Texas' delegation to the American Medical Association has a reputation.
Ask Nancy Dickey, MD, president emeritus of the Texas A&M Health Science Center – and AMA's 152nd president.
“Strong,” she told Texas Medicine. “Strong as a presence. Not just strong, but strong leadership.”
In fact, by her estimation, if Texas isn’t the state with the most AMA past presidents, it’s likely within the top three. And the roles surrounding the AMA presidency are often filled by Texas physicians, too. Over the years, a Texas physician on any given AMA council or committee has been a common fixture.
But this year marks the first in decades without a Texas physician on AMA’s Board of Trustees – cause for worry for many. That includes Susan R. Bailey, MD, an allergist-immunologist in Fort Worth and AMA’s 2021-22 president.
“That concerns me greatly because right now, Texas does not have a voice at the highest level of the AMA,” she said. It’s also one of few states not to caucus with others to strengthen its election odds, she added, which “gets tougher and tougher to do as some of the other caucuses get bigger and bigger.”
TMA does, however, benefit from other advantages. For one, TMA’s House of Delegates is nearly as big and complex as AMA’s.
For Dr. Bailey, who was speaker of the TMA house before she became AMA speaker, that meant, “I knew how things worked; I knew how to get things done. My leadership path through the TMA was incredible leadership training for the AMA.”
And Texas’ git-er-done approach has been known to garner national attention.
When, in the late 1980s, the U.S. Health and Human Services Department Office of Inspector General started kicking physicians out of Medicare without providing due process, TMA formed its Patient-Physician Advocacy Committee – a peer review committee of sorts that to this day advises on regulatory, legislative, and legal matters involving the standard of care – which helped secure reforms.
“We didn’t just sit here and complain about the Medicare review process. [We asked ourselves] what can we do to fix it?” said Dr. Dickey, the committee’s first chair. “I think that helps drive things at the AMA. They say, ‘Oh, wait a minute. What can we do that’s kind of like that?’
“We get things done. We do have a strong state organization. We do things that other states either don’t do or do to a less aggressive degree. We encourage strong relationships with our elected officials both in the state and the ones that we’re sending to Washington. We also understand politics, and so we use the representational process of the House of Delegates very effectively.”
On the other hand, past TMA President Jim Rohack, MD, a cardiologist who formerly practiced in Temple and AMA’s 2009-10 president, felt strongly: “I had to be involved at the national level because that’s where the game is. That’s where the standards are being set.”
A long road
The road to AMA leadership is already a challenging one, often spanning decades. Member physicians typically work their way up from delegate into councils and committees, up into speaker and chair positions, into the Board of Trustees, and finally, with enough hard work and luck, to AMA president.
While the machinations of organized medicine can often feel rigid and linear, physicians aren’t bound to them to find fulfillment from AMA. When Dr. Dickey joined AMA, for instance, she had no intention of becoming president.
It was the late 1970s, and news had just broken: AMA would now have students and residents on all its policy-making councils. The American Academy of Family Physicians wanted resident candidates; Dr. Dickey wanted to soak in life as a mom and physician.
“I said, look, I’ve got a six-month-old baby. I am doing what I’ve always wanted to do. My life is pretty good. Go ask somebody else,” she recalled. But lured by the promise of a free trip to San Francisco, she decided to “see what AMA is about ... and help a friend who needed candidate names.”
Between an “impressive” meeting and a no-show opponent on the ballot, Dr. Dickey was elected to her first AMA role, and thrown into what she calls a “riveting” first two years.
“We were talking about these new things called HMOs,” she recalled. “We were talking about having to change insurance coverage. Everything about how I would practice, other than the science of medicine, was right here in front of [me] with exceptional physician leaders who had been engaged in these topics for most of their life. It was a pretty heavy experience.”
Dr. Bailey was also “hooked” after her very first meeting.
“After going to my first TMA meeting at the end of my freshman year, I got elected to represent the MSS [Medical Student Section] at the AMA.”
Dr. Rohack also started representing his peers at AMA early on as a resident, first in medical education, and as his professional experience expanded, in financing and health care delivery.
It wasn’t an accident that Dr. Rohack sought to work on the latter. Through his residency and beyond, whether in El Paso, Galveston, or College Station, over and over, he saw patients bear significant and preventable illnesses because they couldn’t afford health insurance or weren’t offered it through employment, or their insurance denied coverage.
“There was a need,” Dr. Rohack said. “Organized medicine needed to be at the table and needed to have an influence to make sure that insurance companies that were making profits by not giving health care or not paying doctors for health care – they needed to be reined in.
“It was clear the Texas Legislature wasn’t interested in doing anything to expand health insurance so that all Texans would have coverage. This had to be a federal fix.”
Gaps in understanding
That national solution became the Affordable Care Act, for which Dr. Rohack became organized medicine’s face as then-AMA president. TMA, however, opposed the legislation.
Drs. Bailey, Dickey, and Rohack all acknowledge the bill’s passage damaged Texas physicians’ allegiance to AMA.
Letters from physicians flooded Dr. Rohack’s inbox, announcing their departure from AMA over the issue.
“Certainly, [AMA’s] involvement in the Affordable Care Act cost some memberships, but their failure to be involved in that would have cost memberships, too,” Dr. Dickey said.
Nor is the legislation the be-all and end-all of AMA’s work, which includes fighting for better pay and against needless prior authorization, Dr. Rohack says.
Indeed, AMA’s size and the range of issues it covers may work to its disadvantage when it comes to presenting a united front.
“The AMA is so big and does so many different things that physicians and students aren’t aware of,” Dr. Bailey said. “We’re all fighting on the same side, but sometimes the word doesn’t get to the grassroots that AMA stands for most of the things that they’re fighting for as well.”
And a fractured physician profession helps no one. TMA’s ability to unite counties and specialties contributes to its success in advocacy; the goal of AMA is to do the same, but Dr. Rohack says it has a much harder task at hand.
“Just you think about it, how crazy it would be if Harris County took a different view on a particular subject than Dallas County, than Bexar County, than El Paso County. And all of them were lobbying on First Tuesdays [at the Capitol] with a different message,” he said. “The legislature [would say], ‘Well, you guys don’t have your act together, so we aren’t gonna do anything.’ Unfortunately, that’s what’s happening in Washington, D.C.”
As states and specialties increasingly lobby separately to Congress, “AMA’s trying to keep everybody on the same page,” Dr. Rohack added.
Shared wins
While that happens, physician participation ensures those in leadership roles represent the majority of the profession. After all, when AMA wins a battle, all physicians get the win. But wins are much tougher to get if legislators and regulators know you are speaking for only a portion, possibly a small portion, of the profession, Dr. Bailey says.
She learned early in her career that “advocacy was a professional responsibility. … Being able to take good care of your patients meant working with legislators and insurance companies and regulators to make sure that there were good policies that let you take good care of your patients. TMA and AMA, to me, were the best places to do that.”
And Texas’ unique perspective on medicine is an integral part of organized medicine on a national level, just as Texas learns from other states in return, she says.
“An organization like the TMA or like the AMA is much stronger the more diverse it is and the more opinions are expressed and discussed.”
Dr. Dickey urges physicians to stay involved in AMA, even if only to uphold the principles of democracy.
“The vast majority will never go to an AMA meeting. The vast majority will never be a delegate to the House of Delegates,” she says. “But then, the vast majority would never go to Congress, either. I still think they ought to go to the ballot box.”