Unity of purpose: Get involved and we'll get things done

A message to all physicians from the chair of the AMA Board of Trustees, J. James Rohack, MD.

By J. James Rohack, MDis senior staff cardiologist at the Scott & White Clinic in Temple, Texas. He was AMA president during 2009-10 and served as chair of the AMA Board of Trustees during 2004-05. Posted Oct. 4, 2004.

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On the AMA's 100th anniversary, the United States Postal Service commemorated the occasion with a stamp simply called "The Doctor." The stamp depicts a physician sitting at the home and bedside of a very sick child, looking down with a furrowed brow and compassionate gaze. The child's parents hover in the background, anxiously awaiting the doctor's verdict and advice.

Providing compassionate medical care has been the hallmark of the medical profession from its beginning. In the course of the last century, however, the delivery of medicine has been transformed as it has moved from the patient's home to the physician's office -- and the local hospital.

With the explosion of science in the 20th century, U.S. physicians increasingly found they could provide better care to their sickest patients in hospitals. Thanks to technological advances, hospitals offered physicians novel and better ways to diagnose and treat the sick. Physicians soon found that providing medical care in a hospital setting was crucial for the health and well-being of their patients.

But who would determine whether a given physician had the right to practice medicine in a hospital setting? In the early 20th century, county medical societies had boards of censors to provide physician peer review and to ensure professional standards. As a result, a physician who wanted to provide medical care in a local hospital had to be a member of the county medical society.

This county society, in turn, was part of the state medical society and the American Medical Association -- and each of these organizations used the AMA's Code of Medical Ethics to guide them. In this way, physicians and their ethical principles determined -- and enforced -- the professional standards of practice for medical staff.

The late 20th and early 21st centuries have seen a different relationship between physicians and hospitals, however. In 1978, the Supreme Court ruled that physicians no longer had to join the county medical society to belong to a hospital medical staff. The Joint Commission on Accreditation of Hospitals (now known as the Joint Commission on Accreditation of Healthcare Organizations) instead required an organized medical staff for hospital accreditation.

State licensure laws prohibiting the corporate practice of medicine made certain that the governing body of the hospital could not practice medicine. As a result, the hospital governing body, administration, employees and organized medical staff all needed to work interdependently to provide high quality and safe medical care for patients and their communities.

The success of such a system depends on active physician involvement. Since 1978, however, there has been a decrease in membership as well as participation in organized medicine overall, and a parallel decrease in physician participation in organized medical staffs.

Thirty years ago, for example, it was common to have 70% of a county medical society's members attend a meeting. Today it is not uncommon to have less than 10% attend meetings, and it is often a struggle to find members who will serve on committees and in leadership roles.

Organized medical staffs aren't faring much better. In recent years, the JCAHO decided it would no longer require physician attendance at hospital medical staff meetings as a standard. Today, attendance at organized medical staff meetings in many hospitals hovers at the 10% level, and the organized medical staff faces the challenge of finding physicians who will volunteer their time to serve on committees and in leadership roles.

So what does this have to do with you? This lack of participation allows others who are not physicians to fill the power void and to determine the future of patient care in our nation's hospitals. This is of concern to us and to patients.

We cannot afford to forget that, for decades before 1978, physicians worked hard for authority over patient care activities, as well as functions such as credentialing, clinical privileging and peer review as part of a hospital medical staff.

The AMA hasn't forgotten. Our AMA created an Organized Medical Staff Section to provide a national forum for sharing concerns on how best to provide patient care amid changes in health care delivery and financing in the United States. And when conflicts occur at a local level between a hospital and the organized medical staff, help provided by the state medical associations and the AMA has been crucial -- as recently seen in California (link).

We are also actively working to prevent such conflicts from happening in the first place. In recent months, AMA leaders have met with leaders of the American Hospital Assn. to draft principles for hospital-medical staff relationships. These principles emphasize shared values and responsibilities, organizational framework, physician participation and joint processes. They make it clear that to resolve a conflict, physicians and hospitals need open communication, trust and mutual respect. These principles will be reviewed in the next two months, and we hope they will be available by the end of the year as a resource.

It is unfortunate, however, that physician support of organized medicine, the AMA and OMSS is not what it could be. For example, although each organized medical staff can send a representative to meetings held prior to the AMA House of Delegates, only a small percentage choose to attend.

While physicians can't bring back the days when physicians made house calls -- nor, on many levels, would we want to -- we can still ensure the provision of compassionate, excellent care for hospitalized patients. We can do so by being active participants on our organized medical staffs, in the AMA's Organized Medical Staff Section, and in organized medicine in general.

To paraphrase Albert Einstein: The world is a dangerous place to live because of people who don't do anything about it.

Don't be one of those people. Be active -- and be proud.

J. James Rohack, MD is senior staff cardiologist at the Scott & White Clinic in Temple, Texas. He was AMA president during 2009-10 and served as chair of the AMA Board of Trustees during 2004-05.

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