Subscribe to The Podcast by KevinMD. Watch on YouTube. Catch up on old episodes!

Palliative care physician and certified physician development coach Christie Mulholland discusses her article, “Reclaiming physician agency in a broken system.” She shares her personal story of leaving a prestigious academic position after realizing that “being a good doctor” was impossible within the constraints of corporate health care. Christie explains how for-profit entities now control seventy-eight percent of hospices, leading to worse patient care and deep moral injury for clinicians. The discussion explores the four paths physicians can take to reclaim agency: working within the system with boundaries, building alternatives like direct primary care, organizing through unions, or planning a strategic exit. Christie emphasizes that while the system is broken, physicians still have the power to make conscious choices about how they engage with it. Learn how to move from passive demoralization to active, values-driven leadership in your medical career.

Our presenting sponsor is Microsoft Dragon Copilot.

Want to streamline your clinical documentation and take advantage of customizations that put you in control? What about the ability to surface information right at the point of care or automate tasks with just a click? Now, you can.

Microsoft Dragon Copilot, your AI assistant for clinical workflow, is transforming how clinicians work. Offering an extensible AI workspace and a single, integrated platform, Dragon Copilot can help you unlock new levels of efficiency. Plus, it’s backed by a proven track record and decades of clinical expertise, and it’s part of Microsoft Cloud for Healthcare, built on a foundation of trust.

Ease your administrative burdens and stay focused on what matters most with Dragon Copilot, your AI assistant for clinical workflow.

VISIT SPONSOR → https://aka.ms/kevinmd

SUBSCRIBE TO THE PODCAST → https://www.kevinmd.com/podcast

RECOMMENDED BY KEVINMD → https://www.kevinmd.com/recommended

Transcript

Kevin Pho: Hi. Welcome to the show. Subscribe at KevinMD.com/podcast. Today, we welcome Christie Mulholland. She is a palliative care physician. Today’s KevinMD article is “Reclaiming physician agency in a broken system.” Christie, welcome to the show.

Christie Mulholland: Hi, Kevin. Thank you so much for having me.

Kevin Pho: All right. Let’s start by briefly sharing your story. Then we will jump right into your KevinMD article.

Christie Mulholland: As you said, I am a palliative care physician. I am also a certified physician coach, and I am the director for the Faculty Well-being Champions Program at my health system, which is Mount Sinai in New York City.

Kevin Pho: As the champion for physician well-being, just tell us about some of the things that you currently do under that role.

Christie Mulholland: I work with faculty well-being champions from all across the health system and from every specialty. Each one of them is really passionate about well-being, and they are working on different initiatives within their own departments to try and do things that we know can help with well-being. This includes things like reducing clerical burdens (such as reducing charting time) and increasing access to mental health services. I support them and their department chairs in developing and executing these initiatives.

Kevin Pho: Your KevinMD article is titled “Reclaiming physician agency in a broken system.” For those who didn’t get a chance to read your article, tell us what it is about.

Christie Mulholland: This article was really my reaction to an article that I found recently in The Lancet in October 2025. It is written by Adam Gaffney and his colleagues, and it is called “Health care in the USA: money has become the mission.” When I read this article, it really spoke to the exact experience that I had been having and that I hear talking with other doctors. Specifically, there was one line that really grabbed my attention. It was about how doctors feel demoralized as we try to do good work in a bad system.

I knew that was exactly where I wanted to explore further because we can’t just stop at describing how bad the problem is and how bleak the situation is. I wanted to delve more into what we can all do as physicians when we are trying to exist within that reality and do as much good work as possible.

Specifically, I had gone through my own personal experience recently navigating what I call my disillusionment. Some might describe it as burnout. A few months ago, I had really reached my own personal limit with continuing to work in the way that I had been within that bad or broken system. So I made big career changes. I took a sabbatical. I am now part-time, and I am developing my coaching practice.

This article spoke to me for a number of reasons. Interestingly, I also pitched this article for a journal club at work, and at the end of the day, we decided to go a different direction and talk about a different article. We didn’t want to risk leaving a group of doctors just feeling demoralized and feeling like: “Well, what are we supposed to do with this information?” So we picked a different article that focused on something a little more realistic that we could change in the short term while working within the system. But I still felt like I wanted to talk about this article with other doctors. Writing my article was my way of starting a conversation, and I hope a lot of people listening today are interested in keeping this conversation going.

Kevin Pho: So what in particular about that Lancet article resonated with you?

Christie Mulholland: That article described in stark detail how corporatized health care has become in our country. The result is patients are no longer at the center of health care, but really profit is. Even working at a really wonderful department and a wonderful health system, there are forces acting that are beyond my control, beyond my boss’s control, and beyond my boss’s boss’s control. We are answering to corporate interests. We are answering to insurance companies, which are for-profit, and that is resulting in a very difficult environment to live up to our own standards for good care.

Kevin Pho: When the fellow physicians at your journal club passed on the article and wanted to talk about something else, how did you feel about that?

Christie Mulholland: I understood. I didn’t put up too much of a fight because part of what I write about in my article is there are certain things that we are powerful to do inside of the system and changes that we can advocate for inside. Then there are conversations or maybe advocacy work that we need to do from the outside. That made sense to me that when you are on the inside, you are constrained in certain ways. But there is still a lot of great advocacy work that you can do just for the patient sitting in front of you.

For example, when I document in my patient’s chart, I am not going to say: “This patient is non-compliant or non-adherent with their medication.” What I am going to write is: “Patient did not take the medication because their prescription plan wouldn’t cover it or they stopped covering it.” What I am looking to do is empower people to do the change and do the work that they can from the position they have. But if they feel that position becomes too limiting for them or they feel like they are not able to act in alignment with their values, then that might signal that they have to make a bigger change for their own lives.

Kevin Pho: One of the themes in your article, of course, is physician agency and how that has been eroded working in a medical system that is increasingly being corporatized. Give us more detail in terms of what exactly that means or how you are seeing that play out.

Christie Mulholland: This is the central question, really. I think there are perhaps two things happening. One is that our agency actually is being eroded because I have felt these changes even over the course of my career. I used to be more powerful to make an impact on my patients’ lives when I started out. Over time, as the squeeze happens or this corporatization has happened, I do feel real ways in which my agency or my impact has been eroded.

I try very hard in hospice and palliative medicine to help patients have the end of life that they hope to have. Patients decide they want to die at home, and I set them up with home hospice services. Over the years, I have just noticed more and more that these patients wind up in the emergency department not because they wanted to be there, but because their hospice didn’t have adequate staffing or adequate resources. So all that work that I have been trained to do and that I do remarkably well doesn’t matter when the resources aren’t there to meet the patients at home.

That is the first part: We have lost some agency and some power. But the other is really a limiting belief that a lot of us working in health care have. We forget how much agency we do have, or we lose touch with it. We tell ourselves stories that limit us more than we need to be limited. One example is silos. My silo is academic medicine. I trained in academic medicine. Those were the attendings that I worked with coming up, and I wound up working in an academic department. When you are only surrounded by other people that are practicing medicine the exact same way as you, you only have a narrow perspective. But when you actually remember that you have choice and you have agency and there are all kinds of doctors practicing in different ways and different models, then you remember that you have that agency and you can tap back into it. That can really empower doctors to make changes.

Kevin Pho: So what are some ways to tap back into that agency? You mentioned in your article the concept of physician unions. I know that in various parts of the country—I live just north of Boston, so I know that there are a lot of organized physician unions in Boston—you talk about that as a potential way where we can tap back into our agency. Talk more about that.

Christie Mulholland: That is such a great example. It is a powerful one because it requires some courage to join a union. It also is powerful because it brings doctors together in numbers doing collective action. I do think at the end of the day, if the system is going to change, that is the power that we need: the strength that we have in numbers.

But even before we get to that step, when I think about agency, I think the key is doing your own individual work of discerning: “Where do I want to stand in relation to this broken system?” That individual work can take you from just passively participating in this system, doing things the same way you always have, to making different choices. Those different choices involve choosing with your eyes open. Maybe you end up coming to the conclusion: “You know what? I have student loans. I can’t make a big change right now. I have to stay working where I am working.”

But what is one small change that I can start making to advocate more for my patient within my role? How can I game this prior authorization battle so I can win more of them? How do I draw my own boundaries for work-life balance? Maybe I am going to do a negotiation so that I don’t have to take as much call. Agency doesn’t necessarily mean “I am going from where I am to joining a union tomorrow,” but I think it really starts with that individual work of teasing out what are my real options, laying them all out, and figuring out which things are actual limitations on how you can act and which things are more like limiting beliefs that hold you back.

Kevin Pho: You are saying that depending on each physician’s individual situation—and you gave the example of perhaps a newly graduated physician with hundreds of thousands of dollars of medical school loans—they may be in a different position to push back or set boundaries versus a physician who may be in a little bit of a different financial situation or a different part of their career.

Christie Mulholland: That is absolutely right. But that doesn’t mean that they are powerless. If you are a resident or you are a junior attending, you might have fewer options, but you can still do the work of consciously understanding for yourself: “Where do I want to be, and what are my options to get there? Where is the way forward?” If you can change from having the perspective that “Things are horrible and I am stuck and it is forever” and move yourself into: “Well, here is my timeline. I have seven more years left on these loans. Here is what I can do in the meantime. Maybe there is a mentor that I can start connecting with that will help me find ways to make these next seven years more sustainable. Maybe I will join the faculty well-being program. Maybe I will start working with a coach or a therapist.” You could still make incremental changes for yourself, even though you are right, Kevin, you can’t make all the changes all at once.

Kevin Pho: You work at a large academic medical center. Tell me what the climate is there, because one of the scenarios you mentioned where some physicians may feel stuck in a job that is increasingly encroaching on their autonomy sounds like a path to burnout. The physicians that you see, your colleagues, what are their perspectives? Are they seeing things the same way that we are describing? Are they trying to find ways to retain or reclaim some of their agency?

Christie Mulholland: I work with some really wonderful doctors, and the well-being champions in particular are so passionate and so motivated to do more and go beyond just the work of getting through the day and seeing the patients. Yes, people find their own ways to make an impact where they can and where they are passionate.

When I see physicians that come to coaching, oftentimes they are the ones that feel a little more stuck or a little more trapped by this system. Their presenting problem might actually not be “health care and the USA money is the mission.” It sounds like something else. It sounds like: “I am really struggling with work-life balance. I can’t get my charts done in time, and I am not getting home to my family.” So it may present as a different-sounding problem, but a lot of this distress can be traced back to the way that the system is and all of the many ways that it impacts the culture of health care and individual well-being.

Kevin Pho: Tell us the type of questions a physician should ask themselves, no matter where they are in their career or financial or personal situation, so they don’t get stuck. What kind of questions should they be asking themselves?

Christie Mulholland: Before I go into the questions, when you mention about avoiding getting stuck or avoiding burnout, a lot of people think that they are going to avoid burnout in their careers or that that is the goal. The way that I think about it is it is a reality. We are all going to experience burnout that comes and goes. We might feel stuck at different points in our career. This is a practice we need to have for ourselves rather than just having a foolproof system that is not realistic.

There are some great coaching questions that can help people move from a place of being stuck to getting unstuck. The GROW model is one coaching framework. G stands for goal: What is the goal? What is my goal for this coaching session today? Or what is the goal for the next one year of my career?

R stands for reality: What is my current reality? What is the reality of the situation? I think that Lancet article is a very bleak description of the reality of the whole system. But what is my reality? Am I in debt, or have I gotten past that milestone and now I have a little more financial autonomy? Do I have the freedom to go part-time or pursue a different kind of practice?

O stands for options: This is really laying out the options of what you could do to make a change. I go into that in the article, the four pathways that doctors are finding to take more agency for themselves.

W stands for the way forward: Where do I want to go next? I might not have the whole blueprint, but I need to figure out the next step so I can move forward.

Kevin Pho: We are talking to Christie Mulholland. She is a palliative care physician. Today’s KevinMD article is “Reclaiming physician agency in a broken system.” Christie, let’s end with some take-home messages that you want to leave with the KevinMD audience.

Christie Mulholland: I think the biggest take-home message for your audience, Kevin, is: We have more power than we think. We might forget, but we do have agency already. The more of us individual physicians that reclaim that agency for ourselves and our own careers, the closer we are to that collective power where we are all working together to change some things that we all know need to change in the system.

Kevin Pho: Christie, thank you so much for sharing your perspective and insight, and thanks again for coming on the show.

Christie Mulholland: Thank you so much for having me, Kevin.