The AMA was founded back in the mid 1800s, and it was basically established to improve medical education, promote public health, advance medical science, and create a standard set of ethics for doctors around the country. Today, they claim to be the largest medical association in America. I was shocked to find out that less than 20% of doctors are actually members of the AMA, and about 30% of the members are actually medical students, residents, or fellows--not practicing, licensed, physicians. I think it would be accurate to say that most Americans believe that the AMA is the spokesperson for the beliefs of all physicians, but this is clearly not the case from these statistics. This is an important point. The AMA does not speak for the majority of practicing physicians in the U.S. However, they are seen as having tremendous political power, acting as the lobbyist for the entire medical community. The President of the United States makes it a point to speak at AMA meetings every once in a while, and Obama was relieved that the AMA accepted the House Health Reform Bill not too long ago. The AMA also performs charity work on national and international levels, contributing money and physicians for public health improvement.
On to my dilemma.
The emails I have gotten about the AMA have all been incentive-oriented. Here's the basic layout of all these emails:
Hello, and congratulations on being accepted to _______ School of Medicine! I know how hard the first year of medical school can be, which is why I would like to invite you to join the largest support group of medical students in the nation. Because the AMA helps create policy, you can make a difference in the issues that matter most to students like us: expanding coverage for the uninsured, medical school loan debt relief and reasonable resident work hours. You also receive complimentary subscriptions to a number of AMA publications, most notably the Journal of the American Medical Association, to help keep you informed on these and other issues. We are currently offering a 4-year membership, which is $68, and free Netter Flashcards, a $35 value, which are essential for Human Structure. If you happen to already have the flashcards we also will have very nice dissection kits that you can choose instead, also a must have for Anatomy. Join the AMA today and start making a difference.As much as I like flashcards and dissection kits, I wanted to know what the real benefits were of joining the organization. What better place to look but their website, where they detail the top 10 reasons for joining. I won't spend too much time on them here, since you can read them for yourselves, but a good number of their reasons for joining are again these small incentives: flashcards, online subscriptions to their journal--which incidentily every medical student should have access to through their school, a residency search tool--which again everyone has access to (if you're a member, you can print mailing labels!), access to certain health policy internships in D.C. (politics isn't really my cup of tea as a med student...I rather spend the extra time doing something to increase my abilities as a physician, and worry about politics later), networking through conferences and meetings (networking as a med student should not be one of your highest priorities, in my opinion), and a web-based forum (now that's cool!--sarcasm intended), and other misc. leadership opportunities/advocacy benefits. To be honest, I still wasn't persuaded to join or not to join at this point. I had to do more fishing around on their website, to get a clear idea of what they stood for ethics-wise.
Now, before I get into specific ethical stances, I want to discuss how the AMA works. Essentially, the AMA is a union. Doctors get benefits, and they agree to abide by certain rules and regulations of the union--otherwise, bad things happen. The code of ethics is basically the AMA's set of rules, and, as I understand it, members have to agree to the code to become members. What can the AMA do to doctors who don't abide by its rules? Well, the networking structure that the AMA has can be a blessing or a curse, depending what your standing is with them. For example, they could effectively cut off your referrals from other AMA members, making it harder to get patients. Word of mouth is an untamed beast, especially in medicine. Ultimately, they could kick you out of the organization for numerous violations of their code, which would not look good to anyone reviewing your CV. Fortunately (or unfortunately?) they do not have the membership that they once had, so dissenters of the AMA have much less to worry about than they used to.
Conveinently, the AMA has their code of ethics section right on their website. I found a couple of entries in this code to be contrary to what I deem is ethically correct. The AMA believes that euthanasia and physician-assisted suicide are absolutely wrong in every case, and that performing these acts is "incompatibile with the physician in a role as healer." It's interesting, then, that palliative sedation is deemed ethically permissible by the AMA. If euthanasia and physician-assisted suicide are not allowed, why should palliative sedation be any different? Along these lines, I feel like the role of a physician is not only that of a healer, which seems to run counter to the very ideologies that the AMA holds. In the role of a healer, physicians treat diseases. They fix pathological issues in the body. Of course I do not disagree with this statement...this is what doctors do! But I feel that doctors should be treating illnesses, which encompass much more than the disease itself. Illnesses affect the patient, their families, and their psychological, social, and physical issues. Doctors have a responsibility to care for the entire patient, something that I feel is lost in our culture of attacking diseases and waging wars against pathogens, etc. End-of-life care is as much in the doctors realm as is giving a vaccination to a child.
I also find objection to the AMA's stance on gift-giving by companies. While they do take a stance that is mainly anti-gifts, they do allow for companies to take physicians on trips and provide meals, etc. that are "for the ultimate benefit of the patient." I believe that under no circumstances should a doctor become entangled with the companies that provide them with medical supplies and equipment. The act in itself is not beneficial for the patient, as it may persuade the doctor to give medication or perform a procedure that is ultimately unnecessary or not in the patient's best interest.
Finally, I am not one to let others make decisions for me, which would essentially be the case both with advocacy in Washington and in providing care for my own patients if I became a member of the AMA. Members are finding this hard to swallow in recents weeks, with the AMA's support of the House Health Reform Bill. The former AMA president as well as various AMA regional groups are in strong opposition of the AMA's support of the bill, since it will decrease physician salaries and allow for less physician control in the care of their patients. They are finding out the hard way that only a select few people have a tremendous amount of power in the organization, determining organization-wide policy endorsements when there is considerable divide in the organization itself. That's a shitstorm that I will happily avoid.
So, in the end, I decided not to join the AMA. I felt that surrendering my ethics to the AMA was too high of a cost, not to be outweighed by the promise of professional networking and a nifty set of flashcards. As much as I appreciate their efforts to get higher salaries for physicians, money won't make me a better doctor. Having a good set of ethics will.
Jim
"But I feel that doctors should be treating illnesses, which encompass much more than the disease itself. Illnesses affect the patient, their families, and their psychological, social, and physical issues. Doctors have a responsibility to care for the entire patient, something that I feel is lost in our culture of attacking diseases and waging wars against pathogens, etc. End-of-life care is as much in the doctors realm as is giving a vaccination to a child."
ReplyDeleteJim, I couldn't agree more. I feel like in such an anxiety-driven situation for most patients, doctors are too often unsympathetic or removed from the worries of their patients. Sometimes it seems like this one-on-one war between the doctor and the disease, and the patient's body is simply seen as the arena for this war to be waged. I feel like this applies to something as huge as physician-assisted suicide as well as something as minor as calming a child's fears over a shot.
As for the AMA, I have questions regarding the scope of their influence. You mentioned that only 20% of doctors are members, a figure I think has been brought about by the negative views towards the AMA recently, but do you think their influence extends beyond their membership? The analogy is exaggerated but could it be something like the mafia, where only a small percentage are real "henchmen" but their influence spreads beyond the membership? I can't really think of any examples, so I hope the question is clear by itself.
That's an interesting way to think about the organizational structure of the AMA, and I think that it's true, in a way. Especially on the political side, the AMA seems to have a "you scratch my back, I'll scratch yours" type of attitude when endorsing various policies. We can also see their influence in the medical research community, where the Journal of the American Medical Association is certainly one of the main medical journals in the U.S. They are also cited world-wide, alongside the New England Journal of Medicine and the Lancet. And, as I alluded to in my post, the AMA lobbies for all American doctors, whether nonmembers want them to or not. For example, policies endorsed by the AMA to increase pay for doctors would not only benefit members of the AMA, they would benefit all physicians nationwide.
ReplyDeleteI think that this influence outside of membership might be a reason for the AMA's low membership levels. Why join an organization when you can receive most of the benefits for free/at low cost, without the constraints of membership rules? We can see that most members do not really have a say in the endorsements that the AMA puts out, so whatever happens policy wise will probably happen whether or not you're a member. It's an interesting relationship that physicians and the AMA hold, something that may be better explained by an economist or (coughmikecough) a public policy guru.
I think that just about answers your question, but if you had something else in mind, let me know.
Jim
I'm not really familiar with the AMA's internal structure so I'm curious: how much power do rank-and-file AMA members have in determining the policy direction of the organization? Or, more precisely, in determining the stated national policy preferences of the AMA?
ReplyDeleteAs an interest group/union-like organization, their duty is to deliver for their members (which I suppose usually means protecting salaries). But how do the majority of doctors feel about, say, a single-payer system? I really have no sense of what most doctors prefer. Just the system that most fattens their wallets?
Mike, your question about the AMA's internal structure is an important one, and I believe that the answer provides further support for my decision not to join the organization. There really isn't that much information about this online--the AMA's website provides just a very basic explanation of their structure:
ReplyDeletehttp://www.ama-assn.org/ama/pub/about-ama/our-people.shtml
(don't know how to put hyperlinks in a comment, sorry)
Based on this, we can see that there is an elected House of Delegates as well as elected and appointed Councils that provide advice on medical issues. The AMA's website says that the House of Delegates is the principle policy-making body of the AMA. This group of individuals meets twice per year to vote/discuss various policies. There are a few interesting things about this body. First, only about 500 people are creating policy, representing a membership of roughly 250,000 individuals. These 250,000 people are so far removed from the policy-making body that we could say they have virtually no power in the AMA's policy-making. Examining how officials are elected can show this more clearly.
The AMA is organized into county, state, and federal bodies. The only voice that individuals members have is in electing their county representatives. From then on, indirect elections take place. County representatives then elect state representatives, which in turn elect the members to the House of Delegates. An interesting point about any election is that the candidates cannot solicit for votes from AMA members, and therefore the election itself is often equivalent to a lot of people's strategy for picking, say, a county judge--pick the one that is affiliated with your party, or better yet, the one with a cool sounding name. AMA members often do not know the people they are electing.
Sifting through information about this subject on the internet, I came across a good article on this very subject. The authors compare the American Medical Association with the American Library Association (odd choice, I thought, but whatever). They talk about all of the things we've been discussing, but the article was written in 1972. As far as I can tell, the organization hasn't changed all that much since then, so most of the arguments they make should still apply. Also, when you're reading it, keep in mind the numbers are completely different (I guess at that time about half of all doctors were members of the AMA, for instance) and that their use of the phrase "the Association" is confusing, as they can be talking about the AMA or the ALA. Page 23 (Part V) starts the discussion about the functioning of the AMA--before that they discuss historical aspects, which are also interesting to read if you have time. Here's the link:
http://www.eric.ed.gov/ERICDocs/data/ericdocs2sql/content_storage_01/0000019b/80/39/04/0b.pdf
As for your second question, There is a little information on the subject. According to a poll taken in 2007, 59% of physicians in the U.S. were in favor of a national insurance system. Here's the link:
http://www.pnhp.org/docsurvey/annals_physician_support.pdf
Note: Though this link is from the PNHP, the article actually comes from the Annals of Internal Medicine.
It seems that either docs are not as concerned about their wallets as you may think, or they believe that the national insurance system would have no effect on pay or it would increase their pay (as would be the case with psychiatrists, I believe, which may explain their overwhelming support for nationalization...who knows).
Hope this comment answers your questions.
Jim
Thanks, Jim, that's good stuff (I actually took a sociology class on organizational structure and I do find the subject interesting). I found it especially interesting that the higher echelons of the AMA's governing apparatus are dominated (assuming this fact hasn't changed in the last 30 years) by specialists, well out of proportion with their presence in the general population of physicians nation-wide. I'm not sure what the implications of that are but it strikes me that there would be some.
ReplyDeleteAnyway, that survey of doctors is interesting but the question is vague enough ("In principle, do you support or oppose government legislation to establish national health insurance?") that I'm not entirely sure what to make of it. Perhaps many doctors are interested in having a larger base of patients and potentially earning more money (e.g. a national mandate for health insurance, maybe coupled with subsidies for lower-income households to buy insurance, could mean more money for doctors). I'd be interested in seeing if those numbers hold if the possibility is raised of doctors earning less or at least possibly switching to a salary system of reimbursement instead of fee-for-service. I'd also like to know how widespread support of a public option is among the rank-and-file. But ultimately I suppose that doesn't matter, as the AMA did endorse the House health care bill (H.R. 3200). I think it's worth reprinting Michael Maves' letter to Charlie Rangel (the chairman of the Ways and Means committee) in full:
Dear Chairman Rangel:
On behalf of the Board of Trustees of the American Medical Association, I am writing to express our appreciation and support for H.R. 3200, the “America’s Affordable Health Choices Act of 2009.” This legislation includes a broad range of provisions that are key to effective, comprehensive health system reform. We urge members of the House Education and Labor, Energy and Commerce, and Ways and Means Committees to favorably report H.R. 3200 for consideration by the full House.
In particular, we are pleased that the bill:
•Promises to extend coverage to all Americans through health insurance market reforms;
•Provides consumers with a choice of plans through a health insurance exchange;
•Includes essential health insurance reforms such as eliminating coverage denials based on pre-existing conditions;
•Recognizes that fundamental Medicare reforms, including repeal of the sustainable growth rate formula, are essential to the success of broader health system reforms;
•Encourages chronic disease management and care coordination through additional funding for primary care services, without imposing offsetting payment reductions on specialty care;
•Addresses growing physician workforce concerns;
•Strengthens the Medicaid program;
•Requires individuals to have health insurance, and provides premium assistance to those who cannot afford it;
•Includes prevention and wellness initiatives designed to keep Americans healthy;
•Makes needed improvements to the Physician Quality Reporting Initiative that will enable greater participation by physicians; and
•Initiates significant payment and delivery reforms by encouraging participation in new models such as accountable care organizations and the patient-centered medical home.
The AMA looks forward to further constructive dialogue during the committee mark-up process. We pledge to work with the House committees and leadership to build support for passage of health reform legislation to expand access to high quality, affordable health care for all Americans.
This year, the AMA wants the debate in Washington to conclude with real, long overdue results that will improve the health of America’s patients.
Interesting. He praises the bill for several laudable provisions but I was most interested by the "Provides consumers with a choice of plans..." bullet point. He makes no specific mention of the public health insurance option. A notable omission.
There's been some talk lately about the possibility of an independent commission getting more power over Medicare payments. There was some controversy because of a CBO analysis of the proposal (mostly the whole affair just exposed how widely misunderstood the economic concept of expected value is). Anyway, it looks like the AMA isn't pleased (not sure how this reflects on doctors as a whole). Here's the link.
ReplyDeleteDoctors are objecting to one possible provision of a reform bill - favored by the White House and Blue Dogs - that would give an independent commission more power over Medicare payments.
The Wall Street Journal reports that while the American Medical Association and the American College of Surgeons "have thus far supported significant pieces of the Democrats' health-care agenda, and President Barack Obama has repeatedly cited physicians' backing for his health-overhaul plans... doctors are objecting to proposals that would allow a federal commission to set the size of Medicare payments to doctors, hospitals and other health-care providers. ... Doctors' objections to the commission idea highlight the difficulty of maintaining the support of different health-care constituencies when the focus turns to controlling costs."
The Journal reports: "The AMA also argued that Congress already has a provision in place intended to slow the rise of Medicare payments to physicians. That curb on payment levels has repeatedly been overridden by Congress in the face of pressure from doctors' groups fighting scheduled pay cuts. As a result, Medicare payment rates to doctors are now roughly 20% higher than levels called for under the cost-control provision. The AMA and the surgeons' group both backed the health-care bill House Democrats introduced earlier this month, in part because the legislation would retain the higher payment level for physicians. ... Mr. Orszag responded that the proposal was aimed at the longer term" (Goldstein, 7/29).