AMA's Moving Medicine video series amplifies physician voices and highlights developments and achievements throughout medicine.

In today’s episode of Moving Medicine, AMA Chief Experience Officer Todd Unger discusses the American Medical Association's 175th anniversary and its recovery plan for America’s doctors with AMA CEO James L. Madara, MD.

Speaker

  • James L. Madara, MD, executive vice president and CEO, AMA

Moving Medicine video series

AMA's Moving Medicine video series amplifies physician voices and highlights developments and achievements throughout medicine.

Unger: Hello, this is the American Medical Association's Moving Medicine video and podcast. Today I'm joined by Dr. James Madara, the AMA's CEO in Chicago to discuss the AMA's 175th anniversary and its recovery plan for America's physicians. I'm Todd Unger, AMA's chief experience officer in Chicago. Dr. Madara, 175 years, that is a pretty impressive accomplishment for any company or any organization but it's a particularly proud moment for the AMA. Why is that the case?

Dr. Madara: Well, let me just use the words that you used, are impressive for any company and put this in perspective. The Dow Jones Industrial Index is of all the major companies, the largest companies, aggregated for the largest impact in the various fields. The Dow Jones started 50 years after the AMA. Not a single company that was on the original Dow Jones is currently on the Dow Jones. So, by that measure, the remarkable staying power that the AMA had, has is really punched out and we started 50 years before that. A lot has happened in that 175 years. In one area, technology, we're just in a very different place right now.

Anesthesia had just been discovered as we were being formed. There were no antibiotics for another approximate 75 years, no mechanical things like robotic surgery, obviously. So, the field has markedly changed but some things have remained kind of constant. In 1847, the relationship between a physician and a patient was really important, and the same holds true today. Medicine is a really personal, deeply personal issue and throughout this remarkable journey of 175 years, we remained the strong voice for American physicians.

Unger: Well, it's very interesting too, you think about all of the … that transformation that's occurred over what is approaching 200 years. When you think about why the AMA was founded in the first place, are those core principles still relevant today?

Dr. Madara: I think the keyword for our founding was rampant quackery, that existed in our country at the time. Medicine in the United States in the mid-1800s was behind that in Germany, England, Italy, France. So, we had a lot of work to do to catch up. There was no certification, no educational standards. So, the first things that the AMA did, the first two products were standards for medical education and also the Code of Medical Ethics to get this field into a better position. Now, that has served us really well because when we look now 175 years later, the last two years during the pandemic, there was a lot of quackery.

There were drugs that were promoted that had no effect, and in some instances were dangerous. There was sort of a lack of a strong voice, if the AMA had been absent to really think about medical education in a really rigorous way and how do you apply that at a time of a pandemic, and how do you deal with the misinformation simultaneously? So, those core principles from 1847 have been used throughout the history of the AMA and were particularly important during the recent pandemic.

Unger: Yeah. It's amazing to see how a mission can stay relevant, stand the test of time, adapt as you say, to new challenges as they come. How, when you think about the mission of this organization, how does that continue to drive the work and adapt to where we are?

Dr. Madara: Yeah. Well, I'll tell you the mission to promote the art and science of medicine and the betterment of public health is why I'm here. That mission was really appealing to me. We think of that, we can think of that mission in two parts, promote the art and science of medicine, and the goal is really in thinking through that, is how do we take the $4 trillion that we spend on health care in this country. And then in the context of 800,000 physicians, 330 million Americans, 4 million nurses, 5,500 hospitals, how do we as physician leaders deploy all that for the best health outcomes of our population? So, a really broad-based thought when you think in the beginning of our mission statement and then the betterment of public health is also incredibly important.

Dr. Madara: We've throughout our history, have voiced strong statements against dangerous and unproven therapies. We've promoted childhood vaccines when they were created. We argued strongly and successfully for requirements of seat belts in automobiles, argued successfully against the tobacco industry, all of which were incredible to probably improving public health in this country. The other thing that stands out is a newborn in 1847, had an expected lifetime of under 40-years-old. Now, ours, although variable among populations, because of problems with health equity overall, we're about twice that. We're about almost 80-years-old and that's a remarkable achievement in 175 years.

Unger: Now, look, when you think about looking forward, especially when circumstances like life expectancy have changed and technology, all these things you outlined earlier, when you think about kind of the work going forward, how do you translate that mission into the challenges that the future offers now?

Dr. Madara: Well, since around 2012, we've had a long-term strategic plan framework of, for a long-term strategic plan that we revisit every year. We have a sort of a rolling five-year thinking about this plan but also think beyond that. Where will we be in a quarter of a century? What we've done based on the, our House of Delegates policies are select things that relate to a lot of policies that you could characterize as being pre-competitive. What I mean by that is, any health system that exists in 2047, mid-century, if you don't have these three things somewhat figured out, it's not going to go very well. So, it's needed for whatever health system we have. Those things are to remove the obstacles that interfere with physician-patient interactions, to drive the future of medicine through enhancing medical education, educating for the 21st century, not the 20th century.

And, recognizing that in the last 50 years, the disease burden has shifted in our country from episodic disease to chronic disease, and that chronic disease is now 85, 90% of that $4 trillion spend, and we get more and more chronic disease. This pandemic is producing yet another origin of chronic disease. So, unless we get these three things, make progress in these three areas, no matter what health system we have, it will suffer, due to the absence of progress in these three things. Then we've also identified accelerators that touch all three. One of those is the advocacy that we do to memorialize the progress that we make through regulation or legislation. Another is the innovation that's done in all these areas. The third and most recent is health equity. We know that there's are great inequities in our society and the pandemic really punched those out in a really significant way, and I would say almost an embarrassing way for a country as rich as we are. So, through all these things, we are the powerful ally to physicians in their care of their patients.

Unger: Well, the past couple of years have certainly thrown us quite a challenge in doing that, taken a huge toll on this nation and particular on this nation's physicians. There was an article recently published by the Mayo Clinic, that told us that one in five physicians plans to lead the profession within the next two years and a lot more plan to reduce the hours they work. We've seen this headlines across the country about the great resignation for non-physicians but what are we looking at here in medicine in particular?

Dr. Madara: Yeah, well, I would pause, just to go back to the beginning of the pandemic and what was the state then. We know through work that has been done in our Professional Satisfaction Unit, that work with RAND multi-market work demonstrated that what satisfies physicians is face time with patients, sort of one, two and three, and the dissatisfiers are all the things that get in the way of that. Then we did a time-motion study, multiple markets, and found that for almost every hour that a physician has face to face with a patient, there are two hours of administrative load. So, that's where we were at the beginning of the pandemic, that kind of feature that creates burnout. Then we layer the pandemic on top of that in the beginning. And it's just been a real challenge for physicians in this country and you think of them at various levels.

If you're a medical student, you've had two years of disrupted training in a four-year program. If you're a resident, you may have imagined becoming an expert in gastrointestinal surgery but what you're now expert in is covidology. If you're a physician in practice, practices were severely disrupted. So, what we know about physicians is that's it's not a resilience issue. In fact, physicians are more resilient than the remainder of the non-physician population but it's the dysfunction that surrounds the physician that brings this toll. Then adding to that toll, I've already alluded to it, is the disease burden that is asymmetrically carried by the historically marginalized populations. It's interesting that Johns Hopkins did an international study of what country would best handle a pandemic.

That happened to be published at the end of 2019, just before the pandemic, over 100 countries and the United States was number one. Yet, when the pandemic hit, we were at the bottom in terms of performance. So, if we look at the 30 plus factors that they ranked, where were things that were low? One was in access and the related inequities. That showed to be really important. Another was in the not completely stable nature of our political system. Again, these two or three things that were low, were actually the drivers that took us from a prediction of number one performance to a really poor performance.

Unger: When you think about what you're saying, basically like so many things that were already kind of broken and very, very strained before the pandemic were really crushed by a lot of the issues that popped up with the pandemic. I mean, who would've thought we would've in a situation where we saw such significant shortages around PPE and then complications around polarization, politicization of issues around misinformation. Just the extreme amounts of trauma and death that physicians were facing. It's incredible what physicians have done to help this nation recover. How is the AMA at this point, kind of turning that around and helping physicians recover from what they've been through over the past two years?

Dr. Madara: Well, what you've alluded to is exactly right. There are a lot of problems that are binging on physicians. So, there is a laundry list of things that needed to be done. First of all, the support of practices during this extreme time, which required billions of dollars in emergency funding to prevent further Medicare cuts, that were really hurting physicians. Medicare reimbursement, although it's increased for hospitals, as an example over the last 10 years has remained flat, which is in real terms, downward for physicians. We needed telehealth and telemedicine coverage. We got that. That was incredibly remarkable. An entrepreneur would say that if I'm going to have a venture, a new company that is really impactful, I want to get a 10X result. Well, from January 2020 to May 2020, the increase in utilization of telehealth, wasn't 10X and it wasn't 30X, it was more like 100X.

It was really, truly remarkable and we can't let that slip out of our fingers now. And then combating misinformation, as I mentioned before. A lot of false information that was amplified many times through social media, and there had to be a voice of medicine and science around that. I think we supplied a strong element of that in our own messaging. One of the things that in talking to a person who studies communication and science, one of the things that they met, they point they made to me, is when you're talking about the best practices in health and science should be done by physicians and scientists. As soon as the voice behind the podium is a politician, and it doesn't matter what party they're from or whether they're inaccurate or accurate, you've politicized the message. That's something we had to fight through as well. Now, after physicians have gone through this heroic event on their part, over the last two years, is probably time we think of a recovery plan for American physicians, that would of course, benefit American physicians but also benefit the patients they cared for.

Unger: What is a recovery plan for America's physicians look like?

Dr. Madara: Well, a lot of it deals with support for practices and also getting rid of administrative tasks that take away that face-to-face time with patients. So, a lot of administrative burdens. One is prior authorization, and you'll see that really, in a large remarkable form right now. A third of American physicians surveyed report a serious negative consequence to patients in their practice, due to prior authorization. Basically, all physicians recognize the administrative, the brutal administrative. One form of this is what is called Step Therapy. So, a health plan will say that, we recognize that in the instance of this disease, there are three drugs that could be given and we want them given in this order. A, and only go to B if A fails, and only go to C if B fails. A lot of that has to do with finances.

So, you're on a drug. You're on C. You've gone through A and B, and now it's time for, it's November and time to re-up your plan. And either your employer or your plan changes, and you're told prior authorization Step therapy. You have to go back to these drugs that don't work. Then if you look at prior authorization, at large, there's an average physician has something like 30 plus, 34 of these a week. It takes that physician, him or her, or people on their staff, basically two full days, 16 hours to work through and most of the time everything is let go to move forward. So, that is part of recovery plan. Elements like that really drive physicians crazy, utilize time and are deleterious to patients, and interfere with that face time that physicians have and they need. We need to keep this extended telehealth effort so that the flexibilities don't go away, that there are some geographic restrictions, for example, prior to the pandemic.

We need to address physician burnout. That's really important. It's really, as you pointed out, limiting our physicians from thinking about their, the length of their own careers. Then lastly, things like promoting physician-led teams, making sure the physician voice as leadership of the health care team remains as such. So, all of these are really important agenda items in a recovery plan for American physicians, after they've gone through the wringer. Mention one thing about going through the wringer and in, I think it was April or May 2020, during the height of the pandemic, initial pandemic in New York City, I talked to a head of an emergency department at a hospital in the Bronx, and they had 15 bays in that emergency department but they had 85 gurneys occupied by patients. So, this is the sort of extreme pressure that physicians and other health providers were under over this period of the last couple of years.

Unger: It's remarkable. When I listened to you talk about a legacy, 175-year legacy, and you think about the achievements on, throughout that process but then even more so when we look at it through the lens of the last two years, knowing the issues that we stepped into this pandemic with, and what the AMA was able to achieve for physicians, for patients over the last two years, particularly around emergency funding, preventing Medicare cuts, securing coverage for telehealth, which expanded so greatly like you talked about. Then the role in stepping up, only an organization like this can, to fight misinformation. But I hear your point that we've got a lot of work to do.

This recovery plan for America's physicians, you'll be hearing a lot more about but key focuses on those obstacles like prior authorization, and key issues like Medicare payment, telehealth reimbursement and physician wellness. So a lot of work to be done in the aftermath of this pandemic to take care of America's doctors. Thank you so much, Dr. Madara, for joining us today. That wraps up today's episode. We'll be back soon with another Moving Medicine video and podcast. You can find all of them at ama-assn.org/podcasts. Thanks for joining us. Please take care.


Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.

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