News

A bold plan to achieve unity in medicine

Ronald M Davis, BMJ USA

This article originally appeared in BMJ USA

At the last two meetings of the American Medical Association's House of Delegatesin June and December of last yearparticipants debated and approved the broad outlines of a bold plan to achieve unity among medical associations. Here in the US the medical profession is represented by a system of medical associations often referred to as "organized medicine" or the "federation of medicine." At the core of the federation is the American Medical Association (AMA) and its House of Delegatesthe AMA's policy-making body comprising 550 delegates representing state medical associations; national medical specialty societies; military services; and special sections for medical students, residents and fellows, young physicians, medical school deans, and international medical graduates.

As the medical profession in the US has become increasingly specialized, ^{1 2} organizations representing medical specialties and subspecialties have proliferated. About 100 national medical specialty societies are now represented in the AMA House of Delegates. As physicians have turned to specialty organizations to serve their needs, their support of the AMA has waned. An AMA task force on membership reported that AMA membership among physicians had fallen to 34% by 1999, and it projected that membership would decline to 23% by 2010 if current trends continue.³

With a weakened AMA, and a proliferation of specialty societies, the voice of medicine has become splintered. Outside forcesespecially government, employers, and managed care organizationshave gained an upper hand, and in the opinion of many physicians, the professionalism of medicine and the quality of health care have suffered as a result.

To remedy this problem, the AMA House of Delegates formed a "Commission on Unity" in December 1998. At the AMA's annual meeting last June, the Commission delivered its first report.⁴ It concluded that "the current Federation is dysfunctional and disintegrating . . . [and if] current trends persist, the Federation and the AMA as we know it today, will disappear within the next decade or two."

Using a methodology called "idealized design" (which assumes that today's external environment exists, but internal constraints do not), the Commission proposed the creation of a "system of participating organizations" with three major elements. A "Congress of Participating Organizations" would serve as the principal convening mechanism of the overall system, and would include representatives of the participating organizations in proportion to the number of physician members of each group. A "Core Organization" would support the system of organizations in policy development and advocacy; building consensus and resolving disputes; setting standards on professionalism, ethics, quality of care, medical education, medical science, medical practice, and public health; offering products and services to participating organizations; and providing direct benefits to individual members. Finally, the Congress would elect an Executive Council, which would be the principal governance element of the Core Organization.

Each of these three elements parallels an existing organization or entity. The Core Organization could be the AMA. The Congress resembles the AMA House of Delegates. And the Executive Council corresponds to the AMA Board of Trustees. But the relationship among the three proposed entities is substantially different from the relationship among current elements of the federation. One radical change is that all physicians who join a participating organization would automatically become a member of the Core Organization. Thus, unlike the AMA, the Core Organization would not compete with participating organizations for members and membership dues. Another important change is that the leaders of the Core Organization and the participating organizations would use a cooperative and consultative process to develop "official positions" of the medical profession. Participating organizations would be required to notify the Core Organization and other participating organizations "of any intent to deviate from agreed on positions."⁵

After substantial debate, the House of Delegates agreed that the unity commission's design shall be "a conceptual starting point for transforming the current Federation." The House directed the AMA Board to convene the leadership of federation organizations "to determine if and how the design of the Commission on Unity can be achieved and to provide a reality test of the design." The Board is to submit a progress report to the House at its June 2001 meeting that includes a detailed proposal for a final design, an implementation plan, and a risk/ benefit analysis.

References

1.	Rivo ML, Kindig DA. A report card on the physician work force in the United States. N Engl J Med 1996; 334: 892-896[Free Full Text].
2.	Donini-Lenhoff FG, Hedrick HL. Growth of specialization in graduate medical education. JAMA 2000; 284: 1284-1289[Abstract/Free Full Text].
3.	Report of the Task Force on Membership at A-99. Chicago: American Medical Association, June 1999. www.ama-assn.org/meetings/public/annual99/reports/tfm/rtf/tfm1.rtf (accessed 30 December 2000)
4.	Commission on Unity: a progress report. Chicago: American Medical Association, June, 2000. www.ama-assn.org/meetings/public/annual00/reports/cou/coua00.doc (accessed 30 December 2000)
5.	Report of the Commission on Unity. Chicago: American Medical Association, December 2000. www.ama-assn.org/meetings/public/interim00/reports/rcf/cou-i00.rtf (accessed 30 December 2000)