Physicians leading through change with AMA President Jesse Ehrenfeld, MD, MPH

. 40 MIN READ

Moving Medicine

Physicians leading through change, with AMA President Jesse Ehrenfeld, MD

Oct 30, 2023

Physicians today face disinformation, a critical shortage of medical professionals, policies that complicate patient care and more. In this episode of the Moving Medicine podcast, Jesse Ehrenfeld, MD, MPH, president of the American Medical Association explores strategies for addressing these issues with executive vice president at The Permanente Federation, Stephen Parodi, MD. This episode was created in collaboration with Permanente Medicine.

Speakers

  • Jesse Ehrenfeld, MD, MPH, president, American Medical Association
  • Stephen Parodi, MD, executive vice president, The Permanente Federation; associate executive director, Permanente Medical Group

Host

  • Todd Unger, chief experience officer, AMA

Listen to the episode on the go on Apple Podcasts, Spotify or anywhere podcasts are available.

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Unger: Welcome to Moving Medicine—a podcast by the American Medical Association. Today’s episode was produced in collaboration with The Kaiser Permanente Federation’s virtual event, Physicians Leading Through Change. It features AMA President Dr. Jesse Ehrenfeld along with host Dr. Stephen Parodi, executive president of the Permanente Federation and associate director with the Permanente Medical Group. They’ll talk about physician shortages, the use of augmented intelligence in health care, navigating the misinformation physicians encounter from all sides and more pressing issues in medicine. Here’s Dr. Stephen Parodi.

Dr. Parodi: Hello everyone and welcome to our Physicians Leading Through Change. I am Steve Parodi, executive vice president of the Permanente Federation and associate executive director with the Permanente Medical Group. I am really looking forward to a robust discussion with our esteemed guest, Dr. Jesse Ehrenfeld, president of the American Medical Association, about some of the most pressing issues that we have in health care today.

Let me just set the stage for all of us here. We are living through an age of immense change that touches every aspect of our world. While some of these changes clearly represent progress, many are threatening some of the most basic norms we share as a society. As physicians, as leaders, we must ask ourselves—how will we meet this moment? Rapid technological advances accompanied at a breakneck pace of clinical change, distrust, disinformation, the criminalization and politicization of evidence-based health care and on top of that chronic workforce shortages. These factors have driven physician job satisfaction to historic lows and fueled an increase in burnout and mental health concerns. Our esteemed guest today is present in one of the organizations leading the way in responding to many of these challenges that we face as physicians.

Dr. Jesse Ehrenfeld is a practicing anesthesiologist, senior associate dean and tenured professor of anesthesiology at the Medical College of Wisconsin. He leads the largest statewide health philanthropy known as Advancing a Healthier Wisconsin Endowment. He is an adjunct professor of anesthesiology and health policy at Vanderbilt University and an adjunct professor of surgery at the Uniform Services University of Health Sciences in Bethesda, Maryland. Dr. Ehrenfeld is a graduate of Haverford College, the University of Chicago, Pritzker School of Medicine and the T.H. Chan Harvard School of Public Health. He's also a combat veteran who served in Afghanistan. Earlier this summer he was sworn as the 178th president of the American Medical Association. And I just have to say on a personal level, he's a great friend, somebody that I've gotten to know and embrace from the American Medical Association's connection with the Permanente Medical Groups writ large. Dr. Ehrenfeld, thank you so much for joining us today.

Dr. Ehrenfeld:  Well, Steve, thanks for having me. This is such a treat to speak with you and so many of the folks in your organization about a lot of challenges that we're seeing and what's ahead. I really appreciate the time.

Dr. Parodi: So, Jesse, you've been president of the AMA now for some time. What have you learned being president so far? You've been traveling the country. What are the challenges that you're seeing amongst your fellow physicians?

Dr. Ehrenfeld:  Well, sure. So as president of the AMA, I've got a pretty important platform, which I am trying to use to positively impact the health of our nation, improve health outcomes for all people. And I got to tell you, it was pretty humbling to step into this role in June as one of the youngest AMA presidents in AMA history and the first gay president in AMA history. It is clear to me, it's clear to all of us, as you mentioned in your opening comments, that this is a really challenging time for our nation and just a hard time to be a physician. There is so much division, there's so much stress that we all are experiencing. The AMA has been outspoken against the intrusion of government and other third parties, like third party payers into the practice of medicine. We've been working hard to stop the criminalization of evidence-based care, which is happening in more and more states.

During my term as president, our primary state and federal advocacy priorities really make up what we call our Recovery Plan For America's Physicians that we launched just a year ago. So many of us put everything we had into the fight against COVID-19. Now we really need the nation to renew its commitment to us by fixing some of these urgent challenges that we are all up against—the burdensome prior authorization process, reforming what is a totally unfair Medicare reimbursement system that is putting enormous financial pressure on physicians, especially our colleagues in private practice. When you adjust for inflation, Medicare reimbursement for physicians is down 26% since my first year of medical school in 2001.

Working to address the stigma around physician mental health is also a priority. We've been trying to get rid of outdated language on state medical licensing board and employment forms that ask about past diagnoses that become a deterrent from people seeking care for their mental health. Supporting team-based care stopping inappropriate scope of practice expansion by non-physicians is really important. We have partnered with so many states, so many specialties and we've secured more than 85 scope legislative victories this year alone. We're up against a lot. And then finally, we're in an AI era, supporting the creation of digital health tools that are an asset, not a burden to our teams. Telehealth, other thingsAI—while bringing to the table our experience, our values is critical. And that's a bit of what we're up to right now.

Dr. Parodi: Well, that's a lot, Jesse, to take on. And let me touch on actually the very last thing that you were talking about, which is technology and AI. Can you sort of frame for us where do you see AI playing a role in health care? Is it a force for good? Is it a force of potential replacement? What should we be thinking about? What's the AMA thinking about?

Dr. Ehrenfeld:  Look, anybody can tell you that we are entering an AI era. It's an exciting time, it's a challenging time. How do we navigate this new digital world? And it's really hard to tell anybody who purports to tell you how exactly this is going to unfold. Don't believe them because they don't know how many of these tools are actually going to transform care. There's a lot of hype out there. There are a lot of companies, a lot of vendors, a lot of entrepreneurs who will sell you things. There are, however, success stories in digital health. A lot of the technological advancements in medicine that we've seen over the years have fundamentally changed how we can deliver care. They have improved patient outcomes, but we also know a lot of horror stories, digital health products that were rushed into the marketplace without proper testing, without proper oversight. Tools that may have worked in concept in a design studio, but don't actually work in the clinical environment.

So, from our perspective, we need to make sure that digital innovations work effectively. They've got to be evidence-based, they've got to be validated, they've got to be actionable, they've got to be connected. And that means that physicians have to have input at the earliest stages of the divine and development cycle. Unfortunately, that just is often not happening. Now we've got a really unique opportunity from our lenses in AMA to make sure that the evolution of AI in medicine is benefiting patients and physicians and the health care community at large. And so again, there's a lot of promise out there. We've got so many administrative burdens; we've got so many challenges that we know that these things could be used in direct patient care. We've seen OpenAI's ChatGPT, other generative AI products, but they also have known issues. They're not error free. They're the problems of hallucinations where they're trying to predict what you want to hear and they give you something really convincing, but it's just not right.

Those fabrications, inaccuracies, if you don't manage that, if you don't understand that, if you don't integrate it into the workflow in a way that makes sense, it can harm patients. And we need to understand those risks. We need to think about liability before we rely on an unregulated machine learning algorithm and tools. But I remain very optimistic, the FDA needs to get the regulatory framework right. We need to address these issues of liability and transparency, but I think we're going to see a lot of these things sort themselves out in the next three to five years. Now,

Dr. Parodi: Dr. Ehrenfeld, you referenced that, so the administration, different agencies are interested in this. Congress is interested in this. State governments are interested in this. You mentioned the physician voice. So where does the physician voice fit into this? How do you see physicians actually informing policymakers, lawmakers before they make these decisions?

Dr. Ehrenfeld:  Well, it is so critical, and we have seen technologies that have been thrust upon us when things weren't really ready for prime time. And we all lived through the rollout adoption incentivization with taxpayer dollars, electronic health records. And that's been a bumpy ride. The number one dissatisfier nationally for physicians for about a decade was electronic health record. I don't know anybody who loves and sings the praises of the electronic health record. Maybe you do. Now EHR is the number two dissatisfier, prior authorization is the number one. We continue to see opportunities where, again, if we had a clinician who really understood how the workflow was going to change, how we needed to integrate these tools, things could be better. And so, we're trying to do that.

We have an innovation company that the AMA created. It's a wholly owned subsidiary. It's out in Silicon Valley, right in Menlo Park. It's not a startup. Its job is to make startups. And so, they bring together experts, tremendous expertise, clinicians, engineers, machine learning experts, security people to take ideas that are informed by physicians that align with the priorities of the AMA around burnout, burden reduction, trying to get people more time in their day, and then they create companies that are hopefully bringing products that can make things better. And there've been almost—I think 15 spin outs from that company—if people want to learn more, you can go to health2047.com and it's an easy way to plug in. We also have something called the Physician Innovation Network. It is a free online platform to connect clinicians, physicians, trainees and companies who want to do development. Again, check it out if you're interested in actually getting involved at the development stage.

Dr. Parodi: So Dr. Ehrenfeld, you were just referencing, I think one of the biggest issues of our time, which is physician burnout. And I know this is a part of the AMA's recovery plan for physicians post pandemic. So in your mind, what needs to be done? Who needs to do it? How do we better support physician wellness?

Dr. Ehrenfeld:  So when a physician experiences burnout, it can have a significant impact on productivity, morale, lead to increased errors, poor patient satisfaction, and it can divert attention to tasks that can ultimately reduce time that physicians are delivering care. So, we know burnout is bad for everybody, not just the individual physician. And a really important point that sometimes is glossed over in these conversations is that while burnout manifests in an individual, it originates in systems. Burnout is not the result of a deficiency in resiliency amongst physicians. It's due to the systems that we're working in.

And so that's why our work is really focused on the system-wide solutions to burnout, trying to focus on the key drivers upstream, and that's the origin of our recovery plan and why it remains the focal point of our advocacy efforts. And we're excited about some of the work that's happening. We have a wonderful international conference every year—well, every other year it's international—and the other years it's in the U.S., it's going to be hosted in October, bringing together some leading academic centers, experts from the AMA to elevate best practices to do these system level fixes to measure, address and reduce burnout.

Dr. Parodi: And this is such a critically important time. I'm reflecting on actually some recent information that we heard about ER physicians and particular residency slots not being filled and of course worrying about that pipeline for the future. As a nation, we are facing a growing population of patients that are going to be over the age of 65. There's going to be a greater need for physician expertise. Talk to us a little bit about securing that pipeline for the future. How do we make sure that there are enough physicians, enough residency slots, enough training slots available for the future?

Dr. Ehrenfeld:  So there are a bunch of things we can and have to do. So for starters, the recovery plan that I mentioned has some really easy legislative fixes that address some of the most common challenges. And we know this from our own surveys. We know that there are often key drivers of burnout, frustration that is making the physician shortage worse. And so, it's important as we're talking about shortages, this isn't a theoretical crisis a decade from now. It's a serious problem that we've got to address today because it takes 10 years to train and educate a physician. So, the work to ensure that patients don't experience a severe physician shortage in the next decade has to start today. So Conrad 30 is an important legislative vehicle. International medical graduates, physicians, people born in other countries, but working in the U.S. already make up a quarter of our U.S. physician workforce.

They play a huge role in our health system despite a lot of considerable and frankly unnecessary obstacles. So we support international medical graduates on a number of issues including addressing immigration, green card delays, duration of status, wage protections, recapturing unused employment based physician immigration visas, trying to streamline administrative visa requirements. And there is this bill Conrad 30 and the Physician Access Reauthorization Act. It's in Congress now. Bipartisan support, which you don't hear a lot about. This act would make improvements to the J-1 Visa waiver program to help with physician shortages. So rather than train here and then have to go back to your home country for two years before you can come back and practice, it would allow people to go to shortage areas, to work in rural and underserved communities. Really obvious easy tool, we need that passed. There's also the Healthcare Workforce Resilience Act that would recapture 15,000 unused employment-based physician immigrant visas and 25,000 unused employment-based professional nurse immigrant visas from prior fiscal years so that they could be reused in a way that would be helpful.

There's also the Physician Shortage GME Flex Act that would provide teaching hospitals and additional five years to set their Medicare GME cap if they establish a residency training program in primary care or specialties with shortages. So those are really important legislative vehicles that we are promoting heavily with our lobbying efforts. There's also the issue of medical school debt, and we've got very robust policy, just updated it this year to address the strain of medical school debt on our students. And so, we're trying to work with states and specialties to talk about how do we reduce the cost of medical school education and debt through public and private sector advocacy. We continue to advocate for and support the expansion of some of these federal scholarship and loan repayment programs, things like the National Health Service Corps. There's also the VA has some comparable programs. We need to do these things so that it encourages people to go into specialties in areas where we have the most needs.

There are also some programs that are really great through NIH that give loan repayment in exchange for a commitment to doing target research. We'd like to expand those. And we know that there are some federal options around creating student loan savings accounts where you could take pre-tax dollars to pay for student loans, which would be really, really helpful. Ultimately reducing the cost of attendance at medical school, opening up flexibility and allowing students to choose to practice in the areas that they want in the specialties that we need.

Dr. Parodi: Dr. Ehrenfeld, I'm going to go off script here because you brought up something that's really important in terms of what you sparked for me when you were describing those programs, which is in a way that's a commitment to diversifying the physician workforce. And I know the AMA through CEJA and a number of other initiatives have worked on and thought about. In fact, the last AMA session that I went to in terms of the open session annual meeting, there was a whole section on that very focus—talk a little bit about the AMA's commitment to diversity and diversification of the physician workforce.

Dr. Ehrenfeld:  So, we strongly support diversity in the physician workforce. We opposed the Supreme Court decisions this June that have eliminated affirmative action from higher education. And the reason is not necessarily because it's just a nice thing to have. The reason is because we know that diversity in the physician workforce leads to better patient outcomes. There is very clear, very convincing data that when we have diverse communities served by diverse physician workforces, that patients do better. And so we're very concerned about what is likely to happen in the coming years around who's admitted in the medical schools, who's in the pathway to get admitted to medical schools and what the diversity of the training pipeline looks like.

We've been working very carefully with our partners and trying to understand what options schools do and don't have based on what is now the law of the land, and we're committed to obviously ensuring that. We have a really, really wonderful Center for Health Equity was founded in 2019 by an incredible leader—Dr. Aletha Maybank—who was recruited from running, she was the deputy director at the New York City Department of Public Health, and she founded and has launched the AMA Center for Health Equity. It has an incredibly aggressive strategic plan around how do we embed equity in everything that we do. How do we make sure that we transform the drug and technology development pipeline so that innovations work for all patients, not just some. And if folks are interested in learning about those commitments and those activities, you can find that center's strategic plan on the AMA website.

Dr. Parodi: Your comments are spot on from my perspective in terms of physicians knowing their communities, being in those communities, representing those communities critically important. And so, I want to ask you a question about credibility, because that's been called into question really in the course of this pandemic. What is truth and trust in physicians trust in organized medicine? And I want to ask you from the AMA's perspective, how do we restore trust in our profession as society as a whole? But to be honest with you, it's also an issue. I mean, I think about when I go to my clinic this week, I have patients that are actively questioning, should I get a vaccine or not? Should I take this treatment or not? And they're citing sources that I would've never had to have rebutted. And this isn't just Dr. Google that we're struggling with here, Jesse, so interested in your perspective there.

Dr. Ehrenfeld:  Yeah, this is a really challenging problem. We have seen from study after study and polling data that trust in science, trust in medical institutions has eroded since the pandemic. And that has had a significant impact on our ability to respond to COVID. But studies also show that even people who mistrust medical institutions, the FDA, the CDC—they still trust their doctors. They still trust their doctors in large numbers. And that has to do with the personal relationship that we have with our patients. It has to do with the personal relationship that we form that is so essential in the healing process. So from that standpoint, physicians are trusted. But you're right in that health care organizations like the AMA, like Permanente need to do more to rebuild trust in science, rebuild trust in medical information, public health institutions that are just so critical to our ability to respond to the next public health crises.

Medical misinformation and disinformation have always been a big problem in the U.S. That's actually how the AMA got started in the 1840s, by calling out and raising public awareness of quack remedies and junk science. People were selling snake oil, and we said that that's not good for the profession. But unfortunately, these misinformation campaigns have become very sophisticated, very widespread in this era of social media. And we saw what happened during the pandemic. So we always have to stand on the side of science, data, evidence, and it's just critically important that physicians do the same. And it's also important that we hold ourselves accountable. When another physician intentionally spreads medical misinformation, we have to call that out. And that was unfortunately a shameful part of the pandemic. It's why we have called for state medical boards to respond swiftly when a physician is deliberately spreading falsehoods online or through the media.

It's critical that state licensing boards and specialty societies do their part by stepping up when we see that kind of behavior that undermines public health confidence in vaccines. So there are policy options around limiting the spread of disinformation, ensuring accountability. We have been in touch with all of the major media outlets, including the social media companies. We've asked them to try to help their readers separate fact from phishing, reduce disinformation. That's not going so well. We know that there's more that can be done, and there's a way to do this while upholding the principles of the First Amendment that obviously we hold so dear.

But I will tell you, I'm an anesthesiologist. I am in the operating room every other week. And this past year, I had a patient who, I was pre-op for cardiac surgery. I got to the part of consent where I was talking about blood products. And this patient says to me, "Well, Doc, I don't want a transfusion." I said, "That's fine. It's obviously up to you. There are risks and benefits. This is cardiac surgery. There's potential that we might need to give you blood. I need to understand if this is a life and death situation, why you don't want me to give you a blood transfusion." And the answer shocked me, which was, "Well, I haven't been vaccinated for COVID, and if I get a transfusion, I'm afraid that I'll get the COVID vaccine through the blood. So I don't want a blood transfusion." That is a bad decision. That is a decision that is informed by misinformation that potentially is putting that patient's life at risk.

And so, of course, in this moment, we're three years into COVID here I am trying to get through my day. I am exhausted from having conversations like this over and over and over. And so, you have to decide what do you do? Do I take 20 minutes and sit there and try to walk through the science, walk through the safety, walk through the evidence, or would I just go about my day? And unfortunately, more and more physicians who are exhausted, who are burnt out, continue to just move on. And that's unfortunate for patients, and it's a real challenge.

Dr. Parodi: Yeah, no, you're right. I mean, you have to sort of try to take up that torch as much as you can. There's another interesting aspect to this I'm going to ask you about, which is, as physicians, you referenced the social media piece. What is our role on social media? I mean, AMA's got a major presence in social media, and I'm curious, that's sort of at an organizational level. What do you think about us as physicians? Should we be out there more? What does that look like? Do I invest the time in that?

Dr. Ehrenfeld:  Yeah, I mean, there's an art to it, and my belief is that we need to be there. We need to be on these platforms. We need credible messages that can cut through the noise and drown out the crap. And I tell you, I was feeling pretty deflated about this whole misinformation problem about a year ago. And I was here in Washington. I had the opportunity to speak with Dr. Fauci at a meeting, and the question that we posed to him was, what do we do about all of the junk that's out there? And he said, "The only thing we can do, can't give up, is we got to turn up the volume." And for all of my Spinal Tap fans, turn it up to 11. That means we have to be on the platforms, we have to know how they work. We have to bring credible voices into the space, and we've just got to drown out the junk.

Dr. Parodi: Dr. Ehrenfeld, you are dating yourself with that reference. My goodness. So let me pivot for a second here and talk about some issues of our time. When it comes to the practice of medicine and the sanctity of the physician patient relationship there's a lot of questions now about who's in that room with us. So I want to talk to you about, and you've been on network television referencing the criminalization of care, especially when it comes to LGBTQ plus issues, gender-affirming care, women's health. Talk to us a little bit about what you mean by that in terms of criminalization.

Dr. Ehrenfeld:  Yeah, so the foundational principle that applies to those two issues, but it applies really to everything, is that we oppose the interference of government in the practice of medicine. And we oppose any laws that prohibit a physician from providing evidence-based medical care that is in the best interest of our patient, and that includes government intrusion in the care of transgender people, as well as intrusion in reproductive health and other areas of health care. It's our longstanding view, and this comes from our ethical principles that decisions about all health care are made through shared decision making between patient, family, physician. And there should not be a politician in the exam room—literally or figuratively—inserting themselves into or second-guessing health care decisions. So we're very worried about what's becoming increasingly hostile rhetoric. We're very worried about threats of violence directed at physicians who provide evidence-based care, whether that's gender-affirming care or abortion services, even in states where it remains legal.

So we've been working very closely with our state medical associations to try to make sense of what's becoming an increasingly confusing legal picture in terms of what are your legal obligations in a state with a restrictive law, trying to identify strategies to mitigate harm, and obviously pushing against newly restrictive laws. In states where abortion remains legal, we've worked with our state medical associations to try to get additional legal protections, professional protections and active physicians in those states, particularly if patients are crossing state lines to receive care. On the gender-affirming care front, gender-affirming care, which is provided to often reduce the distress experienced by transgender and gender diverse individuals. Having a supportive non-judgmental environment is really important. We know that these things really help. And so, we have advocated against state restrictions on providing evidence-based gender-affirming care, but Missouri, Montana, New Hampshire, South Dakota have passed laws that restrict unfortunately these things. And so, we're trying to make sure that we don't see more bans.

We have filed a whole bunch of legal briefs and multiple federal court cases supporting evidence-based care. Look, we've got an ethical obligation to help patients choose the optimal course of treatment for them, and that's through shared decision making that should be fully informed by whatever the science is, the date that we're using it and shaped by patient autonomy. Anything less puts our patients at risk, anything less undermines the practice of medicine and the health of the nation. So, we continue to fight these discriminatory actions in states that are pulling back patient protections, criminalizing the work of physicians who are trying to do their best to provide care with compassion and dignity.

A couple other examples. So, we joined the American Academy of Pediatrics and the Children Hospital Association in a letter to the Attorney General asking the Department of Justice to investigate the increasing threats of violence against physicians and hospitals and families of children who are providing or seeking evidence-based gender-affirming care. We know that those threats of violence are having an impact. Many health systems, many clinics have taken the list of services off of their website when these threats erupt. That's damaging to those care teams, it's damaging to the patients who then struggle to find and receive care. So, there's a lot that we can and need to do, and obviously this is a priority for us.

Dr. Parodi: You're referencing hostility in the workplace, which unfortunately has become more commonplace, whether it's in health care or outside of health care. And of course, it was in reference to specific clinics, but it's actually become a generalized problem. In my role, Jesse, it's not unusual that now we're planning for active shooter drills within our Kaiser Permanente system. We're preparing for the violent patient or the potentially violent individual. What do we need to be preparing for as clinicians, as physicians, as owners of our practices? What are you hearing from people? What are they doing?

Dr. Ehrenfeld:  Well, unfortunately, these very well coordinated medical disinformation campaigns, all of this anti-science aggression online is now resulting in threats and intimidation and physical violence at physicians and other workers. And so, people have been targeted in their homes, in their hospitals, in all sorts of very, very frightening ways, shootings, bomb threats, assault. And so, we know that one of the most important things we can do is to support physicians who are in situations like that. I'm really worried though that people are just starting to become numb to these experiences. And so, we have to call it out for what it is. That's why we wrote to the Department of Justice and asked the Attorney General to investigate, and we are not asking for a witch hunt. We are asking for people who threaten health care workers with violence to be held accountable for it. And there's a lot more that our politicians ought to do and need to do, and we continue to remain focused on that.

Dr. Parodi: In this sort of trying time now, you are still practicing, you practice with colleagues. How are people finding fulfillment now in these difficult times?

Dr. Ehrenfeld:  I got to tell you, it is a tough time to practice medicine, but yet I continue to see my colleagues show up and try to do the right thing in spite of the obstacles that we throw at them, the hurdles that they constantly have to jump. The fact that we move the goalposts every single day with another click, another quality metric, another thing that you have to do to get your patient the care that they need. And so, it is so easy to be discouraged. It is so easy to be turned off by the enormity of what we are up against, but there's a reason that people chose the profession and that's what keeps me optimistic. I have seen how my colleagues have stepped up to counter disinformation online, to call out falsehoods, to shine a light on the unacceptable total of mental illness and violence, to work to eliminate health disparities, to get every patient the care that they need.

And I get the privilege of working with a lot of young physicians and trainees and students who are driven by such a bottomless sense of curiosity and a commitment to making difference. And I've seen the impact that the AMA can have to speak out to, to adapt, to fight injustice, to support physicians in every corner of the country. And so, I know people are struggling out there. I hear it, I see it, I experience it. But for those who are struggling, I hope that they see that we continue to have their backs and to push to ensure that physicians have all of the support that they need. There is so much joy that can still be found in medicine, and that is a reason why so many of us dedicated our professional lives to helping and to healing others.

Dr. Parodi: So the corporatization of medicine and consolidation that's occurring out there, and you could pick whatever market, whatever entity, private equity, hospitals, plans or even conglomerate groups. What's the AMA's take on that? What's the stance on consolidation and corporatization of medicine?

Dr. Ehrenfeld:  Well, in general, we support a pluralistic system where people have choices, and we do believe that physicians should have the freedom to choose the practice modality and the type of place that they work. I worry that those choices are getting limited. We continue to see the erosion of small practices, independent practices, which I think is a challenge. We continue to see market dynamics that in many cases are favoring one type of practice through federal financial incentives or other things that maybe ultimately are disadvantaging individual physicians and patients. We obviously are very worried more about some of these horizontal mergers and vertical mergers that are happening around pharmacy companies and provider networks and insurers, and we've asked the FTC to do their part to make sure that those things are not creating anti-competitive marketplaces. But I think we're going to continue to see the evolution of how care is delivered.

I will tell you; I have the incredible privilege of interacting with my National Medical Association president, colleagues from across the globe. And this coming Sunday, I will travel to Rwanda to meet with about 75 of those international leaders from many different countries. And when I talk to them, I hear a lot of the same challenges. I hear about the workforce pressures everywhere, internationally. And I think that we are running 90 miles an hour into a workforce wall. And unless we redesign the delivery system, unless we pivot and think about how do we embrace technology to scale capacity to make it easier for us to do the things that we are most equipped to do as physicians, I think we're going to be in trouble. So, I don't know what that means for the organization of the care delivery system, but I wouldn't be surprised if it looks quite different 20 years from now than it does today.

Dr. Parodi: Looking at primary care and mental behavioral health care. Both are in crisis, both have different issues, and yet both are intertwined together. How should American medicine be tackling those issues? And I'm going to throw a little twist in here, but you referenced this complex patchwork now of scope of practice. We've had concerns around scope of practice and yet we have these shortages here in mental and behavioral health and primary care. What does that look like? Because you're referencing something that's really important. What is the workforce 10 years from now, 20 years from now?

Dr. Ehrenfeld:  Well, look, everybody ought to have a primary care physician. And we know that that is not the reality today in America. And unless we do something drastic, it will not be the reality in the future. And we continue to be very worried about the erosion of how primary care is delivered with physician-led teams. I love my APP colleagues. I depend on my APP colleagues, but they bring a different skillset to the table. And we know that when you remove physicians from the care delivery team, the costs go up and quality goes down. So we're trying to balance these requirements for workforce expansion, re-engineering of our teams with the data that's really clear about the value that we provide as physicians. And I don't get the push for independence because we shouldn't create more silos. We ought to be creating high functioning interprofessional teams that can rely on each other.

And I think there are organizations that do that very well. I think there are organizations that have a long way to go, but when you look at the primary care workforce and you look at what's happening in behavioral health, people are exhausted and the pressures on those practices are immense. The Medicare payment issues, which are huge, particularly for the small practices, independent practices, are only getting worse and making it harder and harder and harder to keep the lights on. We've got to solve those foundational payment issues if we have any hope of keeping things afloat. We've got to expand the workforce and we have a lot of policy on how we can do that. We've got to make it easier for students who want to go into primary care to choose to do so.

I'm very proud that in Wisconsin, the Advancing Health of Wisconsin Endowment paid for the creation of two three-year regional primary care medical schools—one in Green Bay, one in central Wisconsin—and about 80% of our graduates go into primary care. Some change their mind, and that's okay, but we're very proud of what impact that's having in rural communities, underserved communities in Wisconsin. We need to do more things like that. We've got to address these student debt issues and make it easier, obviously, to practice out in the wild.

Dr. Parodi: It is an interesting points you're bringing up here, and you brought it up in your opening, which is Medicare and Medicare reimbursements, which have not kept up when it comes to supporting physicians. Certainly, there are other portions of the Medicare program in terms of other entities, players that have had inflation adjustments over time, but not true for physicians. What's the AMA doing about that?

Dr. Ehrenfeld:  Yeah, so I wish I could flash the graphic on the screen that shows the gap between the rate of inflation and the rate of Medicare reimbursement for physicians. But it's now at 26% and it's grown year after year after year since 2001. And unfortunately, we've got this funny system that does not have predictability, that does not have realistic cost adjustments, that unfortunately sort of disincentivizes quality care because you've got all these metrics that are so disconnected from what we actually do day to day. So I think there are definitely many opportunities to get there.

We know that we've got to just reform the system. We can't do these one-year patches year after year after year. We need wholesale reform. And so, we've been working with Congress to educate our members, and I will tell you, light bulbs are going off. People see the grass. They see that this doesn't make sense, that this is not sustainable. People know that in an environment where inflation is 5, 6, 7%, labor costs are up, it costs more money to get copy paper, that reimbursement's going down just doesn't work. So again, it's a priority for us. We know we have to get there, and we know that it is foundational to the health of America.

Dr. Parodi: There's another interesting thing that's sort of coming out of this pandemic, that we had, and it's hard to know because it hasn't all sorted out here, which is telehealth, and we sort of by necessity had to transform our practices, which had varying effects basically depending on how you were reimbursed, whether that was sustainable or not. And then there were some patches in the last session of Congress to sort of keep some of those waivers going that allowed telehealth. Where do you think that's going from either a congressional standpoint, administration standpoint and actually as physicians what should be our point of view in terms of telehealth and making sure we get reimbursed for it?

Dr. Ehrenfeld:  Yeah, so we have been working on payments, coding, resources to support telehealth and digital health writ large for a number of years. We convened something called the Digital Medicine Payment Advisory Group, which helped us with some of the CPT issues and getting coding and things like that squared away, which fortunately happened before COVID. The waivers that we've had during the public health emergency that have been serially extended, we'd like those to continue, and there is a really nice bipartisan piece of legislation in Congress that would expand these telehealth flexibilities permanently. We're optimistic that we might get that through, but there are a lot of questions. And in fact, last week we did an AMA Advocacy Insights webinar. It's free online, you can find it, 700 people dialed in talking about licensure issues in telemedicine with our experts, folks from the Federation of State Medical Boards, the Interstate Medical Licensure Compact, because there's still a lot of uncertainty around what is okay today and what's going to be okay tomorrow.

Ultimately, we know telehealth can be really, really valuable. It can be really important, and it can really improve the care delivery for a number of patients, particularly those in rural and underserved communities. But the standards of care have to remain the same. And so how do we figure that out? How do we know what is appropriate when it's not a public health emergency to do over video or over the phone? How do you know when you need to examine a patient? How do you deal with issues when patients are out of state for various reasons or the site origination is maybe different than you were expecting? So, there are a lot of these technical issues that in many cases are decided by the state where you're practicing.

And so those rules are actually really important in addition to the federal, obviously, issues as well that we're working on with CMS as well as the DEA, a lot of issues around prescribing and what can be prescribed and DEA is trying to figure it out. They had a listening session I think two weeks ago trying to think about what they might promulgate through rulemaking, but still a lot of uncertainty and questions. But we are firmly supporters of trying to maintain a lot of the flexibilities that we've had throughout the pandemic.

Dr. Parodi: We talked about diversity amongst the physician workforce. This is a different angle on diversity, which I think is important. And the question is how do we restore trust in underserved communities as physicians and in particular communities that have experienced or continue to experience health inequities or even mistreatment either by the medical profession or others.

Dr. Ehrenfeld:  It is an important issue and we want the trust, but I tell you, we got to earn it first. And there are so many horrific examples of places, times, experiments where we didn't do the right thing, and those memories linger and are long. And so, I will tell you there was a huge push with Operation Warp Speed and vaccine development to make sure that all communities were represented in vaccine trials for COVID, an unprecedented push to make that happen. I think a big part of it, frankly, is showing up and you all have the benefit of being tied to specific communities. The AMA, we have the challenge of being a national organization, but I'll tell you, in our hometown of Chicago, we are deeply committed to elevating the health of the Chicago community, particularly an underserved part of Chicago on the West Side. And a big piece of that is showing up and showing up in restoring and building that trust.

And so, the AMA has put its proverbial money where its mouth is, and we've made multimillion dollar multi-year commitments to support this coalition called the West Side United, and people can look it up online. It's a coalition, AMA health systems, other players in a particular neighborhood where the goal is to lift up the health of this community, family by family to hopefully reach scale where we can reach hundreds of people. And a big piece of that is being out there and developing that trust and letting people know that we're not just there to take, we're not just there to study and to research, but we're there to stand with them.

Dr. Parodi: Dr. Ehrenfeld, I want to thank you so much for taking the time to have this conversation, to share your thoughts with thousands of Permanente physicians across the country and for the service that you are providing to the house of medicine and to the American Medical Association. Thank you to everyone who tuned in today and who are going to be watching this recording later. That simple act demonstrates your resolute hope and a commitment to the practice of medicine and improving our patients' health and lives. Even if right now some of us feel like there's not much left to give, your willingness to face today's challenges and this changing world is truly inspiring.

I hope this conversation showed how much can and needs to be done to lead medicine into the future. I look forward to the Permanente Medical Groups continuing to partner with the American Medical Association. We encourage all of you to seek opportunities to demonstrate leadership and commitment to our profession, however and whenever you can. Thank you all for joining and have a great day.

Unger: Listen to more episodes in collaboration with Permanente Live. Subscribe to the PermanenteDocs Chat podcast and register for upcoming events by visiting permanente.org/amadocschat.


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

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