The Ask


Leonard Zwelling

         You learn this early on Capitol Hill. Lobbyists and
constituents have at most 15 minutes with a Senator or Congressman, if they are
lucky enough to get an appointment with either rather than with the staff. They
may have been waiting weeks for this time, but it is fleeting. The first few
minutes may be filled with niceties about hunting, fishing or the old
neighborhood. The Congressional equivalent of Jewish geography may be played
where the visitors try to identify mutual friends of the member or staff. (It
is said that any two American Jews can meet and within 5 minutes find someone
they know in common and it will not take six degrees of Kevin Bacon to do so.
Bacon isn’t kosher anyway).

         On the Hill the critical moment is “The Ask”. The member and/or
his or her staff want to know in as few words as possible, preferably
monosyllabically, what it is you want. In essence, what are you doing here and
what are you asking of me? (The next question is usually “what’s in it for me,”
but that’s another blog).

         Since leaving the Hill, I find I have become like this as
well. When people come into my office I want to know what they need me to do.
The more clearly they can articulate their ask of me, the more quickly I can
make a decision as to my willingness to do what they wish, to refuse or to make
a counter offer. It’s all about efficiency in business.

         I have found both on the Hill and since returning, that
doctors do “the ask” really badly. Doctors do not know the art of The Ask.

         All day long during the debate about what would and would
not be in the Affordable Care Act, lobbyists and constituents would come to our
office and meet with the staff. Very few made it to Senator Enzi, especially if
they were not from Wyoming. Groups of physicians ranging from the urologists,
to advocates for victims of Lyme Disease, to cancer center directors and
medical school executives who couldn’t believe I was sitting in the front
office of a senator’s office with the rest of the lowly staff came in. Other
than the pediatricians, they were among the least effective spokespeople I have
ever met. (It is fascinating that the pediatric lobbyists were the most articulate for their constituents, many of whom literally could not speak for themselves). Not only could most doctor groups barely articulate their “ask”, the various groups
of docs all had different asks, some which conflicted with the asks of other
medical groups. This allowed the staff to ignore the doctors or their lobbyists.
The ask had become too convoluted and inconsistent to be forged into a piece of
legislation. That’s why the docs made out so poorly under the ACA.

         The most effective lobbyists came with actual legislative
language they wanted inserted into a pending bill. This is the most effective
form of lobbying because it entails the least amount of work for the staff.
Rarely did a medical group do this. Once again, the doctors have not figured out
that politics is a team sport.

         As the practice of medicine and the delivery of health care
have become more corporatized, even within academia, physicians are more
marginalized than ever from the decision making that will affect their lives.
Executives, financial staff and regulatory experts (i.e., lawyers) to a large
extent govern the practice of medicine. I saw it at Anderson. I see it
everywhere. The doctors are AWOL when it comes to the decision-making that will
govern their professional lives. Why?

         They cannot settle on The Ask.

         What do the doctors want besides everything to go back to
the way it used to be where they controlled everything? That dog ain’t gonna

         So let’s see what might happen if the clinical faculty at MD
Anderson developed a simple ask. What might that include:

1.  They and only they determine who will be promoted and
receive tenure with no possibility that a decision of the doctors’ peers could
be overridden by anyone in the administration without the credentials (e.g.,
medical, surgical or pediatric oncology board certification) to make that

2.  The operations of the clinics and the hospitals will
come under the jurisdiction of the clinical staff through its divisional,
departmental and clinic-based leadership. Nurses, clerks, and all staff serving
the patients will have dual reporting to operations and the medical staff.

3.  No administrator not caring for patients or performing
direct patient care will receive the clinical benefits. If you are a lab
jockey, you will be paid like one and if you are a desk jockey, surely this ought
to be the case.

4.  Finally, there will be NO appointments to leadership
positions in clinical medicine, especially at the division head or vice
presidential levels, without a real search committee being formed and vetting
candidates from outside and inside the institution including women and minority

are my suggestions. I am sure that you have even better ones. The Faculty
Senate ought to form a committee of its clinical leadership to develop a list
of “Asks”, preferably working with the Division Heads, and be willing to do
what is necessary to get the asks heard, addressed and hopefully implemented by
the institutional leadership. If implementation is not forthcoming, the next
decision ought to be the administration’s to address and it ought to be
difficult for them to refuse The Ask a second time.

     If they refuse, stop asking. Or, if you
must ask, ask for forgiveness instead of permission. Do something.

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