Wednesday, February 1, 2012

A tip of my hat to ACP’s physician leadership

One of the things that I like most about my job is engaging with ACP’s physician leadership—the internal medicine doctors who dedicate enormous amounts of time, at great personal sacrifice, to represent the interests of our members and their patients.

One of the things that I like least is when an ACP member (or non-member physician) caustically dismisses their efforts, usually because they disagree with some aspects of ACP policy. It is one thing to disagree with ACP’s policies and priorities or to be frustrated with the pace of change, but it is another thing altogether to label your colleagues (whom you probably don’t even know) as being “out of touch” or “Ivory Tower” doctors! I can’t think of anything that is more insulting to physicians than a colleague implying that they aren’t “real” doctors taking care of real patients.

Why am I worked up about this today? Because yesterday I witnessed what ACP’s physician leadership do for ACP’s members and the enormous challenges and sacrifices involved. Yesterday, ACP’s president, Dr. Virginia Hood, and ACP’s chair of the Board of Regents, Dr. Yul Ejnes, came to Washington to join with the leaders of the other three largest national specialty societies to lobby Congress to end the cycle of Medicare payment cuts, once and for all. Along with the leaders of the American College of Surgeons, the American Osteopathic Association, and the American Academy of Family Physicians, they spent a grueling day meeting with 22 members of the House and Senate and their staffs to urge SGR repeal, paid for by money that has been budgeted—but will never be spent—on military operations in Iraq and Afghanistan.

What did this involve? Drs. Hood and Ejnes had to come in on Monday night, after a full day at their real jobs—being internal medicine physicians. To be here, they had to reschedule all of their Tuesday appointments, when I know that inconveniencing patients is the last thing they want to do. On their flights to DC and late in their hotel rooms, they had to read arcane explanations of how the Congressional Budget Office “scores” federal spending (not exactly what they learned in medical school!) They had to be at a 7:30 a.m. breakfast on Tuesday to meet their counterparts from the other participating societies and to be briefed in advance of the Hill meetings. Then, they spent the rest of the day being directed around Capitol Hill to their respective meetings, one after another, all day long.

And the Hill meetings themselves were hardly a walk in the park. Yes, some of the members of Congress and their staff welcomed them enthusiastically and indicated support for their request. Others listened politely but didn’t commit. Others were at best skeptical. Some lectured the doctors and tried to get them to choose sides in the partisan fight over health reform. A few were even dismissive or hostile.

What did they accomplish? Lobbying is a slog, and we won’t know for a few more weeks what Congress is going to do about the SGR. But we know that the good doctors accomplished one very big thing: they showed Congress that the four largest national physician specialty organizations, representing more than half a million doctors, speak with one voice on the need to repeal the SGR. And by taking the time to come to Washington, they showed Congress how deeply they care about patients and their profession—as only real doctors who take care of real patients could do.

So I hope that next time you know of someone who is tempted to blast ACP’s leadership as being out of touch, remind them of this: ACP’s leaders are just like them, except that they have chosen to dedicate a substantial portion of their professional lives to organizational efforts to make things better for their colleagues and their patients.

And by doing so, they are living up to Alexis de Tocqueville’s famous 1831 observation that:

“Americans of all ages, all conditions, all minds constantly unite. Not only do they have commercial and industrial associations in which all take part, but they also have a thousand other kinds: religious, moral, grave, futile, very general and very particular, immense and very small; Americans use associations to give fêtes, to found seminaries, to build inns, to raise churches, to distribute books, to send missionaries to the antipodes; in this manner they create hospitals, prisons, schools. Finally, if it is a question of bringing to light a truth or developing a sentiment with the support of a great example, they associate.”

Yesterday, Drs. Hood and Ejnes came to Washington to unite with other physicians to bring light to a truth and develop a sentiment in Congress to end Medicare cuts, using their own great example as internal medicine physician specialists who care deeply about their patients. I tip my hat to them. They would have made de Tocqueville proud.

Today’s question: What do you think of my view that it is simply wrong for physicians to dismissively label the leaders of ACP (and other professional associations) as being “out of touch” and “Ivory Tower” doctors (no matter what you think of the organizations’ policies)—when in fact they are real doctors, taking care of real patients, who have chosen to live up to de Tocqueville’s perhaps idealized view of America?


Doc99 said...

I would suggest to ALL leadership that they refrain from using the term "doc fix." It's NOT a doc fix. It's a Patient Fix.

ryanjo said...

I hope I have never said that the ACP leadership wasn't hard working. However, I don't think that their direction in the health care debate is correct.

ACP is too set on convincing a dysfunctional government to mend its ways, which the past several years has convinced me is not possible. While I realize that the attitude of our ACP leadership is to promote the "good" in the laws that have been put in place, and keep banging away at the defects, the success rate on SGR and other payment reforms, bureaucratic reduction, and liability reform is negligible. Moreover, as a result of ACP overall supporting the ACA despite its flaws, it appears (and many of my patients have voiced this) that ACP supports the Obama administration's efforts. (Sorry, Bob, but nobody outside the Beltway understands the distinctions ACP placed on its support.) The ACA is widely felt to accelerate the decline in private practice set in motion by prior government tweaks to the healthcare system and general deference to an aggressive insurance industry, sometimes with tacit ACP approval. Everyone out here in the rest of the country is saying "what were they thinking?"

Forget about the idiots in office now. They will stick to their guns until they pack their bags next January. The common emotion in the electorate, patients and physicians alike, is fear and rage. Emotions that will upend the present political structure and result in more years of turmoil.

To avoid becoming irrelevant, I would love to have ACP & AMA simply state that the government is not fit to manage the healthcare system. Which means immediately acting, legislatively or judicially, to eliminate the "par"/"non-par" system of the insurance industry and Medicare/aid that makes physicians slaves to accountants and government drones.

As a first step it would give us back our dignity, and we could answer again to our patients and our principles, instead of a prior approval clerk in a call center, a hospital employer or a "meaningful use" checkbox.

djeffersmd said...

I am in agreement with ryanjo. I personally participated in the lobbying effort with congress, and I came away with the impression that the whole effort was a complete waste of time. The physician organizations have been committed to repealing the SGR, and have so far failed miserably. The SGR serves a very important purpose for the members of congress, which is that it demonstrates on a daily basis that physicians are completely dependent on the members of congress for survival. This is exactly the feeling that congress wants to engender, so they have absolutely no motivation to ever change the system. Having all the leaders of national physician groups rushing to Washington to beg members of congress to change the reimbursement system is exactly what the members of congress. If the leaders of the ACP were meaningfully engaged in activities to restore dignity to internists, and to rationalize the reimbursement system, I too would be more than happy to tip my hat to them.

Steve Lucas said...

I would first like to thank Doc99 for remembering the patient in all of this; we are often overlooked when talking about reforming the payment system. Being fair I also have to acknowledge patients who want all of the “free” medicine they can get not caring who pays the bill, including their doctor.

I also have a minor issue with ryanjoe’s comment. The AMA and other advocacy groups, such as AARP, have such a vested financial interest in maintaining the status quo that they will only appear to be interested in reform so as to maintain a place at the table and search for additional financial gain. The enemy of my enemy may be my friend, but beware of Snakes in Suits.

The AMA controls the RUC, and the associated sales of the related computer codes, and AARP makes hundreds of millions of dollars per year selling insurance.

djeffersmd’s experience mirrors the feeling many of us have about the Washington establishment; they are only interested if there is some personal gain. We have reached a sad political state where the only interest is self interest.

Steve Lucas

Harrison said...

I'm one of 3 partners in a small practice. My income is pretty easy to figure out -- Revenues minus expenses in real dollars. Month to month my income goes up and down. February (for whatever reason) is really looking bad this year by the way -- based on January's revenues.
I am very much in touch with the day to day vagaries of an internal medicine practice.

But I can see myself advocating for policies nationally that don't necessarily reflect self interest, and I would understand it if someone were to label those things as out of touch.

So I don't think it is all that bad to use the Ivory Tower and Out of Touch stuff rhetorically.
I know who I am and I can usually understand my positions. I also try to understand opposing positions, or positions that are in some degree different than my own. I even occasionally concede that I am wrong.

What isn't fair is to argue without substance about the principled, well considered, and well documented positions that are taken by the ACP and that In Touch and Out of Touch physicians alike may agree with.

And I think it is truly admirable that physicians like Dr. Hood and Dr. Ejnes take time and sacrifice income for important principles and positions.


Arvind said...

Bob, yet again you try your best to divide the doctors. While the efforts of the ACP leadership is notable, the whole concept that they are trying to lobby for is wrong. Perhaps they could have made this point more forcefully before the ACA was passed. Aren't we crying over spilt milk?

Just to refute your idea that those that criticize the ACP leadership are just sitting on their hands, let me give you the real story. Despite being a solo practitioner, I have traveled to DC 3 times in the past 18 months, not to lobby, but to present positive ideas from physicians in independent practice (not university-based ones, to Congressmen/women. I have done this at my own cost and time. So please stop patronizing those of us that disagree with the ACP leadership. It time for reflection on your false accusations, Bob.

BDoherty said...

My hope, in writing this blog, is to encourage spirited dialogue and civil debate. I get uneasy, though, when the comments label other people's opinions as "wrong"--as if there is no other side of the argument, no other points of view to consider? I may not always succeed in doing this, but I try to understand the views of those that have an different take on things than I do, or that ACP does. For instance, I don't think someone is "wrong" to oppose the Affordable Care Act and to call for its repeal, although I disagree with them. For the most part, those who advocate repeal of the ACA are doing so because they sincerely believe we can't afford it, will endanger private practice, and gives the government too much control. I disagree with them--and welcome the debate and will try to persuade readers to my point of view--but that is different than saying that they are "wrong" to express those views. I would hope that the opponents of the ACA would allow that most of the supporters of the law believe that it is a reasonable and pragmatic approach to expanding health insurance coverage and improving access to millions of patients, and even though you disagree with our point of view, it doesn't mean we are "wrong" to express those views.

The point of this particular post is that some of the criticisms directed at ACP's leadership have,in my mind, crossed a line that I believe shouldn't be crossed. They have been called out of touch, of not representing ACP members in the real world (even though they live and practice in that same real world) of being elitist. Comments that suggest that that the views and experience of ACP members and leaders who are teaching the next generation of doctors (while also taking care of patients) are someone less legitimate than those in private practice. Calls for "all" of the leaders of physician membership societies to resign.

These divisions are real, and they come from the ranks of physicians themselves, including within the ranks of ACP membership.

I welcome a civil debate over ACP's policies. Second-guessing of our policies and strategies goes with the game, and is a good thing. It is something that we on the ACP governmental affairs staff, and in the ACP leadership. do all of the time. We are always looking for better ways to achieve the organization's objectives. But remember that ACP's policies are determined by the members of ACP who have opted to become involved in the policy development process. We may not always get it right, but for the most part, I think ACP's Board of Regents, Board of Governors, Councils and Committee members, themselves constituting an amazingly diverse group of internists and medical student members from all walks of internal medicine careers, from all political perspectives, do a terrific job in developing principled, evidence-based and consensus positions that represents the best of the profession and patient care. And they sacrifice an enormous amount of time to participate in ACP. They deserve respect,and yes, respectful disagreement when you think they got it wrong.

Arvind said...

Bob, you have what seems a rational explanation of your motives. But you insistence that calling the actions of ACP leaders "wrong" is bad, is incorrect.

The "wrong" part is when these ACP leaders perpetuate the myth that they represent "110,000 Internist members of the ACP" because they do not. So in fact when you as the ACP spokesman, make such proclamations, you are "wrong". The more accurate fact would be to propose a particular ACP Policy Paper, along with an admission that a certain % of dues-paying members oppose it.

As far as those leaders who teach and also practice clinical medicine, the reality is that they do not represent those of us that actually provide care for the larger community. So indeed such folks are "elitist and out of touch" with those in the trenches. No matter how you try, you cannot hide this reality. It is best you accept the truth and modify the organization to make it more representative of its membership.

Harrison said...

You would have the ACP put "percent approval" on policy papers?
What kind of an organizational statement is that?
If we have to do that then we shouldn't have the policy statements at all.

Members of an organization get to decide whether to continue being members.
They can decide on the basis of many things: Political disagreements; lack of adequate membership benefits; lack of enough money to keep paying dues; etc....

But the organization has to be able to voice opinions for the organization -- and individual members get to decide whether to continue to be in an organization that makes such statements or takes on such policies.

I can promise that I would cease to be a member if this organization were to suddenly start claiming that the health care system that we have is perfect and is not in any need of change.


Arvind said...

Nothing wrong with being honest, Harrison. I realize that it may make you uncomfortable. I would like to effect change from within an organization rather than walk away from it. Of course, I wouldn't try if is was a hopeless cause like the AMA.

Harrison said...

I agree with dissent.
I love it that you voice dissent for the ACP positions.
But I think the honest way to do it is here in this forum, or emails to the leaders, or running for positions in the organization and sitting at the table when policy is hashed out -- so you then have to win the argument against those who would not share your opinion but who are part of the same organization.

Arguing for a popularity rating to be published on the statements that come from the organization would weaken the positions.
They would weaken all of our positions, and effectively take us out of the political debate.

We have to have a voice together.
It is already a weak voice because we don't 'pay to play' like other professional groups and trade groups.
Our PAC is pretty anemically funded.
We won't have a voice at all if we start airing our internal debates in public.


ryanjo said...

ACP policy papers are not expressions of the membership, not even a minority. They are developed by the "thought leadership" at the top levels of ACP. Have you ever seen a draft of these documents? Or been asked to comment on them? I get a lot of correspondence from ACP (mostly ads for products & services), but nothing that would allow me to engage in the policy formulation. Oh -- I should give more time to the organization? All well and good for the large groups and specialists, but the people who ACP has abandoned, the small groups and solo primary care MDs, already face economic extinction. More meetings and travel aren't an option. Not surprisingly, the ACA that ACP fondly supported is predicted (in the Annals last year) to eliminate those of us who can't make the cut anyway.

If you want an example of how ACP formulates policies, read ACP's Ethics Manual spurs debate about costs of health care in the ACP Internist Blog today (Feb 14th). As Stephen Kirsch FACP relates, the ACP Ethics manual has been subtly altered, from physician being the advocate for our patient alone, to advocating for "efficient health care". Admirable concept, but those of us who weren't at the committee meeting might have pointed out the dilemma of efficiency (as defined by government & industry) may result in our patient receiving less prompt or less expensive care, "efficiently". As if anyone knows how to make that call correctly.

Did any of the members who post here hear about this before the change was made?

Well said, Arvind!