James L. Madara, MD, address at the 2023 Annual Meeting of the HOD

In his address at the American Medical Association (AMA) 2023 Annual Meeting of House of Delegates, AMA CEO James L. Madara, MD, talks about how the physicians’ unified voice is essential. Download the complete transcript (PDF).

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Dr. Speaker, members of the board, delegates, and guests … 

The Internal Revenue Service classifies us as a membership organization—now, how’s that for an exciting opening line!

AMA membership grew 11 of the last 12 years and our market share increased as well.

But we’re not solely defined by that.

The AMA engages physicians in multiple ways ... more like an equation.

The components of that AMA equation include not only membership, but the resources we create, our business products, our research and education activities, our state and federal advocacy, legal actions to improve the health of our nation, and finally, the work of this House of Delegates.

The House is a vital component of that AMA equation, with policy being your product. The vast majority of physicians belong to one or more of the societies of this House. I belong to three. Thus, by definition, most physicians are represented here in this room.

That connection conveys something specific to many, particularly those in Washington D.C.  It conveys that AMA policies provide the clearest surrogate of the net of physician voice.

Having said that, there’s another fact to wrestle with.

Although physicians love democratic debate, we also highly value our independence of thought. We are protective of our individual agency.

Can we all agree on that: the duality of attractiveness of democratic debate coupled with fierce independence?

What results from that duality? Just because a policy is adopted by a 60-40 margin doesn’t mean that those 40 percent voting against it are now perfectly—or even generally—aligned with that policy.

I suspect many of those voting against an adopted policy continue to think that policy is flawed. Personal agency is valued even when contrarian to the majority.

I experienced that tension on entering the AMA as CEO, 12 years ago.

When asked about a health issue, I had to recognize that the answer to such questions was simply: “AMA policy states X and Y.” That answer is specifically responsive to the question of “what do physicians, broadly considered, think about this topic?”

This habit of deference to our policy also aligns with what sociologists refer to as “the wisdom of the crowd.” Group decisions do arc toward wisdom.

That tension between agency and democracy is amplified in our current environment, an environment of tension around social conflicts of the day.

A few weeks ago, I learned of a physician who had been a member of the AMA for 43 years ... and now he was cancelling his membership. Curious about why, I gave him a call.

We had a warm chat; at the end he offered to treat me to lunch.

He enjoyed our products, the viewpoints in JAMA, and how we effectively advocated on his behalf of him and his patients.

We discussed how the AMA fights for the sanctity, privacy, and freedom of the patient-physician relationship. He appreciated all of that, but still thought he would cancel his membership.

So, since he believed he received value from his membership, why was he still inclined to end it after 40 years?

It boiled down to this: Regardless of the various benefits and alignments, his decision hung on a strong objection to one, I repeat, ONE, specific policy.

To me this seemed a bit unreasonable—unreasonable in the sense of his agency being so narrowly vested in a single issue. But, who knows, I suppose I might get cantankerous in my later years as well.

The reason I share this physician’s story is because, increasingly, our national environment tilts toward defining our individual stance, by where we differ instead of where we agree.

That’s particularly true around issues involving race, gender, reproductive rights, religious beliefs, all which can lean toward absolutist disagreements given that focus on differences rather than commonalities.

There’re no shortage of hot-button issues taken on by this House. You debate and discuss firearm violence, reproductive health, vaccine science, gender-affirming care, the consequences of structural racism, and other topics.

The result of these debates are House policies some of which lead to the creation of new programs and initiatives such as the AMA Center for Health Equity, important work that now extends to the newly launched Truth, Reconciliation, Healing and Transformation Task Force which was requested by this House. This is a Task Force composed of nationally recognized leaders, which will advise the AMA Board.

You can learn more about this task force at Sunday’s Heath Equity Open Forum. 

In arriving at policies on challenging topics, one might take the approach of technology forecaster Paul Saffo. And that is to formulate “strong opinions, weakly held.” “Strong opinions weakly held” at first sounds an oxymoron, but consider the intent. 

A strong opinion is such because it’s based on the best available evidence. But the strong opinion is weakly held in the sense that should new evidence come along that supersedes that of the past, one should be willing to modify opinion. That’s to say, we should be willing to adjust our opinion to best fit current evidence rather than holding tightly to views based on legacy environments.

If you agree that our macro-environment nudges toward conflict and that conflict is heightened if strong legacy opinions are allowed to trump new evidence, then one tonic for this dilemma might be a willingness to forgo narrow definitions of personal agency …

… to consider our agency as a balance instead of a narrow set of non-negotiable must-haves …

… to be satisfied with a 70-30 personal portfolio of policy outcomes rather than either a thirst for 100-0 or push all one’s agency cards to the table based on a single policy or two …

…  to support the wisdom of the crowd as a means of moving forward the needs of patients and physicians—and doing so respecting the majority.

If just a few on the 40 percent side of any policy vote would do that, the effect could amplify cooperation. A study in the Proceedings of the National Academy shows exactly that.  Cooperative behavior by one person tends to cascade through social networks.

Unfortunately, uncooperative behaviors also cascade.

APCO Worldwide, a strategic communications firm, releases an annual branding study of 50 impactful associations representing all industries, and the AMA represents physicians within the six-member health care group.

The other five in this group include major associations representing hospitals, payors, biotech, insurers, or the pharmaceutical industry.

The AMA routinely does well in comparison to these other associations, and one strong key performance indicator is “unified voice of the profession.” We can be stronger and yet more effective if we are willing—even if only to a degree—to accede to the wisdom of the crowd, that is, to nudge ourselves to embrace, or at least not actively resist, the resulting votes of this House; doing so as a “tip of the cap” to the overall wisdom of physicians.

Typically, in my comments to the House, I highlight advances in our strategic framework.

My intent here was different. It was to focus on culture, particularly given our current national discourse that can feel like a pie-in-the-face is a reasonable form of debate.

It is also likely that the pandemic, particularly in the early going, concentrated attention and helped unify our voice. Let’s not take such progress toward unity and throw it out with the pandemic bathwater.

We would do well by gently sculpting our agency to allow greater cooperation ... acceding to the wisdom of the crowd when it comes to policy—doing so to make this powerful convening association even more impactful as we “promote the art and science of medicine and the betterment of public health.”

And that, my friends, is more thought-provoking than any IRS classification.

Thank you and have a great meeting.