Thursday, May 14, 2009

Should ACP survey its members before taking controversial stands?

Health Affairs has been hosting an ongoing debate about the Patient Centered Medical Home, initiated by Caroline Poplin, MD, a fellow of the ACP. Dr. Poplin has been highly critical of the PCMH and ACP's support for the model. In a posting co-authored by me and my colleague, Michael Barr, MD, FACP, we tried to respond to Dr. Poplin's concerns. Dr. Poplin subsequently responded to our comments, and among other things, posed the following question:

"Finally, I have a question for the ACP. I have been a loyal member since I passed my Boards, and a Fellow for a good part of that. Why didn't the ACP canvass its membership, general internists in particular, before adopting such an important, controversial proposal?"

First, let me say that ACP values the loyalty of ACP members like Dr. Poplin, and we welcome debate about our positions (which is the main reason why I write this blog). I applaud Dr. Poplin for expressing her concerns about the PCMH, even though critical of ACP's positions.

But to her suggestion that ACP should canvass its membership before adopting positions on controversial issues ... well, we don't ... and I am glad of that. As any pollster would tell you, opinion polls provide some useful information, but cannot substitute for a deliberative discussion of policy options based on review of the evidence and considering the diverse views of those we represent.

The more complex an issue is, like the PCMH, the less reliable a canvass of opinion will be. Polls can be manipulated to tell the surveyor what they want to hear. For example, if ACP was to ask our members, "Would you like to be paid for the work involved in care coordination that you do outside of an office visit?" (one of the key attributes of the PCMH payment model advocated by ACP), I bet we would get a very positive response. If we were to ask the question, "Do you think primary care physician practices should have to go through an independent evaluation and qualification process in order to be paid more for care coordination?" I expect we would get a more negative reaction.

This does not mean that ACP does not care about its members' views; we wouldn't survive as a membership organization if we didn't.

Our policy process is designed to ensure that the diverse views of members are considered, but we also consider evidence from published sources and the views of non-physician experts. Everyone of our position papers, including the paper on the Patient-Centered Medical Home, is written and approved by ACP policy committees made up of internist-members; after first being reviewed by ACP's Board of Governors (elected state leaders); ACP's councils representing medical students, associates, young physicians, and subspecialists; and the Board of Regents. A position paper, like the one on the Patient-Centered Medical Home, usually takes up to a year before it is published, allowing many opportunities for views, including dissenting views, to be expressed.

ACP's policy process is our principal strength, making us different from most other membership organizations. The inclusiveness of our deliberations ensures that the positions reflect the wide range of views of ACP's membership, are respectful of those who have different opinions, take into account the views of others outside of ACP, and are supported by published evidence whenever possible. I don't believe our policies would have the same degree of respect among policymakers if they were based on membership opinion polls.

ACP also needs to be able to respond rapidly to changing legislative and policy developments, relying on our policy papers to the extent possible. This will especially be true over the next several months, as Congress works to meet President Obama's deadline of passing health care reform before the August recess. It will not be possible to canvass our members on every controversial issue before taking a position.

Finally, I doubt many of us would want President Obama or the U.S. Congress to make decisions by canvassing public opinion. We want them to do what they think is right for the country, taking into account polls but also considering the evidence on what actually will work and their own values and expertise. Would we expect anything less of ACP as it advocates for what it believes to be right for internal medicine?

Today's question: Do you think ACP should canvass its membership before taking positions on controversial issues?


Jay Larson MD said...

The problem with opinion polls is that the answer is yes or or white. It truth, we live in a very grey world. As Bob points out, the answer is dependent on how the question is phrased. A controversal issue is never black or white. Debating a controversial issue is the only way to explore the shades of grey.

Christopher M. Hughes, MD said...

I think it was Churchill who said, "The strongest argument against democracy is a five minute conversation with the average voter."

Anonymous said...

While learned analysis needs to take priority over popular stands on most things, it would not be unreasonable for the ACP to do what the Endocrine Society does and circulate an invitation to its members for comment on the proposed draft before committing and broadcasting the final position paper. The members who actually deal with patients, laboratories, insurance companies and sometimes hostile attorneys can offer a lot of insight that the people who write these position statements only have vicariously. The final position, though, has to depend on what the leadership of the organization decides.

rich the furrydoc

DrJHO7 said...

No. But, ACP has a mechanism in place for the voices of all 126,000 members to be heard, through communication with its chapters, their leadership, and ultimately through the board of governors, the committees of the college, and the board of regents. ACP regularly polls its governors for their input on policy papers and decisions, before they are published. The organization's leadership is accessible.
I loved the anecdote from Dr. Hughes. Res ipsa loquitor.

dawndawn said...

I can see that canvassing or opinion polls should not be used as a way to formulate a stand. However, I think that it is potentially very valuable to open up important questions to the general members in order to encourage dialogue and different viewpoints, therefore potentially deepening the discussion. Debate is also useful as a more engaging form of education.

I don't see the harm in allowing comments and discussion, whereas I do believe that a lack of such survey is undemocratic and potentially damaging.

Anonymous said...

Something as important as this should have been brought to the governor's who in turn could share it with their councils for comments. It seemed like a "done deal" to me by the time our governors got word of the legislation. While I agree that polling members is not practical, this discussion was certainly not held for public comment. In 1992 the ACP sided with Mrs. Clinton's healthcare proposal. When that collapsed the ACP was left with egg on its face and lost membership that we still have not recovered. I am afraid that history is about to repeat itself.

A. Ruben Caride, MD

Arvind said...

While "polling" may not be the best method, I don't believe Dr. Poplin actually suggested polling as a method to reach ACP Members.

As a dues collecting organisation, ACP, in my opinion, has a duty to represent its membership as accurately as possible, when it makes such a major proposal.

In addition, it is ACP's responsibility to make a fair effort to educate its membership about the pros and cons of its policy proposals and identify whether its own members are able and willing to make drastic changes in the short term in order to qualify as a Medical Home.

The ACP should have devoted significant time in the general sessions at the annual meeting to openly discuss/debate the PC-MH model. It could have, at the least, e-mailed a copy of the PC-MH proposal document to all attendees of the annual meeting, with time allocated for discussion during the meeting. Lack of openness does leads to doubts and suspicion among the membership.

Just saying "well, we don't" only fuels such sentiments. Can you, Bob, say what you mean by "we"? I understand that "we" means the general membership of the ACP. Perhaps you mean the bureaucratic leadership of the ACP. Would like a clarification, please.

BTW, being a native of a former British colony, I share the widespread sentiment that Churchill was a mean-spirited, heavy-handed so-called leader, who did not have the guts to admit his own mistakes. So its best to avoid his quotes.