E

ven before the recent election, physicians felt perched on a precipice.

Changes sweeping health care have threatened their independence, income, and influence. An epidemic of burnout and depression shadows the profession. And the incoming Trump administration promises still more upheaval.

Who represents doctors in this unsettling environment? Decades ago, the answer would have been clear: the American Medical Association, the nation’s oldest and largest medical organization.

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But today, medicine is a house more divided than ever.

The AMA still has more clout — and spends far more on lobbying — than the scores of medical specialty societies and splinter groups that sort doctors by political leanings. But it counts fewer than 25 percent of practicing physicians as members, down from 75 percent in the 1950s.

And the association infuriated many doctors recently with its quick endorsement of President-elect Donald Trump’s choice for secretary of health and human services — Representative Tom Price, an orthopedic surgeon-turned-congressman who’s led the charge to overturn Obamacare. Just two weeks earlier, the AMA’s House of Delegates had reaffirmed the association’s support for coverage expansions under Obamacare.

“That felt like a slap in the face, and many physicians aren’t sure if the organization really stands for us any longer,” said Dr. Christian Pean, an orthopedic surgery resident at NYU Hospital for Joint Diseases and a 2014 recipient of the AMA Foundation’s leadership award for young physicians.

Divisions within doctors’ ranks could make it more difficult for their voices to be clearly heard in the coming clamor to replace the Affordable Care Act with a Republican alternative.

“Doctors are disorganized, and it’s a shame because we seriously need physician leadership to inject some sort of moral authority into [this] debate,” said Dr. Robert Berenson, a senior fellow at the Urban Institute and former high-ranking official with the Centers for Medicare and Medicaid Services.

“This is a real litmus test for the AMA,” Berenson said. “Do they have the will and the fortitude to step up and oppose rolling back all the progress we have made, or will they be accommodating and quiescent?”

A Trump pick roils the ranks

Just hours after Trump named Price as his pick to head HHS, the AMA’s board of trustees put out a strong statement of support.

Controversy erupted immediately. Within days, more than 700 AMA members had signed a letter protesting that endorsement as “divisive.” A separate petition accusing the AMA of disregarding patients’ needs drew 5,500 physician signatures.

Dr. Patrice Harris, board chair of the AMA, found herself in the hot seat.

In a recent phone interview, Harris said the organization’s endorsement of Price doesn’t signal that the AMA has backed off its support for Obamacare. “Our commitment to health insurance coverage hasn’t changed,” she said. “Our commitment to the principles of the Affordable Care Act has not changed.”

Her language puts the association on the record, but it’s hardly the strong, clear public declaration that AMA members had requested at an association meeting last month in Orlando, Fla.

At that meeting, just a few days after the election, physicians passionately debated Obamacare and ended up asking the AMA to publicly reaffirm its dedication to “comprehensive health reform” that “improves access to care for all patients.”

Harris was similarly cautious when asked about the AMA’s support for family planning services, which Republicans have said they want to cut. “We remain committed to preventing intrusions into medical decisions that we strongly believed should be reserved for patients and physicians,” she said.

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Asked about turning Medicaid into a block grant program, which Price has backed in the past, Harris said: “We don’t find it productive to deal in hypotheticals.”

Instead, she noted that Price is a longtime AMA member and praised him for having been “accessible to us.” Harris said he “seeks out and listens to physicians’ concerns” and is “attuned, as a physician, to how policies impact delivery” of health care.

Beyond that, Price’s views align with AMA policies in several areas, including the need to fix problems with electronic health records, reduce regulation, and eliminate a deeply disliked method that Medicare has used to control physician spending.

“But there’s also been times when we disagree,” Harris said, adding that the endorsement does not “equate with an agreement on all his prior policy positions.”

‘Followers rather than leaders’

That kind of caution is characteristic of the AMA, which generally prefers to work behind the scenes and press its agenda at the negotiating table, rather than rally the public.

“They end up being followers rather than leaders because they want to be where the action is,” said Dr. Marcia Angell, a former editor of the New England Journal of Medicine and a senior lecturer in the department of global health and social medicine at Harvard Medical School.

More than 190 medical organizations with various agendas are represented through the AMA’s House of Delegates, forcing the organization to balance often-competing interests. On top of that, there’s growing political polarization among doctors, now split almost evenly between Republicans and Democrats. And clinicians are further divided by type of practice and employer.

Because the AMA’s tent is so large, “they have difficulty articulating strong policy positions,” said Berenson, the Urban Institute scholar.

Dr. Jeffrey Singer, a general surgeon associated with the libertarian Cato Institute, quit the AMA 15 years ago out of frustration with what he perceived as its timidity. He wanted the group to stand up more forcefully against government meddling in physicians’ practices.

But the AMA leadership “no longer wanted to make waves,” Singer said. “I just didn’t feel they represented me anymore.”

A top-dollar lobbying force, but declining clout

Wealth has guaranteed the AMA influence in the corridors of power, nationally and in the states.  The association has spent $347 million lobbying since 1998 — more than any other company or group except the US Chamber of Commerce and the National Association of Realtors, according to the Center for Responsive Politics.

Still, scholars agree that the association’s clout has declined over the last 30 years as specialty societies rose in prominence, health care costs soared, managed care became more prevalent, and physicians’ allegiance to the organization diminished.

“Their influence over health policy eroded badly,” Jonathan Oberlander, chair of the department of social medicine at the University of North Carolina, Chapel Hill, said by email.

“Many physicians aren’t sure if the organization really stands for us any longer.”

Dr. Christian Pean

It’s impossible to say how many practicing physicians belong to the AMA because the organization wouldn’t say how many of its 234,360 members were medical students. But it’s clear that just a fraction of 926,000 doctors practicing in the US pay AMA dues.

Nonetheless, Harris said the association represents “90 percent of physicians in this country” through its House of Delegates — where every specialty medical society and state and country medical county casts votes on proposed policies.

But others point to increased splintering within the profession, with left-leaning groups such as Doctors for America and the National Physicians Alliance and right-leaning groups such as Docs4PatientCare and the Benjamin Rush Institute now competing for doctors’ loyalty.

A history of deep conservatism

Throughout most of the 20th century, the AMA fiercely defended physicians’ autonomy and opposed government involvement in health care, earning a reputation for deep conservatism.

It opposed including health insurance in the Social Security Act of 1935.

It fought President Harry Truman’s national health insurance plan in the 1940s.

It fought the creation of Medicare and Medicaid in the mid-1960s.

Dr. David Blumenthal, a former US national coordinator for health information technology, remembers becoming passionate about improving patient access to care during the late 1960s and 1970s.

“I didn’t think, at the time, the AMA was in the vanguard of these issues,” said Blumenthal, 68, who has never joined the association.  “To the contrary, it was very visible in its opposition.”

But in recent years, the AMA has been more aggressive about expanding access to health care, reducing the ranks of the uninsured, and addressing other social issues.

Its embrace of the Affordable Care Act in 2009 was unprecedented, and deeply controversial. In 2014, it passed resolutions in support of transgender rights. And earlier this year, the AMA declared gun violence a public health crisis — and began lobbying for gun control measures.

“They’ve softened around the edges,” Blumenthal said.

Such moves have won the AMA points with some socially conscious younger physicians, who have worked hard to advance policies the organization once would have shunned.

“I joined the AMA because I saw the ability to make a difference,” said Dr. Laura Faye Gephart, a Texas obstetrician-gynecologist who has been a member since 2005. “A group of us are pushing hard to make the organization more responsive to issues we see affecting our patients’ health.”

That group was dismayed by the Price endorsement, and Gephart was among the physicians who signed a petition asking the AMA to clearly articulate its support for Obamacare, family planning, gay marriage, and adequate funding for Medicaid.

The association has yet to put out such a statement. And now, many are wondering if its voice will be muted in the public sphere in the coming debates over health care.

That would be “unfortunate,” said Beatrix Hoffman, a history professor at Northern Illinois University who studies the politics of health reform, “because people tend to trust physicians and want to hear from them.”

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  • I joined the AMA only for one year of my 45 years of medical practice because I did not think they believed in the Hippocratic Oath; they had no interest in residents’ rights,; the will not stand up to pill splitting (into unequal portions); they do not care that MDs and JDs change medical records after bad outcomes; they do not protect whistleblowers trying to clean up the medical swamp; the have allowed “patient rights” to be rewritten by Kaiser (a medical cult – “the less we do the more money we make”); etc. The AMA is primarily self serving even hiding its income and expenses from being found on the Internet – probably the CPT Code books being the most lucrative. Some 700 rural hospital ERs closed since 1983 – the AMA does little about this. The various medical societies and state medical boards have been taken over by the business MDs who overcharge everyone possible – e.g. $33 billion per the OIG report in 2010. It is hard to imagine a more destructive organisation to pretend to stand up for the MIddle Class patient. In fact, after 20,000 hours of study I believe Dr. Robert Mark Pearl (“Robbie”) in Oakland controls the AMA – 6000 MD partners frightened he might take away their pensions if not doing whatever he wants – even sedating patients to death on Tuesdays. I have tried to get to some of this in my new book Kaiser-fornia – 2017. Like such books as The Jungle, I hope it turns public policy upside down; the corruption has got to stop and a for profit group of Permanente physicians can not have so much power achieved so corruptly.

    Charles Roy Phillips, MD – retired – aka Rural Doc and Hospital Cop – cphil49401@aol.com. Would not mind the title Mad Dog Phillips as I also
    volunteered to stay in a war zone during Desert Storm to keep running the best Emergency Room in the Middle East (though I have not yet been to Israel).

    Copy this to my email for my records.

    • That was awesome! I love it when people go off their meds and crank out a sweet rant. You sir, are Mad Dog in my book.

    • Well, William you may need to go ON some meds to recognise when “awesome” and “true” end up on the same page. I am Mad as Hamlet pretended to be mad to catch the King with in the Play. You are Mad … as in Hatter. Chuck

    • Altering records is as common these days as the actual creation of the record. I’ve seen records altered after “bad outcomes”, which is a euphemism for serious harm or death (which is also referred to as “adverse events” for anyone who doesn’t know), and after a problem-solving protocol which used a logic chain that must have been created by a bad psychiatrist. People die or end up incapacitated in some way and all anyone concerns themselves with is how to best ameliorate the liability and save face with their colleagues. The entire situation within the profession is nauseating.

  • I will give you some content, Barbara. Medical errors are not even acknowledged ninety percent of the time, let alone reported. Only twelve percent of adverse events are collected by hospital reporting tools. Over four hundred thousand people are dying each year from these events and millions are suffering serious harm; and yet the AMA does nothing, says nothing about it. Except to lobby legislators on the behalf of insurers, not docs; because since the inception of tort reform in the 1970’s insurance premiums for docs have not gone down, but gone up, yet the number of lawsuits filed has fallen, as has the amounts of settlements and judgments. If the medical profession would begin admitting when mistakes are made and addressing the patients involved, the numbers of attempted lawsuits would diminish and the esteem of the medical profession would rise dramatically in the eyes of the American people. When medical errors are not reported or acknowledged in any way, it is not only the patient that is harmed. The medical profession is harmed; and it is delegitimized.

    • Your emails Larry Pierce sound like you are very well informed – perhaps a hospital employee or paramedic. Yes, the common law equity that we pay when we harm each other is gone. In Kaiser-fornia it is worse – adding in forced arbitration (another swamp). Sometimes just a good apology would help with all the grief, but the folks in charge are pretty cold. It is getting worse. Saint Agnes Hospital in Fresno went from Ruth the nun as CEO to Nancy as the opposite. Then an $18 billion merger – “Dignity Health” but I see no dignity in it. I have only found one Church hospital I thought actually walked the walk – Saint Lukes Hospital in San Francisco. And, in fact, the worldwide Adventists have rejected Adventist West (many hospitals) due to CEOs’ fancy homes on a Lake. Gag me with a stethoscope. Chuck

    • Chuck, you are one of the few clear-eyed physicians I have ever talked to or seen post on this board. I am not a medical professional. I managed a medical practice for over 15 years. My wife held a PhD in Clinical Psychology and had a private practice within the medical practice I managed. I have read thousands of medical records and I knew long ago how docs treat records. Then my wife became ill, was inappropriately biopsied and therefore misdiagnosed. They treated her for an indolent follicular lymphoma when she had a very aggressive form of large b cell lymphoma, probably Burkitt lymphoma. Her oncologist claimed in a transfer summary to a major cancer center that we had refused a second biopsy. Can you imagine someone doing that who had an IQ over 60? No other notation regarding such a thing anywhere in her entire record. My wife died within 90 days of her “diagnosis”. If it was Burkitt, there is a ninety percent cure rate if it is attacked immediately with a very strong chemo regimen. I have been doing daily research for the past year. All of this is why I know what is happening and continues to happen within the medical community. We need more docs like yourself, and docs that will stand up when they make a mistake, admit it and try to do something about it, instead of hiding their heads and lying to the patient.

  • I joined the AMA as a student back in the 1990’s because of a simplistic belief that the AMA was an organization that stood for the professionalism and autonomy of physicians, and the general advance of medicine. I was quickly disabused of that notion.

    Bluntly stated, the AMA has a liberal/progressive and anti-primary care bias. Politically, the AMA is a perfect illustration of O’Sullivan’s First Law: “All organizations that are not actually right-wing will over time become left-wing.” This explains how an organization which once opposed Medicare is now enthralled with ObamaCare, gun control and transgender politics. And this has led in part to their neglect of the issues which are causing physicians such distress: they pursue their pet liberal social issues instead of protecting physicians of every political leaning from oppressive government policies.

    As a new physician, I read the JAMA and the Pulse student section, and as a Republican Family Practice physician, I found little to interest me, and much to alienate me. In 2002, I was already questioning whether the AMA represented my interests when then-president Richard Corlin’s uneducated and illogical gun control stance. That was the last straw for me.

    If the AMA wants to be a left-wing group for specialists, that’s okay, but if they want to represent all physicians, they need to recall that primary care makes up about 40% of all physicians, and the country is 50% Republican.

  • I have never been a member during my career as a practicing physician because for me the AMA always represented an out of touch group of old wrinkly pricks.

    • Your comment would be more powerful for me if you omitted the personal attack (old wrinkly pricks) and focused on the content.

  • Apparently, the AMA never learned from its prior faux pas picking industry favorites when it climbed into bed with Sunbeam. A redux of such questionable judgment by early endorsing Congressman Price further exacerbates the belief that the AMA does not understand exactly who its stakeholders are–just its members.

    Just like other large organizations that used to have prominence in the debates over health care, the AMA has devolved into an overly generic approach to everything, lacking the expertise it formerly was known to contribute to such debates. Indeed, all we have is a compendium of the absence of the AMA’s position projected for its members:
    -Where was the AMA to be the standard bearer of physician ethics to appreciate how a high toleration of fraud and abuse would only be to the detriment of the physician community?
    -Why did it require repeated Stark amendments to Medicare regs to control the overuse of PETs?
    -Why did it require CMS/FDA to issue strict guidelines to reign in the overuse of EPO drugs?
    -Why did the AMA not speak-out against the insurance industry and Big Pharma conniving over the “brown-bagging” of drugs that overtly threatened the quality and efficacy of such drugs?
    -Why was the AMA silent in not supporting USP797 as a national program to ensure a safer environment for pharmacies in community practices?
    -Given the increased pressure upon physicians caught between Big Pharma and their patients’ needs, why has the AMA chosen silence over stepping in with both feet?

    A classic example of this sitzkrieg approach to issues was the AMA’s unwillingness to create CPT codes for medical oncology as it moved out of the hospital setting into community practices, by failing to properly compensate for physician cognitive time and how drugs were to be reimbursed. To compensate, oncology could negotiate the best possible deals at AWP with the many GPOs; that margin spread tended to cover the gap in reimbursement allowed by the AMA. However, when the GPOs were whittled down by the power of Big Pharma, and Medicare switched to ASP+6%, the AMA did not have the oncologists back, particularly in the community settings carrying the costs for their own pharmacy and higher skilled nurses. Consequently, as a result of the AMA, is their a correlation today between this changed reimbursement environment impacting community oncology practices and the increased incidence of fraud in such neighborhood settings?

    In essence, the AMA needs to step-up its game to be relevant and respected again–by the physicians and overall community.

  • The AMA has become a bureaucracy, not a physician advocacy organization. State medical associations have done the same. By doing so AMA has lost the ability to represent doctors and our freedom to practice medicine. These organizations agendas have strayed from protecting physician practices and well being to more and more advocating for patients. The rise in the number of doctors choosing their specialty organizations to represent them is because specialty organizations are more focused on how physicians work and less on patient advocacy. While patient advoacacy is important, it is not why the AMA and State medical associations were established.

  • Yes the AMA is letting the Government control them and The Doctors they are not what they use to be they should not let the DEA or the FDA telling them how to treat patients and what Drugs they can give them it has become so bad the Government and Insurance companies are controlling the Doctors and patients do something AMA stand up for us and fight

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