AMA Focuses on Graduate Education Requirements

Fifteen physicians represented the MSMA Delegation to the 2011 AMA Annual Meeting in Chicago June 18–22, 2011, and did some extraordinary work on your behalf. From the caucus meetings to the reference committees to the floor of the House of Delegates, your interests were represented admirably.

MSMA is proud to report that David Barbe, MD, Family Physician from Mountain Grove, was elected Secretary of the AMA’s Board of Trustees during this meeting.

Kathleed Doo, a fifth-year student at the University of Missouri-Kansas City School of Medicine, was chosen by the President of the AMA to serve as the student representative on the Council on Medical Education. That is the Council which develops policies for the House of Delegates on Medical School, graduate medical education, and continuing medical education.

The House addressed a large number of items of concern to our patients and physicians in practice. Of necessity, we will be reviewing only a limited number of the issues we addressed; those which we feel are most important.

Missouri Physicians wait for the AMA House of Delegates to begin. Front row: Drs. Jim Conant and Rebecca Hierholzer; and back row: UMKC Medical Student Ryan Meintz, and Drs. Ted Groshong, and Ed Cabbabe.

The House of Delegates directed its attention to a number of issues regarding education. This is a substantial concern of the Committee on Medical Education. The House debated the Maintenance of Certification (MOC) and the increasing burden we are facing with multiple, very expensive and time consuming requirements. Physicians of one specialty are pretty concerned, but those in subspecialties are being overwhelmed. Some of the Delegates indicated they had to take as many as four or five MOC exams in order to cover all of their activities. Additionally, in many states, there are threats to link maintenance of licensure with Maintenance of Certification. This will create an enormous problem for those who are not Board Certified, and a continuing expense for those who are. The House sent a request to the Board of Trustees to urgently develop a strategy for our AMA.

We continue to be concerned about the fact that there are increasing graduates of medical school, but insignificant increases in GME positions. This year there were a number of US medical school graduates who were unable to obtain residencies, not only causing them to be without training opportunities for the coming year, but causing huge problems with their debt.

That in itself is a large problem for young physicians, and the AMA is working on innovative methods to help our recent graduates.

Other topics included the possible certification of for-profit medical schools, a plea to stabilize requirements of resident work hours, and increasing opportunities for the International Medical Graduates, who constitute 25% of our physician workforce.

Your AMA House of Delegates addressed a large number of issues pertaining to legislative affairs, including several reports from the Board of Trustees (BOT). The BOT report on the current medical tort system was issued in response to resolution action of the HOD at the 2010 Annual Meeting, and reaffirmed AMA’s commitment to vigorously advocating for medical liability reform.

The House of Delegates adopted a report on marriage equity – which was issued in response to three resolutions adopted at the 2010 Annual Meeting calling for the AMA to seek repeal of the Defense of Marriage Act (DOMA), and support for ending the exclusion of same-sex couples from civil marriage. The arguments in support were to reduce health care disparities affecting these individuals, their families, and their children. Opposition stemmed mainly from the religious interpretation of the definition of “marriage.”

Among the important resolutions discussed, and ultimately adopted, was a resolution calling for the AMA to advocate for reform of the many deficiencies within the Patient Protection and Affordable Care Act (PPACA), including, but not limited to: repeal of the Independent Payment Advisory Board (IPAB), enactment of comprehensive medical liability reform, Medicare payment reform, and antitrust reform.

The House of Delegates also debated a resolution calling for our AMA to oppose conversion of Medicaid to a block-grant program. This resolution was referred for further study after some amendments were offered, given the reliance of some states with large Medicaid populations – particularly children – on federal block-grants to supplement this program.

Antitrust relief for physicians, expert witness requirements, scope of practice of pharmacists, and Government interference in physician-patient relationship by restricting the content of communication between the physician and the patient, were also important resolutions discussed at the reference committee hearing, and adopted as policy by the House of Delegates.

For the Reference Committee on Science and Public Health, something new was done. There was a virtual committee session for about a month before the AMA meeting, which could be accessed through the AMA website. A great deal of commentary was received from the general membership of our AMA prior to the meeting, and a draft report was drawn up before the reference committee meeting. In consequence, discussions in the committee were short and to the point, without the customary parade of people coming to the microphone to put their caucus, state, or organization on record. The session was over in 90 minutes, and the committee’s report was accepted without any discussion by the House of Delegates. This is the second time the AMA has used this model, and we can hope it becomes standard in the future. A resolution calling for the AMA to cooperate with other organizations to analyze and alleviate the national drug shortages was referred to the Board. Hopefully, the Board will take action, and the Council on Science and Public Health will report back. There were two resolutions which asked for labeling of food with genetically engineered ingredients, which was referred to the Council. There was some question about the value of this action.

There were also resolutions which called for analysis of any adverse health effects from backscatter x-ray scanners used in airports. Physicians who offered testimony basically said that there aren’t any backscatter. A medical physics organization is presently conducting trials. The Council will no doubt enlist their findings in a report next year. Adopted were resolutions recognizing the impact of sickle cell disease, controlling mercury emissions from cement plants, reducing the prevalence of nickel-induced dermatitis in the US, making “bath salts” (methylenedioxypyrovalerone) illegal under Schedule I, and making epinephrine auto-injectors safer.

Reference Committee G had a primary emphasis on issues related to electronic records, fair payment for physician services related to outpatient care, and safe interfacing and transfer of physician’s care in the outpatient setting, to nursing homes and hospitals. A resolution which originated from the Missouri Delegation was adopted. It emphasized incentivizing primary care through physician offices and “physician” directed medical homes. A resolution was adopted to urge the AMA work for fair and equal payment for office based surgical procedures, comparable to other outpatient settings, i.e. hospital and ambulatory surgery centers.

An important resolution for all members of a medical staff was supported, but the House of Delegates, which asserted that a physician has the right to exercise one’s own best judgment when in issues regarding medical staff affairs, regardless of the physician’s employment status.

The Board of Trustees addressed the issue of compatibility of various electronic medical records programs. The ability to access this information would be very helpful for physicians and patients when seen at different facilities.

There was considerable discussion about the many burdens placed on physicians by pre-authorization for commonly used medications, especially when clearly supported in peer-reviewed medical journals. It is necessary that well qualified individuals in the appropriate specialty judge of whether pre-authorization is necessary. Additionally, the name, title, educational level of the individual the physician has to contact should be available. As there is current AMA policy in this regard, it was reaffirmed.

The House of Delegates (HOD) adopted the Report on Financial Relationships between CME and industry from the Council on Ethical and Judicial Affairs (CEJA). This report was in its fifth iteration. This statement urged that any presentation in which there is financial support from industry be clearly noted, that any presenter for CME activities also clearly disclose the relationship, and that presenters with ties to industry only be used when it is central to the subject, and when there is not a suitable alternative. Additional CEJA reports that were adopted included recommendations to be good stewards of scarce resources, and the use of stem cells.

Jay Gregory, MD, Oklahoma Delegate, a member of the Heart of America Caucus (of which Missouri is a part), Chairman of the Organized Medical Staff Section, and an employed physician, was appalled that his new contract discouraged him from patient advocacy, as well as advocacy on behalf of physicians and his community. He authored a resolution regarding this right, and by extracting it from the consent calendar, was able to gain HOD understanding of this serious threat to our profession.

The House also approved a report from the Committee on Constitution and Bylaws that addressed the issue of development of practice guidelines. We have been seeing a lot of them, and are guaranteed to see more in the future. The Committee was particularly concerned about financial conflicts among panel members, and the use of scientifically derived recommendations.

The HOD supported resolutions on Science and the Public Health the urged improved nutrition for children. The use of toys to encourage the purchase of high calorie foods, when in fact these foods are generally a lot less expensive than healthier children’s foods, was addressed. Additionally, it was urged that there be increased attention to physical education for children. Proposals for taxation of sweetened drinks was discussed, but deferred. Additional actions of the House considered support for state physician health programs, new recommendations for fluoridation of water as recently proposed by the Department of Health and Human Services, and improved nutrition for pregnant women.

The House agreed to support the maintenance of the current dues structure, and not freeze the composition of the House of Delegates. The request to do so has been discussed on numerous occasions. States, such as our own, which have lost AMA members, are at risk for losing Delegates, reducing our influence on the organization. However, the House strongly defeated any measure to freeze the current composition of the HOD. A proposal to record all votes of the individual members of the Board of Trustees was also defeated, as it was felt that this would inhibit members from voting their conscience. They agreed that the Board report with unanimity. The House also addressed the compensation for Leadership of the AMA, reviewed an outside reviewer’s recommendation, and adjusted the compensation for the students. Finally, the House condemned efforts by state governments to interfere with the right of physicians to counsel their patients, an action which resulted from a law in Florida which made it illegal for pediatricians, engaged in anticipatory guidance for children, from asking if there were guns in the home.

The AMA Council on Medical Services deals with issues that affect the practice of medicine, as does Reference Committee A. One issue which tended to dominate this was the federal mandate from the ACA which requires all Americans to have health insurance by 2014. Impassioned testimony was heard in the reference committee for over three hours from physicians on both sides of the issue. Delegates from Massachusetts discussed their five-year-old program, which has resulted in 98% of the population insured. Proponents of individual freedom felt that a national system of this type would be too costly, not enforceable, and less applicable to states with a large Medicaid population. After considerable, equally impassioned debate, the HOD voted to uphold the current AMA policy supporting a national insurance mandate for all by a vote of over 60%.

These were just a few of the actions of our AMA. We encourage our MSMA members to review all of the actions of the House of Delegates at www.ama-assn.org.