For Doctors, Autonomy Means Coming Together, Speaking as One

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Commentary — October 2017 

By Robert Tenery Jr., MD

More and more, doctors are facing the demise of the independent practitioner. 

Changing cultural norms that have placed a stronger emphasis than before on work-life balance, along with the complexities of modern health care ― regulation compliance, coding, electronic medical records, outcomes, and the bottom line ― mean that many physicians aren't as willing to make the sacrifices necessary to play a significant role in determining the future of their profession.

This is a trend seen not only in health care but also in churches, the Boy Scouts, and most volunteer organizations such as the Masons and the Kiwanis.

Many physicians have come to accept 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.

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 continuing education and board certification were significant reasons for that loyalty. In some ways, there wouldn't have been so devastating a loss of physician control if the national specialty societies had not been so focused solely 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 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 has been in existence since 1847 and, in the 1950s, had a participating membership in the 70-plus percentile. Today, that number has fallen to the mid-teens. Ask yourself, what influence does AMA have in the current debate over the repeal and replacement of Obamacare? Contrast that with the success and influence of the American Bar Association!

Because the organization has both geographical and specialty representation of the physician population, can this fall of physician autonomy be blamed on AMA? With respect to the individual leadership, the answer is no. AMA's problem was that 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. 

Two changes in organizational structure could have probably altered 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, 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 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 AMA on the right course was to become a true organization of organizations (O of O) by eliminating individual membership in AMA. Under this scenario, the organization could no longer reach out and compete for the dues dollars of the members of the organizations that comprised the AMA governance. 

Both proposals were brought before the AMA House of Delegates. The concept of unification by the states with AMA had limited success in some states, but it mostly died off due to the idea that joining the county and state societies should automatically include membership in the national organization. Not willing to risk losing the dues dollars from their direct members, the pushback came from AMA itself. The AMA House of Delegates voted down the proposal to make AMA a true O of O out of fear of a loss of membership dues dollars, as the new AMA would then have to rely on just direct contributions from its constituent organizations and outside income from other business activities in which they were involved.

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, to build a structure nationally that can impact change. That means unification of state/county societies with AMA or another similar organization, and 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 who came before them! 

Robert Tenery Jr., MD, is an ophthalmologist in Dallas. He is a TMA past president and Distinguished Service Award winner.

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