of things that I probably wouldn't have done otherwise: I served as health policy series editor for the Journal of the American Board of Family Practice, I acted as a consultant to COGME on one of their reports, and I've been involved with the HRSA's Undergraduate Medical Education-21 Project on primary care," he said. He's also stayed very involved with the RWJF fellowship program, joining its board of directors this year.

Meeting with academic medical center deans who came to lobby Congress, Goelzer was often told, "Now that you've done this, you have to become a dean!" With that in mind, she is now participating in the AAMC's Council of Deans Fellowship program, but she has not firmly settled on what she wants to do next.

"How do I best participate in the next phase of my career to really begin transforming health care in this country?" Goelzer asked. "Do I become a dean? Do I go into hospital leadership? I haven't decided yet, but the fellowship has certainly changed my way of thinking, and I suspect ultimately it will affect whatever I decide to do."

Goelzer has already been more active in state health policy, serving on the Wisconsin Executive Board's Health Policy Institute and the board of the Wisconsin United for Health Foundation.

As the chair-elect of the AAMC, Krugman "absolutely" attributes his political involvement to his experience as a RWJF fellow.

"It gave me an extraordinary appreciation for how the government works. The truth is that there are unintended consequences for every action. You can't do something good for someone that doesn't hurt someone else. You may believe that the best thing you can do for people is to eliminate all the crap in the world, but you'll be putting the fertilizer people out of business. You'd never know that until you try to make that change," Krugman said.

Ultimately, Goelzer believes, the RWJF fellowships point the way toward a new aspect of academic medicine's mission. "I think we in academic medicine should add another mission: participating in the policy-making process. It dictates much of the way we practice today, and if we don't participate in it, we don't have the right to sit here and complain about it."

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