Board of Trustees Report 19 (I-00)

Medical Student Representation in the AMA House of Delegates

Background

At the 2000 Annual Meeting, the House of Delegates referred Council on Long Range Planning and Development (CLRPD) Report 4, "Medical Student Representation in the AMA House of Delegates," Resolution 607, "Equal Representation in the House of Delegates," sponsored by the Michigan Delegation, and Resolution 614, "Medical Student Section Representation in the House of Delegates," introduced by the Ohio Delegation, to the Board of Trustees.

CLRPD Report 4 included the following recommendations:

1.  Participation and Representation of Medical Students and Residents in the AMA’s Policy Processes. The policies of the AMA on the participation and representation of medical students and residents in the AMA and in the policy processes of the AMA are as follows:

• The AMA supports the full participation of medical student and resident members of the AMA in the activities of the Association and in the policy processes of the AMA House of Delegates;
  
• The AMA believes that medical students and resident members of the AMA should participate fully on the delegations of state associations to the AMA House of Delegates;
  
• It is inequitable for state associations to count medical students and resident members of the AMA to increase the size of their delegations without placing medical students and/or residents on their delegations to the AMA House;
  
• The AMA strongly urges:
• • The delegation of each state association to have one medical student delegate for each 1000 medical students members of the AMA who are included in the base for determining the size of the state association’s delegation;
  • The delegation of each state association to have one resident delegate for each 1000 resident members of the AMA who are included in the base for determining the size of the state association’s delegation;
  • State associations that do not have 1,000 medical student or resident members of the AMA should appoint medical students and residents to their AMA delegations as vacancies on their delegations occur through the normal turnover process.
    
• The Speaker of the House of Delegates shall report to the House annually on progress toward achieving AMA policy on the representation of medical students and residents on the delegations of state associations to the AMA. (New HOD Policy)
  

2.  That AMA Policy H-545.947: "Full Participation of Medical Students and Residents within the Federation of Medicine" and AMA Policy H-545.993: "Representation in the AMA House of Delegates" be rescinded because they are superseded by the policy position presented in Recommendation 1 above. (Rescind HOD Policy)

3.  That the Council on Long Range Planning and Development continue its work on the project requested in Substitute Resolution 10, "Medical Student Representation in the AMA House of Delegates," and report its findings to the AMA House at the Interim Meeting in the year 2000. (Directive to Take Action)

Resolution 607 asked:

Resolution 614 asked:

CLRPD Report 4, along with Resolutions 607 and 614 were discussed in Reference Committee F, which heard widespread support for increasing student representation, but less consensus on specific mechanisms through which to achieve this increase. The Reference Committee recommended, and the House agreed, that rather than accept CLRPD’s report as an interim solution to the issue, that work should continue to identify a way to increase student representation that would be acceptable to all constituents. The Board has carefully considered this issue, and presents the following report and recommendations.

Discussion

CLRPD Report 4 was prepared as an interim response to Substitute Resolution 10, "Medical Student Representation in the AMA House of Delegates," adopted at the 1999 Annual Meeting. Substitute Resolution 10 directed the AMA to:

Testimony on this resolution emphasized the importance and value of medical student representation in the House of Delegates, and highlighted the inequity of having 38,000 (currently more than 44,000) members represented by a single delegate. In seeking increased representation for medical students, the Medical Student Section has consistently emphasized the value of providing medical student members with increased voice, expanded mentoring opportunities, and increased ownership in our AMA.

Your Board of Trustees agrees that increasing the number of students who are full, voting members of the AMA’s House of Delegates is an important step in ensuring continuity and member loyalty within the AMA. More than 55% of students in medical schools accredited by the Association of American Medical Colleges and the American Osteopathic Association are AMA-MSS members. Your Board is in strong support of instituting a mechanism for representation in the House of Delegates that will more closely reflect proportional representation of the student membership segment.

At both meetings during which the issue of medical student representation was debated (A-99 and A-00), testimony indicated broad support for the concept of increasing student representation, but raised concerns about the specific mechanism through which this would be achieved. In developing our proposal, the Board sought to balance the following:

• Increase student representation in the House of Delegates to more closely reflect proportional representation of the student membership segment
• Ensure a structure that would provide mentoring opportunities for students and integrate students into existing leadership structures
• Maintain state autonomy in selecting individuals to serve on their delegations
• Allow every state the opportunity to benefit from student delegate participation without creating an immediate crisis in the size of the House of Delegates

Strong consideration was given to issues related to the potential role of the Medical Student Section, integrity of existing state and specialty delegations, funding of medical student delegates, and size of the House of Delegates.

Increased Representation through the Medical Student Section

During the preparation of Report 4, CLRPD discussed the possibility of increasing student representation by expanding the number of delegates awarded to the Medical Student Section (MSS). After discussion with the Medical Student Section, the Council determined, and the Board agrees, that this option is not optimal for several reasons. Of primary concern is that the creation of a "stand alone" student delegation would preclude the mentoring opportunities that would be afforded to students who participated as delegates through their state delegations. The Medical Student Section leadership emphasized its desire to have students integrated into established delegations, thus giving them the opportunity to learn about the AMA structure and the issues facing physicians from more experienced delegates.

Increased Representation through Participation in National Medical Specialty Societies

An additional option considered, and rejected, by the CLRPD was to allow students to designate a specialty society. Most physicians in the AMA are represented in the House by their state delegations and their specialty societies. However, only fourth-year medical students are able to designate a specialty, thus leaving the majority of medical students unrepresented in this area. Although integration into specialty delegations would create relationship-building experiences between students and specialty societies, the CLRPD, the MSS, and your Board agree that it is unrealistic to suggest that medical students affiliate with a medical specialty early in their medical school years. Although your Board encourages increased opportunities for student involvement with specialty societies, it is not appropriate to pursue additional student representation through this mechanism.

State Medical Society Delegations

Because of the organizational and issue-based mentoring opportunities available to students who participate on state delegations, the Medical Student Section has advocated strongly for the development of a mechanism that would add students to state delegations. Recognizing that students are already included in the membership count when delegate allocations are made, the AMA has policy (discussed below) urging state societies to give students seats on their delegations. Your Board would like to acknowledge those state delegations that have already made an effort to include students as delegates and/or alternate delegates in their House of Delegates delegation, and we strongly encourage other states to elect medical students as delegate positions become available.

However, your Board is sensitive to each states’ individual structure and needs when electing delegates, and does not believe that medical student delegates should be appointed at the expense of more experienced physician leaders. Resolution 10 sought to address an inequality based on the fact that students do not have the opportunity to be proportionally represented. Your Board agrees with the Medical Student Section that the remedy for this is to create an additional avenue for participation, rather than to rely solely on the adjustment of the existing structure.

Size of the House of Delegates

The House of Delegates has increased dramatically in the last several years, primarily due to the increased opportunities for representation by specialty societies. Your Board is pleased to see a stronger and more cohesive Federation of Medicine as a result of the increased partnership between National Medical Specialty Societies and the AMA, particularly their increased participation and "ownership" in the AMA House of Delegates.

Specialty society representation in the House was phased in over several years, beginning with the development of the specialty balloting process and the awarding of one delegate per 2000 AMA members to each society. After three years, the representation threshold was reduced to one delegate per 1000 members, which mirrors the formula for state society representation.

Using the specialty society representation process as a model, your Board sought to develop a model for increased student representation that would maximize the synergies between our student members and our AMA, without placing an immediate strain on the administrative workings of the House of Delegates. Several variations of adding student delegate seats to individual state delegations were considered, but your Board felt strongly that the potential of adding 40 – 50 delegates, plus corresponding alternates, would seriously handicap the operations of the House of Delegates. Similarly, several plans were discussed that would have capped delegate awards based on membership enrollment or school size, such as allocating an additional delegate per 1000 medical student members in a state. However, as the distribution of medical schools and enrollment figures is uneven, such plans necessarily precluded many states from ever benefiting from student delegate participation, particularly if the state had only one medical school.

Medical Student Section Regional Structure

In seeking an opportunity for all states to benefit from proportional representation of students, your Board believes that the regional leadership structure currently utilized by the Medical Student Section provides an opportunity to select student delegates from a geographic region, without being dependent on individual state student market or membership numbers. The MSS has identified seven geographic sections, or Regions, roughly based on number of medical schools and medical students in each area. The Regions serve primarily as a communication unit for the MSS, and schools within a Region collaborate to strengthen MSS participation and promote activities within their Region. This Regional structure allows the strengths of individual state or school MSS groups to compliment each other, and facilitates peer interaction between established MSS groups and newly developing ones.

The seven Regions are as follows:

• Region 1: Washington, Oregon, California, Nevada, Utah, Colorado, Arizona, New Mexico, Montana, North Dakota, South Dakota, Idaho, Wyoming, Alaska, Hawaii.
  22 Medical Schools; 1999 Year-End Student Membership: 5,619; Total Student Market: 9,879
• Region 2: Minnesota, Wisconsin, Nebraska, Iowa, Missouri, Illinois.
  23 Medical Schools; 1999 Year-End Student Membership: 6,746; Total Student Market: 12,504
• Region 3: Kansas, Texas, Oklahoma, Arkansas, Louisiana, Mississippi.
  16 Medical Schools; 1999 Year-End Student Membership: 6,628; Total Student Market: 9,622
• Region 4: Florida, Georgia, Alabama, South Carolina, North Carolina, Tennessee, Puerto Rico.
  23 Medical Schools; 1999 Year-End Student Membership: 5908; Total Student Market: 9,966
• Region 5: Michigan, Indiana, Ohio, Kentucky, West Virginia.
  18 Medical Schools; 1999 Year-End Student Membership: 6,159; Total Student Market: 9,554
• Region 6: Virginia, Maryland, District of Columbia, Delaware, New Jersey, Pennsylvania.
  20 Medical Schools; 1999 Year-End Student Membership: 7,303; Total Student Market: 12,167
• Region 7: Maine, Vermont, New Hampshire, Massachusetts, Rhode Island, Connecticut, New York
  23 Medical Schools; 1999 Year-End Student Membership: 5,782; Total Student Market: 12,519

Proposal

Your Board recommends the following:

Using the existing MSS Regional Section Structure (Regions), student delegates will be added to the House of Delegates on the basis of one seat for every 2000 medical student members in each of the seven Regions. Using 1999 year-end numbers, it is anticipated this will add 18 student delegates according to the following distribution:

• Region 1: 2 delegates
• Region 2: 3 delegates
• Region 3: 3 delegates
• Region 4: 2 delegates
• Region 5: 3 delegates
• Region 6: 3 delegates
• Region 7: 2 delegates

It should be noted that under this proposal geographic regions are awarded a fixed number of delegates, but delegates will ultimately be seated with state delegations. The states that receive an additional delegate in any given year will vary depending on the students selected from each Region.

Student delegates from each Region will be elected at each MSS Interim Meeting by student members of the Region. Candidates must have written endorsement from their state delegation prior to announcing candidacy. Winners will then be seated with their respective state delegations for the Annual and Interim Meetings the following year.

Because individual states will ultimately benefit from the addition of a student delegate, your Board strongly encourages states to assume responsibility for funding the student delegate to attend AMA and other relevant delegation meetings. However, because individual states cannot rely on having an additional student delegate each year, it is ultimately the responsibility of the delegate to secure funding. Documentation of availability of funding must be provided along with the state endorsement at the time of application for candidacy.

Your Board is confident that adopting a representation structure for students based on regional groupings meets the immediate and long-term organizational goals of the AMA. This mechanism will promote mentoring, integrate students into existing state delegations, respect existing leadership structures of state delegations, and give all states, regardless of size, the opportunity to benefit from a student delegate.

Modification of Existing Policy

Resolution 10 is most completely addressed by a mechanism of adding student delegate seats to the House of Delegates. However, as was noted in CLRPD Report 4 (A-00), the AMA has existing policy that supports inclusion of medical students (and residents) on delegations.

AMA policy H-545.947 (AMA Policy Database): "Full Participation of Medical Students and Residents within the Federation of Medicine" states:

Also, the AMA has policy on states that gain additional delegates as a result of student members. AMA policy H-545.993: "Representation in the AMA House of Delegates" states:

Lastly, AMA policy H-550.998: "Student and Resident Representation in the House of Delegates" states:

Your Board agrees with the conclusion of the CLRPD that AMA policy H-545.947 and AMA policy H-545.993 are unclear and/or are subject to interpretation. We recommend that, in addition to adding student seats, the HOD clarify its policy positions on the participation/representation of medical students and residents and adopt language to consolidate and clarify H-545.947 and H-545.993.

Recommendations As Adopted 12/00

The Board of Trustees recommends the following be adopted in lieu of CLRPD Report 4 and Resolutions 607 and 614 (A-00), and that the remainder of the report be filed:

That our AMA establish a mechanism for additional delegate representation of medical students in the House of Delegates as follows:

• Recognize the Medical Student Section Regional Section Structure (Regions) as follows:
• • Region 1: Washington, Oregon, California, Nevada, Utah, Colorado, Arizona, New Mexico, Montana, North Dakota, South Dakota, Idaho, Wyoming, Alaska, Hawaii.
  • Region 2: Minnesota, Wisconsin, Nebraska, Iowa, Missouri, Illinois.
  • Region 3: Kansas, Texas, Oklahoma, Arkansas, Louisiana, Mississippi.
  • Region 4: Florida, Georgia, Alabama, South Carolina, North Carolina, Tennessee, Puerto Rico.
  • Region 5: Michigan, Indiana, Ohio, Kentucky, West Virginia.
  • Region 6: Virginia, Maryland, District of Columbia, Delaware, New Jersey, Pennsylvania.
  • Region 7: Maine, Vermont, New Hampshire, Massachusetts, Rhode Island, Connecticut, New York
• Each Region will be awarded one student delegate and corresponding alternate delegate for every 2000 student members, to be elected by the student members of the Region at each Interim Meeting.
• Student candidates for each Regional Delegate Seat will be required to receive written endorsement from their state delegations, and elected students will be seated with their state delegations.
• That state societies are strongly encouraged to provide full financial support to student delegates elected from the Regions.
• That the Regional mechanism for adding student delegates to the House of Delegates be re-evaluated at the end of the fifth year of implementation (Directive to Take Action)

2.  That the AMA supports the full participation of medical student and resident members of the AMA in the activities of the Association and in the policy processes of the AMA House of Delegates. (New HOD Policy)

3.  That the AMA strongly encourage the delegation of each state association to have one resident delegate for each 1000 resident members of the AMA who are included in the base for determining the size of the state association’s delegation. (New HOD Policy)

4.  That AMA Policy H-545.947: "Full Participation of Medical Students and Residents within the Federation of Medicine" and AMA Policy H-545.993: "Representation in the AMA House of Delegates" be rescinded because they are superseded by the policy position presented in Recommendations 2 and 3 above. (Rescind HOD Policy)

Fiscal note: No significant fiscal impact.