Diagnosis for Democracy
Insights into the State of Our Union
A Blog by Rob Tenery, MD


January 10, 2011: What if There Were No AMA?

By Rob Tenery, MD on January 10, 2011

Somewhere between the empty front porch swing and the illuminated CRT screens atop desks in semi-darkened rooms across this country, society’s priorities have shifted from community to self. Now the fruits of our own ingenuity are moving us back into a state of isolationism.  With these changes have come a decrease participation, in and influenced by, the very institutions that had taken this country from a predominately agrarian society that relied on its own independence to an industrialized nation. Accustomed to those conveniences, but not wanting to individually participate, collectively, we are letting the responsibilities and social inequities that need almost constant adjustment, fall to others. The leading example that permeates all levels is the insidious take-over by our federal and state governments. Despite short stints of half-hearted efforts to ‘move the power back to the people,’ there appears to be a never-ending encroachment on our personal freedoms.

When individuals join in a collective endeavor, it is usually to accomplish goals that are otherwise not achievable on one's own. The reason cited most often is that individual efforts are, in many cases, not as effective than if we act as a community. The examples given are national defense and public education. Synergistic to this move toward communalism, but away from individual participation in the effort, is an almost epidemic apathy (let someone else do it) and the 'me now' perspective. Both concepts seem to have their roots in the movements of the ‘60s.

Many of the traditional voluntary organizations, relying on public beneficence for support, have been hit the hardest. Involvement in the Boy Scouts of America, which peaked in the early ‘70s, has declined by 17.9% in recent years. (1) The membership in the Masonic Lodge has fallen 24.8% from the ‘60s. (2) The conventional churches have been hit hard too. The number of Protestants and Catholics has declined 19% in the last part of the twentieth century. (4) The Evangelical Lutheran Church has reportedly had a decrease of 11.3% from 1987 to 2007. The Presbyterian Church (USA) had a slightly greater decrease of 17.9% over the years, 1997 through 2008. (6) Even the largest Protestant church, the Southern Baptist Church, reported a 0.24% membership decline last year. (5) The ‘good work’ accomplished by these organizations either goes undone, or is assumed by a larger body that is less sympathetic to the individual needs and wishes of those who comprise the whole. The term most often used is socialization. Considering that the population of the United States has increased by 46.2% from 1950 to 2000, and 11.6% from 1990 to 2000, these decreases in participation are even more troubling. (3)

To give credit that all is not gloomy, one only has to look at the successes of Habitat for Humanity, the efforts of the Red Cross in the Haitian disaster, the almost exponential growth of the so-called ‘mega-churches,’ the TV ministries, the smaller, ‘non-traditional’ churches in this country and how Christianity is flourishing in Africa, South America and even Communist China. (5)

The problems are not singly tied to apathy and isolationism. There appears to be a public perception that many of the ‘traditional’ organizations are not as important to current needs as they once were. Aware of this, some churches have been willing to adjust by adding worship services where the standard dress-code and music are more akin to today’s line of thinking.

The practice of medicine has been cast into the forefront with the recent passage of health care reform legislation, but the roots of change began much earlier. Physicians had always considered their efforts as private transactions between themselves and their patients. That was until the costs of technology surpassed their patients’ ability to pay. It started with the advent of the third party payers and the Federal funding programs that, at some predictable point, had to introduce cost constraints. At first, the physicians were able to resist most intrusions into their ability to practice medicine. For over 100 years the American Medical Association was able to establish quality standards for those who called themselves physicians and was instrumental in blocking what has been referred to as ‘socialized medicine.’

The first changes only created ripples. In the 1950’s, physicians no longer were required to be members in good standing of their local county medical societies in order to have hospital staff privileges. The 1970s introduced DRGs. The ruling by the FTC, and upheld by the Supreme Court in 1982, cleared the path for advertising by physicians. Work-hours and time to enjoy the benefits from years of training began to move up the list of priorities. Medicine was still important, but increasingly it was no longer the physician's life. Hit by increasing numbers of restrictions and regulations, and coupled with a patient population that was more questioning, the thinking by the physician population was changing. The organizations that educated and represented physicians needed to change too. Relevance had become the ‘only cure’ for apathy and isolationism.

For a history of the formation and evolution of the AMA from 1847 to 1969 see the insert at the end of the references. (*)

In the early 1950s, AMA membership was almost 75% of the eligible physician population. By 1995, that number had fallen to 37%. Five years later, it was in the 32% range. If one eliminated medical students and residents, only counting all eligible physicians after their residency, the percentage had fallen to 22% by 2000. From 1995 to 2009, the total membership in the AMA dropped by 68,000, while the eligible physician membership after residency had increased from 620,3457 to over 954,000. The Executive Vice President of the AMA, in his report to the House of Delegates, stated that membership in the organization had fallen another 3.4% in 2010. He claimed that with the AMA’s strong support of the Patient Protection and Affordable Care Act of 2010, their leadership had anticipated an even worse decrease, as if that interpretation was to be of some consolation.

From 1980 to 2002, the membership of the American College of Surgeons has grown by 55.6%, and from 2002 to the present, by an additional 16%. (7) Between 1995 and 2009, the American College of Physicians added over 42,000 members for a 48% growth. (12) The Texas Medical Association’s penetration into the market was 73.2% in 2009. While the Medical Association of Georgia registered a membership growth of 12.7% from 2005 to 2009 in physicians who are in active practice, the Medical Society of the State of New York noted a 12.8% decrease during that same time period. The Pennsylvania Medical Society has experienced a 1% decrease in membership over last ten years. (17) Based on full dues paying members, discounted groups and new members, the California Medical Society’s membership penetration was 29% in 2009. (14) The Arizona Medical Association’s membership has grown from about 4200 to 4500 from 2003 through 2009. (15) The Medical Society of New Jersey has a penetration of eligible members of 25.9%. (16)

Specialty societies' membership penetration seems to vary whether they are connected to board certification on the national level, or the state organizations where CME activities and legislative representation are high priorities. The American Academy of Ophthalmology reports that about 93% of eligible ophthalmologists are current members with a growth of almost 1000 members in the last seven years. (13) The American Urological Association reports an increased membership of United States physicians by 6.6% since 2000. The American College of Radiology reports about a 65% membership penetration of eligible practicing, diagnostic radiologists in the US as of May 2010. (18) State specialty society market penetration averages just above 60% nationally for ophthalmology, where in some smaller states, the percentage can be over 100% (physicians with licenses in multiple states) to as low as 32% in California and Mississippi.

Whether it is the federal and state governments, churches, Masons or organizations that represent physicians, virtually every organization has as its central core the principle to do public good, as well as representing the interests of its constituency. As involvement in any organization fluctuates, it is the responsibility of the leadership to reevaluate and make adjustments when necessary to the three basics that are common to all---responsibilityrelevance, and representation.

Looking at the three basics as they pertain to the practice of medicine and the organizations that profess to represent the profession, responsibility is at the top of the list. Responsibility to the physician---yes, but more important to the patients they serve. In the current era, where the available funds no longer meet the needs of a growing patient population, more than ever, physicians and their organizations must stand behind the founding principle of doing the most good---whether it be cost savings through managed care, prioritization of resources or advocating for more funding by the third party payers and the legislative process. Allegiance to this dictum must never waver. The members and organizations of the medical community also have the responsibility of self-preservation, so that future generations of doctors and patients are assured of the same opportunities prior generations of physicians have enjoyed.

In the early 1900s, the relevance of organizations that represent physicians was somewhat different than today. As mentioned earlier, to have admitting privileges in the local hospital, doctors had to be members in good standing of their local medical societies. If any doctor acted inappropriately, they answered to that society, which was comprised of the physicians in the community. In the 1950s, that role was taken away and put in the hands of the state medical boards and the courts. Although basic educational requirements, along with continuing education may still be designed and delivered by the state associations and national specialty boards, the licensing process is now controlled by the state medical boards and the hospitals, while the scope of practice delineations are determined by the state legislatures. Even though the AMA and state associations put out standards for ethical practice, enforcement of these guidelines are not under physician control, other than continuing membership in these organizations. So what continues to make organizations that represent physicians relevant? It is to educate the physician community about the latest medical advances and confront the exploding regulations being heaped on the medical profession. It is also advocacy against those forces that interfere with the practice of medicine---bringing together the varying interests in medicine to work out their differences.

Representation may be most difficult to achieve. This basic requires ongoing diligence by the leadership to what is happening to the organizations they purport to speak for, and to the changing norms and expectations of both the physician population and society as a whole. The big picture. Unfortunately, that is where the entrenched leadership often fails. So caught up in their own agendas and the precepts established when the climate was different, they tend to try to lead, rather than follow, the wishes of their constituency.

Isn’t that the big question? When should leadership lead and when should leadership follow the lead of their constituency? To be able to look above the fray to see what is best for those they represent. (8)

A close evaluation of the percentage of participation in the various organizations that represent and continue to educate physicians helps to reveal their perceived importance to their constituency. The national specialty societies stand atop of the group because they control board certification, recertification and continuing medical education. State medical organizations and their component county medical societies follow because ‘all politics are local.’ Despite the lobbying efforts of the AMA and the national specialty associations, by in large, the elected officials are responsive to those who elected them to office, both in Washington and the state capitols. State specialty organizations have on-going CME and representation at the state level.

According to information released during the last AMA House of Delegates meeting and published in the latest issue of Texas Medicine, the AMA membership has now fallen below 20% of market share. At the very best, this dramatic membership decline speaks to apathy on the part of today’s physicians and lack of perceived value in the AMA dues dollars. Value being what benefits members receive that they wouldn’t otherwise. They have their national and state specialty organizations to advocate for their single-interest, political issues and all their continuing education needs. If there are crossover issues that are geographically based, many potential members feel their state organizations will represent them in that arena. Why spend the extra dues money? Being so large and trying to represent so many diverse interests on any one particular issue, the AMA is almost always out of step with some interest group. In fact, one of the core problems is that the AMA is too democratic.

Some claim the AMA has not been a good communicator about what it does for physicians and how it represents the profession to the public, the media and the leadership in Washington, DC (even though around 80% are not members). To a great extent this is true, but this mindset alone continues to ignore the more basic underlying problems.

Aware of the growing influence of the national specialty organizations, in 1972, the HOD of the AMA directed the Council on Long Range Planning and Development to explore methods, whereby these specialty societies and other medical organizations could become more involved with the AMA. In 1978, the national specialties were granted direct representation in the HOD, but not at the same level as the state organizations. Then in 1981, trying to stem the tide of falling membership, the HOD voted in the category of 'direct membership.' Now, individuals could become an active member of the AMA and bypass their state/county societies.

In 1993, the AMA’s Council on Long Range Planning and Development brought together a panel of physicians that encompassed most areas of the medical profession to study the then current composition of the AMA's membership and leadership.  In their final report, called The Study of the Federation, the panel suggested a different organizational model for the AMA---more specifically an organization that was comprised of and governed by other organizations that represented the differing physician interests.

Two dramatic changes were occurring in the last part of the twentieth century involving physician participation in activities other than direct patient care. First, with increasing influence by the specialties, physicians were moving their support from the mainstream of medicine to their own areas of interest. The specialty societies, previously known for their educational expertise, were eager to take on this added responsibility. If there was a choice as to where to invest the limited dues dollars of prospective members, the tide was clearly flowing against an organization that represented the whole of the profession, namely the AMA. The problem was that the intrusions into the practice of medicine frequently crossed specialty boundaries. It didn’t take the third party payers and the leadership in Washington long to catch on—knowing it was easier to deal with one special interest at a time, rather than the whole profession. The mindset becoming ‘we’ll tell you how big the pie will be and you workout how it is divided up, or we will gladly do it for you.' Since each specialty and special interest had its own set of priorities, it was easy to see how the medical profession languished in this environment where less and less concerted effort was being directed to change the ‘size of the pie.' The second change was a failure by the AMA leadership to recognize that its basic structure was detrimental to regaining its former influence in the physician community.

After predictions of dire consequences to the AMA membership by the chairman of the AMA's Committee on Membership, along with behind the scene urgings by influential AMA staff and some members of the Board of Trustees,  the HOD voted against the recommendations put forward in the report of the Study of the Federation that the AMA become a true organization of organizations (O of O). Instead the HOD voted to encourage the AMA leadership to put more emphasis on recruiting individual members into the organization by growing the direct membership category.

“…direct membership has the positive short-term effect of increasing membership and dues income. In the long term, however, allowing this large group of physicians to join without requiring that they be part of their grass-roots organizations probably has a negative effect. For it adds to the perception that AMA is detached from the local doctors and the organizations that represent them.

It is difficult to say how state and county medical societies benefit from direct AMA membership. It is true that direct members in a state are counted toward the state’s representation in the House of Delegates. Additionally, the states do not have to collect and pass on AMA dues from the physicians. On the other side, by allowing direct membership, the state’s role as a mechanism to be part of the AMA is circumvented. Thus, the concept of a true federation of medicine is weakened. It also fosters the perception that representation nationally on economic and political issues affecting the medical profession are separate and apart from these issues, on a local and state level.

Most important are the effects to the direct physician members. They do enjoy many of the educational and legislative benefits offered by the AMA, and if they don’t join their local groups, they save dues dollars. However, that’s where their benefits end.

By opting out of the federation concept, with the AMA’s blessing, these physicians have given up their voice, not only on a local and state level, but at a national level as well. Where is the direct member section in the AMA? Who are their elected representatives? They have none.” (9)

The problems that exist today with the AMA are not because of the lack of dedication of the physicians who are in leadership positions. It's not because of the talented staff, or even the message. Although many might disagree, it's because those leaders and staff have, so far, not addressed a fault in the basic structure of this 163-year-old organization. From a membership perspective, in many ways, the AMA operates as an independent member organization similar to the ACP, ACS and the national specialty societies. From a governance perspective, it functions as an organization of organizations (O of O). This creates a dichotomy that puts it in competition with its constituent organizations for dues dollars and allows its independent members little opportunity in the governance process in its HOD.

It’s not that simple. Increasing membership is only a secondary goal. It is about much more. It’s about survival of the concept for the need of a national organization, which affords the differing factions of the medical profession a venue to reach consensus, other than in the corridors of the halls of Congress.

It is about the state societies awakening to the reality that the national specialty organizations do represent a large number of physicians on virtually all issues that affect their practices. It is about convincing the specialty organizations that they have an obligation to work not only for their own membership, but for the whole of the medical profession.

It is about giving meaningful voice to the demographically divergent groups of physicians who feel their concerns are not being heard.

It is about sacrifice. It is about the state societies not moving out, but moving over to make room for the national specialty organizations. It is about the specialty societies giving up some of their autonomy for the ultimate good of their membership. It is about preserving the strength of the county/state coalitions to affect the legislative process.” (10)

The original AMA was created around a locality model. Only late in the 20th century did the special interest organizations begin to take on a significant role. The single interests can never have the influence on locally elected officials that can be brought to bear by geographically centered medical organizations. Although physician loyalty has shifted dramatically over the last quarter of the twentieth century in the direction of the specialty societies, their political effectiveness has not kept pace. Our elected leaders are more concerned with the amount of funding devoted to health care, rather than how those designated dollars are allocated among the differing factions of the delivery system. If the void exists, and given the choice, they will make those determinations for us.

Assume there were no national organization that spoke collectively for physicians. By default, the spokesmen would become the differing state societies, national specialty organizations, hospital conglomerates, HMOs and PPOs scattered throughout the country. To whom would these diverse representatives plead their cases?  What party would act as an arbitrator when there were differences between the groups? The elected leadership in the state legislatures and Washington, DC would like nothing better than to take over that role.

“If there were no AMA, those in the medical profession would have to create one."(11)

-------------------------------------------------------------------------------------

REFERENCES:

1.    Communication with Luellen D and Upton B.

2.    Communication with Guest T and Upton B.

3.    United States Census Bureau

4.    http://www.thinkchristian.net/index.php/2008/01/04/new-poll-is-american-church-in-decline/ 4/7/2010

5.    http://www.christianpost.com/article/20090225/largest-christian-groups-report-membership-decline/index.html

6.    Research Services Presbyterian Church (U.S.A.) 2009 Comparative Statistics 2008.

7.    Department of Membership American College of Surgeons April, 2010.

8.    Tenery RM. American Medical News August 3, 1998.

9.    Tenery RM. American Medical News September 4, 1995.

10.   Tenery RM. American Medical News June 3, 1996.

11.   Tenery RM. Australian Medicine October 5, 1992 p.7.

12.   Weissman A American College of Physicians April, 2010.

13.   Hartle J. American Academy of Ophthalmology April, 2010.

14.  Communication with the California Medical Society. May, 2010.

15.   Communication with the Arizona Medical Association. May, 2010.

16.   Communication with the Medical Society of New Jersey and the New Jersey Board of Examiners. May, 2010.

17.   Communication with the Pennsylvania Medical Society. May 12, 2010.

18.   Communication with the American College of Radiology. May 17, 2010. (*)  

The first meeting of the American Medical Association (AMA) was held in 1847. A constitution was adopted that set forth the original plan of organization that included a code of medical ethics. Delegate representation was one delegate for every ten members of the permanently organized state and county medical societies, two delegates for each regularly chartered medical school and every hospital with one hundred or more ‘inmates,’ as they were labeled, one delegate for other permanently organized medical institutions, and invited delegates to assure geographic representation from other areas of the country where there were no permanent medical societies or chartered medical schools.

This organizational model stood in place until the McCormick Committee’s proposal was adopted by the AMA in 1901---the formation of the federation of the medical profession. The model was similar to the United States with the unit of organization, the local medical society, electing representatives to the state association, which then, elected representatives to the AMA. Initially, the maximum number of delegates was set at 150. From the state medical societies, there would be one delegate for each 500 AMA members, with one delegate for each of the sections and each of the three government services. The Scientific Assembly still functioned as the scientific body, but would send one delegate to the newly formed House of Delegates (HOD) for each section. The House would serve as the legislative body and elect the officers of the AMA.

In 1902, the AMA issued a model constitution and bylaws for the state medical societies. By 1905, all the state societies had adopted the AMA’s model for organization, except Virginia and Maine. Prior to 1949, there were two categories of membership: those who were members of the state medical societies and those who subscribed to the Journal of the American Medical Association (JAMA). Membership bylaws were changed in 1950, so that the dues of active members were paid to the state medical societies and then transmitted to the AMA. Thus, JAMA and any specialty journal became a member benefit.

In 1969, the AMA House of Delegates established twenty-three section councils with participants selected by the national medical specialty societies. Then in 1978, the medical specialty societies were granted direct representation in the HOD.





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