The AMA is not hopeless

After attending the 2009 AMA annual meeting in Chicago (well, all of the MSS – med student section – meeting and most of the “big house” AMA part), I’ve concluded that the AMA is neither hopeless nor irrelevant.  A conclusion made after a week of terrible and even disheartening press (albeit somewhat misconstrued) for the organization.  Seeing all that negativity, reading about declining membership numbers, and getting e-mails from new competing organizations (like Physicians for a National Health Program, Doctors for America, etc.)…well, I was a little disheartened going into Chicago.  Here is an organization that I am putting a lot of time into, and then I turn around and some of the physicians and medical students whom I respect most and are most knowledgeable about health policy are vowing their eternal hatred of the AMA.

I don’t believe in everything that the AMA stands for or agree with everything it does.  But it is the nation’s largest organization of physicians, and it sets policy that affects the entire profession and lobbies on behalf of all of us.  So I’d rather be part of the system, fighting from within, having a voice, than give up on it entirely.  If good people with fresh ideas leave, we’re going to be left with only the most entrenched opinions and then the AMA will be entering into a downward spiral towards irrelevance.  I’m not so sure it hasn’t already entered that downward spiral, but I do know it’s not too late to escape it.  Yes, I know it’s a little naive, but it’s not hopeless.

The AMA is not irrelevant.  Drs. Nancy Nielsen (now the immediate past president of the AMA), James Rohack (new president), Joseph Heyman (chair of the AMA board of trustees) – all have made visits to the White House and participated in roundtable discussions about reform.  President Obama spoke to us Monday morning to offer more detail on his ideas for health care reform.  He wasn’t at PNHP or the American Medical Students Association (AMSA) or other medical groups.  He was talking directly to doctors at the AMA, confirming its status as a powerful player in this process (massaging docs’ egos is an effective way in currying favor).  I’m not going to analyze his speech here, as KevinMD does a good job of it.  President Obama was met with several standing ovations and only one groan (when he said he opposed caps on medical malpractice awards).  His plan is ambitious, and the AMA isn’t opposed to it.

But there were plenty of physicians – delegates to the AMA’s HOD – who were vocal about their opposition.  Some heard the “no caps” comment and called that a deal-breaker.  Some were wary about Obama even mentioning nurse practitioners in his plan to bolster primary care.  Many were uncompromisingly against a public option, before even hearing what it would entail (for what it’s worth, Medicare Advantage and the Federal Employee Health Benefits Program – privately delivered care – are public plans…).  This knee-jerk reaction, this reticence to change of any kind, is seen on the individual delegate level but thankfully doesn’t always manifest itself in the HOD as a whole.

But these individual delegates are what comprise the HOD.  Looking around the room during the opening assembly on Saturday afternoon, I thought to myself, “This is the voice of today’s medicine?”  All I saw was a room full of old white men, many of them retired and no longer even practicing medicine.  There were some women, some young people (under 40…or even under 50…), some people of color.  The HOD may be reflective of what medicine was and perhaps even is today, but it doesn’t look like the future of medicine.  It doesn’t look like my classmates here at Columbia P&S, we who are the future of this profession.  The people who currently have a seat at the table are designing a health care system in which they’ll never practice, while younger physicians are often blocked from taking ownership.

I saw this last point in action and was disheartened – but not dejected.  I was discussing candidates for the Board of Trustees and various councils (respected positions within the AMA) with a group of delegates (mostly older physicians), and witnessed more than enough horse-trading and not enough discussion of merit.  I guess you can characterize it as a gerontocracy.  “It’s his turn to run.  Dr. X will run next year, Dr. Y the year after that, and then it’ll be Dr. Z’s turn.”  “If our state supports Dr. A this time, then Dr. A’s state will support Dr. B’s candidacy next year.”  “He’s put in his time in this position so he deserves this new position.”  “I know him well.  We were elected alternate delegates togetether 25 years ago and have been in the HOD ever since.”

These aren’t inherently terrible thoughts – hey, it’s internal politics and docs are as power/position hungry as anyone else.  But these practices are not only pervasive but are the default.  So much so that younger physicians are often cursorily dismissed as not having put in their time in the organization. I respect and value the wisdom of these older physicians, but I am not willing to defer to them completely.  But I’m not willing to give up either.  I’m not against the aged but rather the entrenched, as I see this as a major reason why the AMA is so reticent towards change.  And a reason why so many have a negative opinion of the AMA.

Even though membership to the AMA itself is low, the vast majority of physicians are represented by the AMA through their state, county, and specialty societies, all of whom have delegates to the AMA’s House of Delegates (HOD).  Sections also have delegates to the HOD, so medical students (the MSS), residents and fellows (RFS), young physicians (YPS). do have representation.  But there is a huge dropoff in leadership after aging out of these sections, a gap in the composition of the AMA’s HOD between the few young physician delegates and the rest of the delegates.  We devote ourselves to the MSS, earn a position in the RFS, and are leaders in the YPS.  We are delegates to the HOD and members of councils or the board at these levels.  But then we will age out and enter the general assembly, relegated to the bottom of the pecking order to languish there for decades, until it is “our turn.”  And who wants to wait that long to have a voice again?  It’s no surprise then that involvement and membership drops off, with med students and residents no longer renewing their memberships to the AMA.

And these sections, these young people and the people with the fresh ideas, are how the AMA will escape the downward spiral.  We are the future of medicine, and we need to take ownership.  We can have a voice through authoring resolutions (fun fact:  banning smoking on airplanes came about because the AMA lobbied based on a medical student’s resolution…way back when).  Resolutions from the MSS or RFS sometimes fail, but they do often pass, changing AMA policy.  We do testify in front of the HOD and its reference committees, quite often successfully and to warm reception.  We do have slotted seats on the Board of Trustees and the councils.  We do have support from many of the state delegations or individual delegates.  So we young people, we with the fresh ideas, we who welcome change, we who are the future of medicine, can’t lose hope for the AMA.  We must fight from within for change.  If we don’t, we are the ones who will become irrelevant.

Tags: American Medical Association, American Medical Associaton - Medical Student Section