Originally published Sept 29, 2014 in The Atlantic.

At a time when many of healthcare’s greatest challenges are business problems, more and more doctors are adding three extra letters after their names.


For David Gellis, the spark came during a class in college on health policy in America. He had known he wanted to become a doctor, but he was looking for a way to contribute to systemic change in healthcare. His professor at the time was Donald Berwick, who later headed the Center for Medicaid and Medicare Services and made a bid this year to be the Democratic candidate for governor of Massachusetts on a platform that includes single payer healthcare. Berwick’s class inspired Gellis to think more about the business skills needed in healthcare.

Gellis decided he wanted to apply business skills specifically to primary care, and he applied to Harvard Medical School and Harvard Business School simultaneously. By the time he began his residency in internal medicine, he’d completed both degrees and had caught the attention of Iora Health, an innovative primary care practice that was planning to start up in a few cities around the country. When he finished his residency three years later, the company hired him as a primary care provider. Half a year later, he is helping to lead their Brooklyn practice.

“I have an actual management title and responsibilities, which is pretty crazy six months out of residency,” said Gellis.

According to Maria Chandler, who is president of the Association of M.D./M.B.A. Programs and herself a recipient of both degrees, the degree combination “fast tracks” graduates up the career ladder. The current nominee for surgeon general, Vivek Murthy, holds both degrees, has founded multiple organizations, and is only 36 years old.

Those with dual degrees have a particular edge when it comes to hospital administration, a field that has traditionally employed M.B.A.s as leaders and M.D.s as middle managers. According to a New York Times analysis in May, the average annual salary for a hospital administrator is $237,000, compared with an average of $185,000 for a clinical physician. A 2011 study found that hospitals with physician CEOs outperformed those with non-medical leadership.

“Just like you wouldn’t want a school superintendent to never have taught, you don’t want the person leading your hospital to never have taken care of a patient,” said Vinod Nambudiri, a fifth-year internal medicine and dermatology resident at BWH and a graduate of Harvard’s joint M.D./M.B.A. program. Chandler wonders how physicians can become administrators without business training. “What industry puts somebody with no business training in front of a huge budget?” said Chandler. “Nowhere but medicine, really.”

* * *

There is a growing complaint in medical education that the curriculum hasn’t changed very much since 1910, when educator Abraham Flexner analyzed medical school curriculums across the country and proposed standardization of pre-clinical and clinical years in his groundbreaking Flexner Report. In the last few decades, the number of students choosing to supplement their M.D. degrees with others in different disciplines is climbing, and more schools have begun offering joint Ph.D., MPH, and MA programs. The number of joint M.D./M.B.A. programs in America has grown from six to 65 in 20 years. (From 2011 and 2012 alone, the number increased by 25 percent.) More than half of M.D./M.B.A. programs started after the year 2000, and most offer the degree in a five-year timeframe, lowering the total cost that business school would traditionally add.

Chandler estimates that there are about 500 students in joint M.D./M.B.A. programs across the country this year. She runs the joint degree program at UC Irvine, where 20 percent of medical students in the incoming class are doing the M.D./M.B.A. program. In the past, interest in business was sometimes derided as a distraction from commitment to medicine: Studentsinterviewed in 2005 said some doctors or peers saw them as “traitors” for getting M.B.A.s. When Chandler herself got the degree in 1992, she said no one told her about the few combined programs that existed back then. She earned her M.B.A. by attending evening classes for four years while working full-time as a pediatrician.

“Many of the greatest challenges in healthcare today are business problems,” says Evan Rachlin, an M.D./M.B.A. graduate who works in the healthcare arm of Bain Capital Ventures. As hospitals implement the Affordable Care Act, and managed care systems grow increasingly complex, many medical students and residents feel compelled to understand the business of healthcare, from team management to budgeting and accounting.

For students in joint programs, switching back and forth between cultures can be surreal. Medical students are part of a clear hierarchy: They wear the shortest white coats in the hospital, reaching only to their waists, while attending physicians wear the longest. In business school classes, however, “you are told that everyone’s opinions are equal and the people at the lowest level may have the best idea,” Chandler says.

Sometimes, it can be difficult for students to balance these two sets of expectations. But they say achieving this balance is the purpose of the dual degree. “Medical people tend to be very risk averse; innovations often come from outside,” said Alexi Nazem, a third-year M.D./M.B.A. resident in internal medicine at Brigham and Women’s Hospital. “Most of medicine is like a giant oil tanker you’re trying to steer with a paddle.” Earning an M.B.A. can give a new doctor more clout in hospital decision-making.

A study in 2001 found that students in M.D./M.B.A. programs at six medical schools exhibited a higher “tolerance of ambiguity”—a characteristic the authors associated with leadership ability—than traditional medical students. “When you read a business case for the first time, there really is no right answer, and initially it can be really frustrating having gone through trying to solve every problem and follow all the rules like medical school taught us,” said Gellis. “You learn how to think about uncertainty.” Gellis finds this sort of thinking relevant in his work as a primary care provider, since he is often the first line of contact for patients coming in with a problem. For example, he says, “you have to think about what one piece of data you want instead of ordering every test.”

Read the rest of the article here in The Atlantic.