AMA Past President David O. Barbe, MD, MHA, a family physician from Mountain Grove, Missouri, was inaugurated earlier this month as president of the World Medical Association. Based in Ferney-Voltaire, France, the WMA’s members include the national medical associations from 115 nations that represent 9 million physicians.
As the AMA’s 2017–2018 president, the former Missouri State Medical Association president presided over a term marked by efforts to repeal and replace the Affordable Care Act and the growing recognition that gun violence is a public health crisis in the United States.
As WMA president, helping doctors around the globe respond to the COVID-19 pandemic will undoubtedly be Dr. Barbe’s primary task. In his inauguration speech, he pledged to meet this challenge by emphasizing teamwork, professionalism and a renewed focus on medical ethics.
Dr. Barbe recently spoke with the AMA about his journey from rural independent family physician to leader of a global organization and physicians’ responsibility to speak out against inequity and put patients’ interests first.
AMA: What are your goals and priorities as WMA president?
Dr. Barbe: A good leader can’t be so focused on one or two issues, that he or she neglects the other very important things going on.
I’ve never been a leader that said: “This is my agenda. We’re going to do this one thing and that’s what I hope to get accomplished.”
I really believe that the WMA—and I would say the AMA as well—is a multifaceted organization that has the opportunity to influence health care and to influence the practice environment for physicians around the world.
I mentioned in my inaugural speech that I think we need to lead on ethics. And it relates back to the professionalism part. I think they are part and parcel of the same concept in health care that physicians must be ethical and must champion medical ethics in their society. We must champion professionalism in our society when it comes to health care.
We must speak out when we see inequities in medicine and when we see unethical behaviors by organizations or even governments. Being the champion for medical ethics and the dignity of human beings is key to what we do.
It is very much the reason that the WMA was founded in 1947. In the aftermath of World War II and some of the medical-ethical atrocities that were committed during that time by various parties, demanded—if you will—that physicians come together in a worldwide body to speak out against the unethical activities that had gone on.
The AMA is leading a workgroup on a pretty significant revision in the WMA Code of Medical Ethics, which is not too dissimilar to the AMA Code of Medical Ethics. Because of the AMA’s experience and expertise in medical ethics, we have volunteered and been accepted to lead that revision.
Ethics is one thing we want to champion. Professionalism is another one, making sure that we continue to remind ourselves as physicians of our obligations to our patients, of our obligations to society, so that we can maintain that position in which others in the health care team look to us—not just for our clinical expertise—but for our professionalism and our leadership, and our patients look to us for those same reasons.
I’m extremely concerned about COVID’s impact across a variety of different areas. It has been a stress test for health care and the WMA can help physicians articulate issues around COVID.
It has stressed us, for instance, in the clinical arena: The evaluation of the pandemic virus, the evaluation of treatments, the evaluation of vaccines. All things in the clinical realm—we’re significantly challenged and stressed in those areas.
We are challenged and stressed in the health care structure and infrastructure: Physically getting personal protective equipment, getting ventilators, freeing up hospital and ICU beds to take care of this new influx of patients who are acutely ill on top of the underlying baseline degree of injury and illness in a community.
It challenges us ethically and professionally. What if resources are limited? How are we going to prioritize? An example of that is the vaccine. Yes, we have clinical challenges developing the vaccine, but we’re also potentially going to have ethical and professional challenges.
Who gets the first round of vaccines? How do we decide?
How are they distributed worldwide? Can we as a profession be silent if more well-to-do countries buy up the world’s supply of the vaccine and make it less or unavailable for other countries?
There is significant inequity and health disparities in most countries. They may differ from country to country, but there are parts of the population who—for a variety of reasons—don’t get the same level of health care or, within those populations, certain diseases occur with greater frequency and that may not be recognized or the resources to treat it may not be available.
For instance, things like diabetes and hypertension occur with greater incidence and greater severity in populations of color and in Asians. Therefore, in some countries, those populations are already facing health disparities because of those illnesses.
Now, on top of that, we have COVID-19, and we know that COVID disproportionately affects individuals with diabetes, hypertension and cardiovascular disease, so it’s compounding the insult and injury in those populations who are already experience health disparity and health inequity.
So, I’ll come back to the original question. What are my areas of interest in this year?
It is literally dealing with each of those large categories—and four or five others that are nearly equally as important. Just as the AMA has an extremely broad scope of activities, because the AMA can influence health care and the practice environment for physicians in so many ways, so does the WMA.
AMA: Physicians and their colleagues in health care are rightly hailed as heroes for fighting to save lives on the front lines of the COVID-19 pandemic. At the same time, there have been high-profile attacks on physician integrity and an undercurrent of mistrust in the medical profession’s response to COVID-19. Why do you think that’s happening?
Barbe: It’s been concerning—to many people—to see the recommendations of medical experts questioned over the last several months during this COVID-19 pandemic. The people need to try to decide who they’re going to believe.
If you don’t believe the medical experts, then what other information are you going to rely on other than speculation or conjecture?
There are two contributing factors to this, in my opinion. One, the science has been changing so rapidly that I think some patients and the public interpret that as uncertainty on the part of the medical community. When I’ve had the opportunity to talk to groups, I’ve indicated to them that this isn’t uncertainty. It is the rapid evolution of our understanding of this novel disease.
And I try to get them to compare it to the advances we have made in diabetes. I don’t treat diabetes the same way I treated it 10 years ago. We know a lot more about it. We know what things help. We know what complications one can get and what treatments can help avoid those.
The difference is those changes with diabetes care have played out over a decade. People expect me, as a doctor, to follow the best science and the best advice. They want to hear from me what’s the newest treatment for diabetes, what’s the newest thing I can do to avoid complications.
In contrast, with the COVID pandemic, what we understand about the disease, how it affects people and what the comorbidities are, has played out over weeks or, at the most, a few months.
When things change that fast, it has caused some people to see it less as “We’re learning more. We’re advancing the science. We want to give you the best advice,” versus “You don’t know what you’re doing. You’re uncertain, you told me this last month, now you’re telling me something different this month.”
That’s right—that’s because we know more this month than we did last month!
That’s one big area—the rapidity of change has been seen by some as uncertainty as opposed to letting the science lead us.
The second part, and we see this across other areas of society as well, is that some of this has been hijacked by the political climate. It depends on who is telling you something whether or not you believe it. It doesn’t have anything to do with the truth or the validity of the information. It has to do with the source of the information. ...
I think the political climate has made it worse and the rapidity of change has been difficult for everyone—physicians and the public—to manage.
AMA: You spoke about the importance of medical professionalism in your inauguration speech. Is that a way to counter this trend?
Dr. Barbe: Professionalism is extremely important. It is part of how physicians have maintained the credibility that they have had historically with the public. We have to rise above the politics.
We have to rise above, in some cases, our own personal feelings and, again, let the science lead us.
I may have formed an opinion of about whether, personally, I like to wear a mask or not. But when the science says: “Dave, you know everything points to the fact that masks help.” Then I, as a physician, need to be able to take that message to the public and, in fact, I have.
Now, I do personally believe that masks help, so that makes it easier. But professionals have a responsibility to put the patients’ interests first, ahead of their own opinion and beliefs, and serve the patient.
I think we do that best by following science—particularly in cases like this when things change. And I think we have to be professional to explain why things are changing. It isn’t because we misled you last month or because we were uncertain. It’s because we know more now.
I hope my patients expect me to keep up with the science and to give them the best advice on that particular day that I see them.
They have to trust me. And I have to earn their trust by keeping up with the science and by putting their interests ahead of my own.
That’s the way we stay credible. That’s why people trust their physicians.
AMA: Can you compare the missions of the AMA and WMA and the power of both to serve as conveners to bring people together to work on common problems?
Dr. Barbe: I see my transition into the presidency of the WMA as very easy because I see much of what the WMA does on a world or an international scale in what the AMA does on a national scale.
One of the AMA’s greatest strengths is its ability to bring together the House of Medicine to convene the state and specialty societies in a forum where we—as a profession—can come together and discuss, debate and develop policy around some of these very thorny issues facing health care.
The WMA does the same. It brings together representatives from the national medical societies of 115 countries to give them a forum to discuss these issues and how they impact countries, patients and physicians worldwide.
Just as in the United States, the issues that affect Florida are different from some of the issues that affect the state of Washington, the issues that affect the British Medical Association may be different than those that affect the Brazilian Medical Association.
We need those diverse perspectives to come to the table to discuss issues and the nuances about how they impact individual populations. It really is an extremely important forum for the exchange of health care-related information across a variety of domains.
To expand on that, the WMA is primarily that forum for discussion and the products of that are statements and declarations on a variety of issues that can then be used by the national medical associations and physicians in any given country to help advance good health care. The issues that we still need to improve here in the United States may be different than the issues they need to improve in Japan, and so the policies we use and take back may be different than those that they take home and use.
The WMA is a convener and policy resource for physicians around the world.
AMA: Tell our readers about your personal story, going from rural Missouri family physician to WMA president and how that has shaped your views on the role of physicians.
Dr. Barbe: The journey has been long. I’ve been in practice for 37 years. And I first began to move into some level of organized medicine leadership after I had only been in practice for about four years.
A practicing physician who had been a board member of the Missouri State Medical Association came to me and said, “I’m moving out of state. Would you be interested in taking the board seat for this part of Missouri?”
I had to tell him honestly that I never had even thought of it. I was only in independent practice four years and still trying to get my feet on the ground, but I said “Yeah, I will.”
Part of the reason I said “Yes” then—almost 40 years ago—was because I saw things then that were happening outside of the exam room that were significantly impacting how I was taking care of my patients. It wasn’t just me and the patient in the exam room.
It was these external factors—some of them related to insurance, some of them related to governmental policy—even back then. And it became clear to me that, if I was going to deliver the best care to my patients, I have to have an impact on these external activities to make a difference, so I became involved in the Missouri State Medical Association.
My approach to leadership—and I give this lecture frequently to medical students, residents and even physician groups—is that you have to show up, step up, develop, and then you lead. ...
I could do so much at the MSMA. I was able to do more at the AMA, and now I’m looking forward to having whatever influence I can have at the WMA level to do those same things: To have a greater influence on the environment of practice for physicians and the health care system for patients. ...
I’ll add that, as a family physician, I think my specialty has actually given me an advantage because family medicine is a specialty in breadth. I have to understand, not only clinically, something about cardiology, something about surgery and something about endocrinology.
But, in my interactions with those specialists, I see what they’re facing. Between my clinical specialty ... and my individual leadership in my health system and a large, multispecialty group, it has given me a unique perspective on the challenges that multiple specialists face. That’s allowed me to be a better spokesperson, I think, for all physicians.
AMA: This type of engagement is being seen as a public health function that physicians can serve. Do you agree?
Dr. Barbe: I think getting involved outside of one’s own practice is part of our giving back, and I think it is part of our professional responsibility to engage at local levels, to engage at state levels, for physicians to be the medical director for their health department in their hometowns, or to provide advice to their school system or city government. I’m frequently called by civic or business leaders to offer medical advice.
I think that serves the public health just as much as being the formal leader in an organization like the Missouri State Medical Association or the AMA where we can certainly have an impact and speak out with a stronger voice on public health issues, but I don’t think that relieves us as individual physicians to be involved in advocating for public health measures, speaking out against the disparities that we see, and participating at our own community level in addressing those problems.
