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


The Demise of the Independent Physician

By Rob Tenery, MD on October 18, 2017

In growing numbers, young physicians are no longer willing to make the sacrifices necessary to play a significant role in determining the future of their profession. It’s not just the fault of the AMA, the national specialty organizations or the state medical associations.

New physicians seem much more concerned with managing their increasingly complex practices--- regulation compliance, coding, electronic medical records, outcomes and the bottom line. More and more, they put off participating and often even joining the organizations that work for the medical profession.

It doesn’t seem these new physicians are any less dedicated, just that, outside of patient care, their priorities are more devoted to family and leisure. What most new doctors are facing is the demise of the independent practitioner. Many come out accepting an employee mindset, whether it's joining a hospital HMO or a group practice. In this scenario, they accept being subjugated, feeling their input as an individual practitioner is immaterial to the larger picture. However, in turning over that authority, they adopt an entitlement mindset--- let me do my job, pay me what I’m owed and figuratively speaking, I’ll be on my way. 

The reasons this has occurred are complex. In a large part, they are just following current societal trends--- fit in, work hard and collect your pay. These are part of changing norms by participating more for personal benefit rather than what is best for the community. This affects not just with medicine, but also churches, the Boy Scouts and most volunteer organizations such as the Masons and the Kiwanis. 

When a void in leadership occurs there will be someone or something to take its place. In medicine, with physicians abrogating the control of their future, four entities are fighting for that power--- the hospitals, the third party payers, the federal and the state governments. 

Physicians had their chance to, at the least, slow down their loss of autonomy. That was in the 1970s before two major changes occurred. The first was when doctors agreed to accept direct payments from the payer for their services; thus bypassing their patients’ responsibility for the reimbursement for the costs of their care. The second was the decline in the percentage of physicians who joined the organizations that collectively spoke for them---- the county, state and national organizations. Most still joined their specialty organizations, but a significant reason for that loyalty was continuing education and board certification. In some ways, that wouldn’t have been so devastating a loss of physician control if the national specialty societies had not just been so focused on their own self-interests, leaving the remainder of the profession to fend for itself.

Physicians’ interests can be divided into two main groups that speak for them as caregivers--- those that represent their location (the county and state associations) and those that speak for their specialty.  Both are essential! Fortunately, many state and county medical societies are very strong and have significant impact in what transpires in the state legislatures that affect the medical profession. 

That effect is not as significant on a national level because of the dilution of many voices. In that arena, one voice that speaks for all of the profession is essential. The obvious answer to represent physicians nationally should have been the American Medical Association. It had been in existence since 1847 and, in the 1950s, had a participation membership in the 70+ percentile. Today that number has fallen in to the mid-teens. Ask yourself, what influence does the AMA have today in the current debate over the repeal and replacement of Obamacare. Contrast that with the success and influence of the American Bar Association!

Since the organization has both geographically and specialty representation of the physician population, can this fall of physician autonomy be blamed on the AMA? With respect to the individual leadership, the answer is no. The AMA’s problem was its elected leadership (the Board of Trustees and the House of Delegates) did not come together to make the transformational changes in its structure to meet the challenges that were taking control of the profession. 

There are two changes in organizational structure that could have probably altered the ability of the AMA’s ability to function in a much more effective way. The first was by unifying the county and state organizations’ members with the AMA membership. As it is now, the AMA is an individual membership organization that competes for the same members as the state and county organizations. Additionally, the individual members have almost no control of governance, since elected representatives of the AMA’s member organizations make those decisions. It is an organization that is competing against itself for dues dollars, which doesn’t endear itself to the state societies that are facing membership problems of their own. 

The other change that could have guided the AMA on the right course was to become a true organization of organizations (O of O) by eliminating individual membership in the AMA. No more could the organization reach out and compete for the dues dollars of the members of the organizations that comprised the governance of the AMA. 

Both proposals were brought before the House of Delegates of the AMA. The concept of unification by the states with the AMA had limited success in some states, but mostly died off. Not willing to risk losing the dues dollars from their direct members, the pushback came from the AMA itself. The proposal to make the AMA a true O of O was voted down by the House of Delegates out of fear of a loss of membership dues dollars. as the new AMA would then have to rely on contributions from its constituent organizations.

Can this loss of autonomy be turned around or have physicians missed the opportunity to have a say in the future of their profession? On a state level, the answer is a resounding yes. On a national level, the answer is much more grim. Only by getting into the hearts and minds of physicians that they still have a responsibility to the profession that only helps when they join and participate in the discourse. Also for the organizations that represent doctors, not hospitals, build a structure nationally that can impact change. That means unification of state/county societies with the AMA, or another similar organization. Then restructure that organization into a true O of O. 

The new generation of younger physicians may never see it that way. Only the generations of physicians that came before them! 

 Published in Texas Medicine October 2017





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