My Kind of Medicine: Real Lives of Practicing Internists: Esther Nash, MD
If you had to choose the one person of the roughly 6,000 people working in the Independence Blue Cross building in downtown Philadelphia who believed in their job the most, there is a good chance it would be Esther Nash, MD. Every day from her office on the 32nd floor she thinks about how she—the company’s Senior Medical Director of Population Health and Wellness and Co-Director of the Office of Consumerism—can improve the health of over three million health plan members. Although she is not their personal physician, she approaches her job as if she were. “The way I look at it is that even though I don’t influence them as much as I would in a single patient visit, I get to impact many more of them in little ways,” she says. “That keeps me going.”
Finding Her Way
Dr. Nash was drawn to medicine by personal circumstance. When she was in high school, her mother, a clinical psychologist, suffered several retinal detachments, eventually going legally blind. The effect it had on the family and on Dr. Nash in particular was substantial. “It put a lot of responsibility on me as the oldest,” she recalls. “I had to take over the errands, drive my sister to and from places. It was also hard to watch her go through it, because my mother had always been a professional role model for me. After she became affected by the condition, she was no longer able to work.”
Dr. Nash spent a good deal of time in the hospital with her mother. “I remember having a good feeling about the environment there,” she recalls. The experience inspired her to become a doctor, as she explains. “Watching my mother go through all of this made me want to help her, and watching the doctors made me want to be really good at something. So that’s when I realized I wanted to be a physician.”
At medical school at Brown University in Providence, Rhode Island, Dr. Nash decided to join the American Medical Student Association (AMSA), for which she was appointed as a delegate for her school. At a meeting one year, she happened to meet David Nash, a delegate from the University of Rochester School of Medicine. A year later they were engaged. While it was difficult living 800 miles apart in medical school, when it came time for internship, they moved together to The Graduate Hospital at the University of Pennsylvania.
Having pursued ophthalmology with passion and determination, Dr. Nash was selected for the residency program at the Scheie Eye Institute of the University of Pennsylvania, at the time one of the most competitive programs. But in the middle of her medical internship, she began to have a change of heart. “I realized that my determination to become an ophthalmologist was influenced by the experience with my mother,” she says. “And I thought to myself, ‘I can’t give up the whole body just for the eyeball!’” She chose internal medicine instead. “It truly fascinated me,” she says. “I liked the ultimate problem solving, the talking to the patients and forming relationships with them. I liked the idea of having that much knowledge. There’s just nothing that compares to internal medicine in terms of the broad range of what it touches.” She contacted the director of the ophthalmology residency and told him that she wanted to relinquish her spot.
A Growing Passion
As a resident, her love for internal medicine was fostered by one of her attending physicians in infectious diseases. “One of the best teachers I’ve had—the late Dr. Russ Stumacher—was a walking encyclopedia!” she says. “He was also the only one who taught us how to do the most basic thing: walk into a patient’s room, listen, and determine whether or not the patient was actually 'sick.'
During their medical residency, Dr. Nash and her husband started a non-profit organization, Dual Doctor Families, to address the career issues of two-physician couples. Together they grew the organization to the point where they needed a board and had to incorporate. Dr. Nash says the experience gave her an idea of what she was good at. “It gave me some exposure in managing something, of running an organization. I found out that I like to run things.”
However, as they continued their work with the non-profit and Dr. Nash’s husband pursued a fellowship at the University of Pennsylvania, they soon found reality knocking on their door. “Someone had to earn a living!” she says. She took her first job as a practicing general internist at an HMO in Philadelphia, and it was not long before she was trying to change things. “I had been there for only a year before I was saying to myself ‘I could do it better,’” she says. “I wanted to change the scheduling system, the record keeping system … I wanted to revamp the processes.”
The urge to improve things for the better was one she knew would last. “These early formative experiences are really what led me down the road to where I am today,” she says. “The decisions I took in my career are reflective of that.” She began taking steps towards this goal, taking positions over the next several years that would gradually pull her closer towards health care management on an executive level. The first of these positions was as an Associate Chair of Medicine at the Albert Einstein Medical Center, Southern Division, which she took at the age of 29. The job had its pressures. “There was a lot of turmoil that area hospitals were going through at the time,” she says, “with utilization management pressures, early quality improvement efforts, and hospital labor issues.” She was also going through her own life changes, as she had become pregnant with twins. “I spent half of the time on bed rest and in the hospital,” she says. Four years later, Dr. Nash and her husband welcomed their third child into the world, a boy. Dr. Nash cites the work-life balance as the toughest test of her career. “I can’t imagine my life without my family or my career, but balancing both together has been a challenge,” she admits. “It’s been hard all the way through.”
The True Populist
A few years later as Director of Quality Improvement and Medical Education at Bryn Mawr Hospital, and then as a medical director at Prudential Health Care, Dr. Nash honed her skills in administrative management. By the time she took a job as a medical director at Prudential in 1994, her work consisted almost entirely of management responsibilities and she was considered a physician executive. Although she was further removed from direct patient contact, she recognized how the path related to her experience as a clinician and teacher. “A lot of the emphasis on health improvement, prevention and managing chronic conditions is focused on or around the major role of the primary care physician,” she says. “GI conditions, hypertension … it’s all the world of the internist. Internal medicine gives you so many directions to go in. Being an internist has made all of the work I’ve done possible.”
Developing health care plans may not seem exciting to some, but for Dr. Nash it could not be a more gratifying job. For example, one of her proudest achievements she says has been developing and shaping Independence Blue Cross’ Connections (sm) program, an award-winning chronic condition support program. “We’ve been a leader in this area and we’re very proud of it. We did the clinical research on the program and we’re seeing a return on investment, which means for every dollar that’s being invested in the program, several more dollars are being saved by avoiding relapses and complications, resulting in less suffering for our members. It means patients are able to manage their conditions better and follow their physicians’ treatment plans.”
She describes her job in simple terms. “We design health programs, figure out how to reach the population, and measure the results,” she says. She explains how much of the work she and her staff do on a daily basis varies. “It runs the gamut,” she says. “It’s chronic conditions, reminders for necessary prevention services, reviewing clinical guidelines; it’s running community collaborations and wellness programs, some of which we deliver at the work site or at public venues, or now increasingly through the internet.”
For Dr. Nash specifically, a lot of her work involves getting feedback from physicians on health plan programs. “I’ll meet with doctors in the community and ask them ‘Do you agree with this? Are you comfortable with this? Is the content ok with you?’” she explains. She describes how the profession, and in particular the medical insurance industry, is moving towards the overall theme of consumer empowerment in health care. “The role of health care plans is to be there for the patient so the patient can make the right decision,” she says, “I like that I am able to use my knowledge to improve health. I work for a very ethical and committed company. What I do can help a lot of people.” She adds how excited she is about a program she’s working on now. “One that is coming out I’m really excited about it,” she says. “It’s based on incentives—it’s similar to a points system for healthy behavior. I think it will work, because incentives are based on realistic behaviors—it’s human nature.”
Dr. Nash is proud of what she does and has a tangible passion for and commitment to the issues affecting health care today. But rather than just talking about it, Dr. Nash is an agent of action. A priority now is health care consumerism through information technology. “I think our system is so disconnected now,” she says. “I want to develop an advanced personal health record system for my community. Health care information belongs with the consumer so they can be partners with their doctors in their own health. If I had to pick one thing to put on my tombstone it would be ‘Bring the power to the people.’”
Check out previous articles as physicians share what motivated them to become physicians as well as why they chose their particular type of practice.
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