New AMA President Plans to Attack Dysfunction in Medicine: Expert Interview

Leslie Kane, MA, and Ellie Kincaid

November 01, 2019

Editor's note: Patrice Harris, MD, the new president of the American Medical Association, is the first black woman to hold that office. Harris is a child psychiatrist living in Atlanta, and has been active with the organization since residency; she was recently inaugurated and has held the office of president for about 3 months. Managing Editor Ellie Kincaid and Senior Director Leslie Kane, MA, spoke with Harris. This transcript has been edited for clarity.

Medscape: Thank you for joining us. In your year as president, what do you want to see the AMA accomplish?

Dr Patrice Harris

Patrice Harris: The AMA has three strategic priority areas. The first bucket is attacking the dysfunction in healthcare. We're working to reduce interference, regulation, legislation, any interference into the doctor–patient relationship, but also many of the administrative burdens, such as prior authorizations. And of course, underneath that area is certainly leading to burnout, which is a huge issue and an important area of work for the AMA.

The second issue is chronic disease, and our improving health outcomes priority. We decided to focus on two conditions: hypertension and pre-diabetes. We are working with physician practices to work with those patients who have high blood pressure and getting them to target. Part of that is measuring blood pressure accurately from the beginning.

And the third area big broad bucket is innovation.

We haven't had a lot of change in how we educate physicians over the last 50 years. We did offer 11 medical schools $1 million grants to stimulate innovation. And then we said, let's do the same for graduate medical education. So we just awarded $15 million in grants to graduate medical education partnerships, looking at the next phase.

The other issue is innovation in a broader sense, regarding technology. We want to make sure there's physician input into the development of this digital technology, unlike the debacle with electronic health record (EHR) with no physician input.

One other thing we're doing in that space is we what we call our Physician Innovation Network, where we match entrepreneurs and physicians.

Medscape: How are you going about progress on these initiatives?

Harris: The first thing we did was we funded and founded a company in Silicon Valley, Health 2047. The purpose of that is, the AMA and physicians know the pain points and the drivers of physician dissatisfaction, the burdens of interference in our ability to take care of patients. We can give that information to the developers, the innovators, the entrepreneurs, and they can work with us in partnership to, again, develop solutions.

We've had three spin-offs from that. The companies are still early in development, but one is related to our work in diabetes prevention. So we have one of our companies looking at providing diabetes prevention programs via your smartphone.

Another company is looking at the social determinants of health, such as transportation. How can we use transportation to perhaps plug those who have food insecurity [in] to places where they can get fresh fruits and vegetables and nutritious meals and so forth and so on?

Medscape: There is a lot of focus on environmental factors

Harris: Yes. They are very important determinants of health.

Also, each president brings their own unique lens and prism. And I'm very excited and honored to be the first African American woman president of the American Medical Association.

Medscape: You mentioned talking about burnout and the system dysfunction. We've been hearing a lot of dialogue lately about moral injury vs burnout.

Basically, talking about burnout implies that physician resilience is the problem, that physicians aren't resilient enough. But if you call it moral injury, that means that the system is broken, and it's the system that has to be fixed. Do you feel it is sort of an equal responsibility of the system and the physician or it's more one or the other?

We are focused on the systemic changes, because this is not about whether or not a physician is resilient or not. Dr Patrice Harris

Harris: I've heard that debate. And if folks want to use one term or another, that's a personal privilege. The point is important and what we are working on at the AMA, we are focused on the systemic changes, because this is not about whether or not a physician is resilient or not.

There's no question all of us should get enough sleep, and exercise, and eat right, and take care of ourselves. But that is not the reason for physician burnout. The reasons are mostly systemic issues. And that is where the AMA is focusing in our work.

Medscape: So let's say it's the system, what can be done? Because we've heard people say, 'Well tell your hospital administrators that they need to do this, and they need to do that.' But the reaction is, they're not going to do that. So how can the AMA change the system?

Harris: Well, I actually think systems are looking at this. The person that's helping us and partnering with us a lot on the research was at Mayo, and now at Stanford, and our CEO several years ago convened a meeting with seven of the largest systems. Systems are listening; they realize that when physicians are burned out, it potentially impacts patient care.

And even from the standpoint of physician turnover [and] physician absenteeism, let's say I am burned out. It costs the system a lot of money to replace me. Systems are realizing it. And I think, due in no small part, by the work of the AMA. The AMA commissioned a couple of studies, and identified that the two largest drivers of physician dissatisfaction are EHRs and prior authorization. So these are regulatory burdens.

Another huge issue is physician autonomy, and physicians' role and input in systems development and in these large systems. And then their overall bottom line is impacted if they are having to recruit, retain, and replace physicians who decide to leave for any reason, but particularly burnout, when that's something that the system could work on and try to prevent.

Medscape: That's good to hear. So let's switch gears for a second. In all of the large reports we do at Medscape, there don't seem to be women in the high-paying specialties. There are very few women urologists and surgeons, and mostly women are in primary care and OBGYN. What's your take on that?

Harris: There are many reasons that physicians ultimately choose their specialties. Unfortunately, some students make decisions based on the amount of student debt they have. But that being said, the AMA is hugely involved in gender equity and looking at all of these issues, and again, promoting gender equity in all specialties, but also at all levels.

The entire neurosurgery delegation is women. So I think just we're making progress, and we can see that. But certainly, there's a long way to go. There's a pay equity there. And I will tell you that there might be some generational differences. I see among more and more of the younger students that women are surgeons and orthopedic surgeons. So it could be you were right in the past, but as our profession has evolved, there are more women.

For many years, the conversation was around women leaders [being told] this is what you have to do. I received that advice, where you say: Don't cry. Don't laugh. Which is good advice, and well-meaning. Certainly that has evolved, which is good, over the years.

But now we are looking more at the system. Not just what do women have to do to advance, but what do systems have to do to make sure there are equitable opportunities to be in our specialty and to advance.

Medscape: We've seen the growth of nurse practitioners (NPs) and physician assistants (PAs). And sometimes, in our articles, there are complimentary comments to each other. But sometimes there's some conflict. How do you see that issue unfolding?

Harris: So from our perspective, PAs and NPs are an important part of the healthcare team. We believe in team-based care. But we are clear that we believe that the team-based care should be physician led.

And one of the reasons we believe that is because one of the current problems is fragmented care. And we really want to be careful about perpetuating any care that continues to be fragmented. So we do believe that [for] NPs, PAs, medical assistants, and there actually may be new members of the healthcare team that we need to look at.

We believe that physicians should lead the team, but let me just say the person who really leads the team is the patient. Dr Patrice Harris

But again, from our standpoint, we believe that physicians should lead the team, but let me just say the person who really leads the team is the patient. This is all about patient-centered care. We say patient-centered, physician-led teams.

Medscape: That's a good thing to keep in mind. Some people ask: Does the AMA represent the majority of physicians, or should it be doing something different?

Harris: I believe that the AMA does represent the views of most of the physicians in this country. I think the House of Delegates is a true asset of the AMA. So we have representatives from every state in every specialty come together twice a year and make policy.

Your number of delegates is based on the number of your AMA members. So the larger your population, the larger your delegates; that's the concept of the AMA. But then those representatives, about 500 or so, come together twice a year. And those folks come representing their states and specialties.

I would say if you look at the representation or the organizations that are represented in our house of delegates, we represent above 90% of the physicians in this country. One person could pick out one policy, and say, "I disagree with that." But that is how democracy works.

Everyone may not agree with every specific policy. But if you have a million physicians in this country, they're unlikely to agree with every specific policy.

Medscape: What other important trends do you see?

Harris: I think there are lots of opportunities to practice differently in different settings. Psychiatrists are using telemedicine. I use telemedicine. 

I live in Atlanta. I was working for an agency that takes care of children who have been in the foster care system. And there's a clinic about 60 miles north of Atlanta, in Cartersville, Georgia. They said, "Would you mind doing tele-psychiatry for our clinic in Cartersville?" What I ended up doing was I wanted to go to Cartersville, and again, easy for me to do, and see some of the patients first and then I would do most of the follow up by tele-psychiatry.

However, if someone asks me to see patients in North Dakota, I just can't get to my car and drive to North Dakota. But North Dakota doesn't have enough psychiatrists. So tele-psychiatry. So I think they are just expanding opportunities for psychiatrists as opposed to either/or. The issue is what the payers reimburse for service. So that is sometimes the rate-limiting step.

Medscape: Are you supporting Medicare for All, a big, big issue in elections?

Harris: We are opposed. The AMA is opposed to a single-payer system. We do believe the best path forward is to build upon the progress of the Affordable Care Act.

Medscape: What about surprise billing?

Harris: Let me say at the outset, and I think most everyone agrees, that the patient should be out of the middle of this debate. Then the question is: How do we come up with an equitable system that's transparent, that holds the insurers accountable? And that there are adequate networks, again.

The AMA believes that it is critical to have an independent dispute resolution process when there is a difference in what the insurer wants to pay and what the physician is charging. We absolutely believe that insurers should not set the rates, such as median in-network rates. It is critical, to be fair, in this marketplace, that physicians have the opportunity for fair negotiation. And with one side having all of the authority to set a fee, that really impairs the ability for physicians to have fair negotiations on what are appropriate and reasonable rates.

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