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Decade Interview with Jean Holt '99

Jean Holt

j1947holt [at] aol.com

City, State: San Antonio, TX

HCAD Class Year: M.S. in Health Care Administration 1999, M.D. The University of Missouri of School of Medicine 1972

Please tell us a bit about your career path. What is your current job title and employer? How long have you held this position and what does it entail?

I graduated from medical school in 1972 and completed my residency in ophthalmology in 1976, at which point I voluntarily was commissioned a medical officer in the US Army, spending two years on active duty as Chief of Ophthalmology at Eisenhower Army Medical Center in Georgia. My husband, who is also a physician, and I had leased offices in Jacksonville, but my husband felt a calling to academic medicine. We’d completed our basic military medical officer training in San Antonio, so, in looking for a warm location where there were positions for both of us, we remembered our time in San Antonio. The medical school was new and we felt we could be a part of developing the medical education programs in our specialties.

I was a clinical professor of ophthalmology at the UT medical school for eight years, including serving as the residency program director and interim chairman, but realized I wanted the challenge of managing my own practice. Now, I’m an ophthalmologist in private practice in Stone Oak.

The hardest part about being a solo practitioner is that it’s difficult to balance patient care with the paperwork and digital work that is required. I took a senior exemption to avoid doing the electronic health records transfer. I’m all for progress, but it takes away from the practice of medicine. My younger associate is doing it and he spends a lot of time on the computer. Physicians have to input all of the information or sit in a room with a scribe to oversee input and it’s a big frustration in medical care, in my opinion. Most electronic health record systems are incompatible with other physicians’ systems, as well as with hospitals. Right now it is not where it should be. Financially, I’d have to cut my patient visits back significantly, and I just don’t want to do that. Additionally, some of the electronic health record systems can increase the risk of inappropriate billing practices inherent to the software. That’s my soapbox on that. My practice is devoted solely to my patients!

Why did you select Trinity's HCAD program? 

I had been in full-time private practice for some time and had become frustrated with it. My husband was still a full-time faculty member at the medical school and we used to invite students over to mentor and discuss ‘real life’ in medicine. Managed care was coming in and I was very negative with these students, explaining that under that plan, I had to ask permission to even order a CT scan. I thought this negativity wasn’t healthy for me or them. My husband, who has four advanced degrees, suggested that I go back to school and learn something new. I needed to create an opportunity for me to make a difference in clinical medicine on a wider scale.

Although Trinity has a great reputation, I actually chose the program out of practicality because our two daughters were still in high school and I couldn’t commit weekends to the MBA program at UT-Austin.  

I attended with the intent to become a full-time physician executive. I was the medical director of several health care entities within the San Antonio medical community and was on a mission to ‘fix’ managed care. 

After graduation I had the opportunity to teach Mary Stefl’s capstone course and directed the students to write a paper on what they felt were the three greatest ills of the American health care system and what they would do to fix them.

I had my own thoughts on the solution to that particular problem. We are trained as physicians to be effective, but after graduation we were supposed to understand cost and be efficient. I saw a need for physicians and physicians in training to better understand how to do this, so along with my previous health law instructor and current colleague and friend, Sarah Fontenot, developed a program entitled, “Your Place in Today’s Medicine,” aimed at preparing young physicians for the transition from American medicine to actual health care delivery. It is a one-day seminar concentrated on understanding financial management of a practice and developing an efficient medical practice model for themselves. This is what I spend 70% of my mental energy on any way in my own practice, and the feedback from students who attend these seminars is frequently very positive because they understand how useful it is. Some students tell us it’s the best practical education day of their residency.

Here’s why that is the case—young physicians aren’t trained in running a physician’s office. I’m proud of having an impact on helping them prepare for these challenges. I’ve always believed and preached to others that physicians themselves need to understand business-related costs, and not engage someone else to do it for them. 

Did Health Care Administration end up being what you thought it would be when you were a graduate student? 

Yes, but I was too engaged in clinical medicine or direct patient care to work in health care administration full time. I thought it was what I wanted to do, but it really was not. However, I did develop a ‘physician relations’ course for Trinity and taught it for several years, with the aim to help the non-physician master of health care administration students understand the important and complex relationships between administrator and clinician. 

Health care administration at this time is extremely challenging, but I’m a clinician at heart. I appreciate what I learned in the program, and am proud of teaching at Trinity as well as the resident physician seminar in conjunction with Sarah Fontenot, but being a full-time health care administrator was not as satisfying professionally as caring directly for patients.

However, in some ways these days, being a physician is becoming more like a job than a profession. Some younger physicians seem to be employed rather than be in charge of their own practices. That is anathema to my generation of physicians. The graduating physicians seek more balance between their professional and personal lives--even the men—not just the women. The era of the physician like me--the solo practitioner willing to work long hours and do what it takes--will soon be lost.

When I was in training, the senior physician was always considered to be the proper role model. Now it seems different.

What benefits and opportunities have you experienced in your career as a graduate of the HCAD Program? 

It opened doors for me. I have credibility as a physician, but the Trinity degree gave me an additional credential. People automatically think a graduate will have advanced and unique knowledge about the health care field. Yes, the knowledge base from the program really helped me better understand the business of medicine overall, as well as helped me develop a more efficient and effective system in my own practice. I have a smoothly functioning office in good part because I better understand good business practices in the health care field and have been able to translate them to my own practice.

We have placed artificial cost containment on a generally naive population. Better educating physicians about costs and cost containment is essential. If we’d understood that at the beginning, we would have been much more effective in our system by now.

In my opinion, the leading frustration for physicians and administrators currently in the industry is what is being done in the name of ‘quality’. What is quality? It hasn’t been defined or measured. We’re not sure what really is the definition of quality medicine. As physicians, we try our best to practice both evidence-based medicine and experiential (not experimental) medicine for our patients. The amount of money being spent in process vs. outcome is very frustrating. Right now, it’s a lot of just checking boxes on a form without any real impact on quality of care. Quality care is what is delivered by well-meaning physicians acting on behalf of their patients in the best way possible.

So, my next challenge is retirement! I am now well beyond patient number 50,000! I love my profession and I love caring for my patients. The knowledge I gained from the graduate program at Trinity University has made me a happier doctor because I can deliver care more efficiently and effectively.

In terms of your career, what are the accomplishments you are most proud of? 

I think my impact on patients is the most gratifying accomplishment. I am proud to say that I have taken care of four generations of patients. It's also a very important responsibility to teach young physicians - giving back to my profession. Imparting experience and knowledge to younger physicians remains the future of our profession. I believe I have had an impact over the past 15 years in that regard. 

This is a very demanding profession. How did you stay motivated during the toughest times of your career? 

I love what I do. Most patients are wonderful and are thankful and appreciative. It's an extremely gratifying profession. 

How has the industry changed from when you first entered the health care administration field until now? 

It is much more complex now. Government regulations and requirements-- for example, electronic health records--have become increasingly burdensome. And, it’s not just physicians who are under the weight of these regulations, as our nursing colleagues will undoubtedly agree.

There is a trend toward having to attend to regulations and paperwork that detract from patient care. Curtailing the rising costs of health care has been the indicated motivator. Practice management “experts” and economists got involved and changed the face of medicine. Costs have seemingly spiraled out of control. Physicians do need to accept responsibility for being part of the problem as related to the rising costs of health care, but are just one part of a huge and complex industry.

As reimbursements decreased, procedures and tests increased. The economy took a nosedive and to me, the Affordable Care Act had an impact. The problem with the ACA was that there was no societal consensus and buy-in. A change in the health care delivery system that is sweeping should have had a clearer consensus among the population.

We do need reform. We have the best medical care in the world, just not the best health care delivery system.

I helped start a physician MBA program at Auburn University, especially the capstone course of “Comparative International Healthcare Systems.” Each year the class travels to one or two countries in the world with relatively successful health care systems—i.e., the UK, France, Switzerland, Australia—and study that country’s system in a concentrated curriculum. Learning about many health care systems around the world has led me to understand that there is no “perfect” health care system, and that each country’s system is unique to its demographics and culture. 

In my opinion, Australia has the best system of developed countries; it is half private and half public. The insurance companies in Australia are not in the business of providing health care; they are financially solvent, but they have to show increased utilization in order to increase premiums. Therefore, the Australian government is in the position of watchdog over the insurance companies. The country’s insurance companies can’t increase their premiums without also demonstrating that they are also taking care of needy patients (such as those with AIDS) and those in emergency health care situations, like hurricane victims. So, I think a combined private company and government oversight partnership might work for this country, too, if properly configured and with broad societal consensus. Additionally, it would be mandatory for the government to be accountable to the people.

The Auburn program has been outstanding, and it’s my understanding that Trinity is currently looking into developing its own international program.  

From your perspective, how different is health care going to look in 15 years? 

Essentially, there will be mega groups. The hospital of the future will be one giant building with half of it providing emergency care and intensive care and the rest becoming a big step-down unit. 

As the large systems take over, physicians may become system employees. I don’t like that scenario, but I do see where the number of employed physicians will likely rise—and we are seeing some evidence now of that trend.  

With any luck, those making the big decisions about health care delivery and systems management will be Trinity Health Care Administration graduates! Hopefully, some will also be physicians.  

What advice would you share with individuals considering pursuing a master's in Health Care Administration in Trinity's HCAD Program? 

The future of health care is going to be a huge challenge for all participants, so get as much knowledge as you can so you will be properly prepared to step into the responsibilities of administering health care. It is also very important that non-physician administrators understand physicians - their education and training, their goals and priorities and their dedication to patient care - so that joint efforts can be enhanced for the common goal of providing the best care to the community population. 

What advice would you share with current HCAD students and residents? 

There clearly are challenges ahead. Health care is becoming more complex and regulatory so, as time moves on, you will have to maintain a passion for your work or risk "burn out." Current students will need to work more closely with physicians as partners and better understand how physicians make decisions because half of their time will be spent balancing the budget and the other half working with physicians! Those in my generation are fiercely independent and hard workers, but I do see future physicians being much more in tune with corporate medicine. 

What book(s) or other resources have you found most helpful in the development of your career as an administrator? 

Well, I read the Physician Executive Journal, but now that I'm out of school and quite busy, that's about it. 

And lastly, tell us briefly about what you enjoy outside of work. 

I am mainly a grandmother to Noah, who's six; Jack, five; Austin, four and Madeline, two; plus, we have another grandson on the way! We are very blessed. 

My husband, Richard, is a retired clinical physician now specializing in bioethics, a topic which is important to both of us. We like to exercise and engage daily in some sort of physical activity. We have traveled around the globe, primarily teaching clinical medicine, but our family of three adult children and four and a half precious grandchildren is really our primary focus in life. 

Richard and I are dedicated to being good doctors with a strong moral compass. That part of the job is critical and I'll be the last one standing, in that regard!