Michelle E. Roland, M.D. -- General Internist, AAHIVM Specialist

To care for people with HIV in an era of strained financial resources, clinicians need to advocate both for their own patient populations and for the broader body of HIV-positive patients. Often this balancing act requires that clinicians and advocates live in two worlds -- one in which their patients are paramount, the other in which limits on services are a harsh reality.

For Michelle Roland, the challenge of moving between clinical advocacy and policy advocacy is a familiar one. "I transitioned from an activist background into a professional position," she explains. "And with the intuitive orientation that I have as a result, it hasn't been hard to figure out how to translate my clinical experience and research findings into policy-related activity." But, she emphasizes, "what I find more challenging is creating the time and the space to understand the many national coalitions and organizations -- which are mostly driven by the advocacy organizations -- and to understand how, as a community of providers, we can effectively play a role with and in those groups. It's really a big investment in time and resources to sort through what these organizations do."

Roland is a 1989 graduate -- summa cum laude -- of San Francisco State University and received her M.D. from the University of California at Davis in 1994. She conducted her internal medicine internship and residency at UCSF and San Francisco General. Roland is now an assistant clinical professor in the Department of Internal Medicine at the University of California at San Francisco and works in the Positive Health Program at San Francisco General Hospital. She serves on the Academy's ethics and public policy committees and sits on the Board of Directors of the organization's California Chapter. She also serves on the Executive Committee of the UCSF AIDS Research Institute and the Medical Advisory Committee of the California AIDS Drug Assistance Program.

Roland says she divides her professional time into three distinct areas, one of which involves melding her clinical duties with her efforts to place patient care within the wider scope of a worldwide epidemic that has both medical and political implications. "I focus on integrating biomedical approaches with behavioral approaches around the prevention of HIV transmission," she tells The Nexus. "I also focus on exploring new options for people with HIV in solid organ transplantation." And, she adds, "I ponder the role of individual clinicians and the clinical community in forming policy, both translating clinical research findings into policy recommendations and considering our clinical experience and how that experience can inform policy decision."

Indeed, she says, her heart lies with her patient care activities. "My clinical work provides the emotionally fulfilling pieces of my professional life," she comments. "The advocacy work is necessary, but not as satisfying because it intersects with the legislative universe, which is not so much about truth and reality, it's about how you can spin things. As physicians, we're so indoctrinated to think about data and evidence and what's right. But in policy, you're also dealing with what's possible. That's a difficult tension. It can be very frustrating."

The problem, she elaborates, is "from the perspective of being on the Board of Directors of a not-for-profit organization that provides services and of having to think about what the mission of that organization is and therefore what the eligibility requirements should be for its services. I see a sense of entitlement among some people with HIV -- and among their providers. There can be an unwillingness to recognize that there are limits to resources. That also speaks to our uniquely American way of thinking about medicine. It's very hard for us to make patient choices that take into account a larger resource-related context."

And if walking the line between clinical focus and more global patient advocacy is difficult for an individual, Roland notes, it's even more so for an organization -- even for the Academy, which strives to adopt a balanced approach to HIV research, prevention, treatment and provider reimbursement. "I'd like for the Academy to look at what is its potentially unique role," Roland explains. "We're faced with questions, for example, about potential formularies for the various ADAPs. Rather than always screaming for more resources and always blaming the bad guy, at some point we may have to look at our role in rationing services -- both medical and social. There is not an unlimited set of resources -- and they're not just for people with HIV."

Providers, she notes, "do whatever they have to do to get those resources for their patients. But to be responsible care providers, we have to advocate for the patients in front of us and at the same time recognize that our actions impact the universe of resources. Many U.S. clinicians are not able to think about that. Many other places in the world have some system of socialized medicine and access to resources, and people understand that not everybody gets everything. That's a thought process that people could undertake within the Academy that could be separate from the coalition work that's done to promote a bigger pot of resources."

It's important, she advises, for the Academy to move forward cautiously in attempting to wear two hats. "The process needs to occur internally before those messages are conveyed to the outside world," she stresses. "We must be clear internally on what our position is, and that will require a whole new effort. In fact, now may not be the best time for the Academy to take on something like this. But as we write our position statements through our Public Policy Committee, it's important to understand both roles that we play as clinicians in looking not only at increasing available resources, but also at responsible utilization of existing resources."

In looking toward the future, Roland notes, "I would like to see the Academy continue to explore all the ways we can partner with and add value to the work of other advocacy organizations. Those organizations are going to push the envelope. Our role at the Academy should be to support that work whenever appropriate -- and to provide the medical backup. But I don't think the Academy's role should be solely focused on the advocacy organizations' coalition work. We also have the potential for a unique role in looking at how our own behaviors as individual clinicians contribute to ongoing problems with limited resources."

Back to The Nexus Spring 2004 contents page.