It seems like everyone has the ear of a member of Congress or a key state legislator - everyone except you, that is. Have you ever wished that physicians could advocate for their interests as effectively as trial lawyers and insurance companies lobby for theirs? Here's your chance.
One morning last November, Vineet Arora, MD - “Vinny” to her friends - found herself seated in the vaulted halls of the nation’s Capitol building. After listening to others speak on healthcare issues for five hours, Arora’s turn came to address the members of a U.S. House of Representatives subcommittee that was considering legislation to halt Medicare payment cuts.
Arora spoke of her love of medicine and her commitment to her patients - a commitment she says is increasingly threatened by declining reimbursements. In fact, Arora told the powerful Health Subcommittee of the Energy and Commerce Committee, primary care is facing a crisis of epic proportions.
“Medical students and young physicians learn early on in our training about the joys of having a continuous, ongoing, and personal relationship with a patient, which is the hallmark of general internal medicine and family medicine,” Arora testified. “Unfortunately, we also learn that primary care is under-reimbursed compared to other specialties, and that many primary-care physicians are struggling to keep their practices open at a time of escalating practice costs, excessive paperwork requirements that take time away from patients, and reimbursement from Medicare and other payers that does not keep pace with their rising costs.
“It is so bad,” she told the committee, “that many of the excellent primary-care physicians that we meet in our training programs go as far as to counsel us not to go into primary care.”
Chair of the American College of Physicians’ (ACP) Council of Associates and a member of its Board of Regents, Arora manages to combine her political activism with her work schedule as the associate program director of the Internal Medicine Residency Program at the University of Chicago.
She says she feels rewarded by her hard work. Following a blitz by the ACP, the American Medical Association, and others, both the House and Senate passed legislation halting their planned Medicare reimbursement reductions, and the impending cuts were averted - at least for this fiscal year.
Many physicians such as Arora are active with their local and/or state medical societies. Some even hold elected office. Others regularly or occasionally open their wallets to support the causes and candidates they believe can enact the best healthcare policies.
But many more sit in their offices and stew.
Politically and socially active physicians say this apathy is detrimental to their colleagues’ physical health and mental well-being, and they add that they need more help to enact reforms that can make physicians’ lives easier and their careers more enjoyable.
“I see a lot of physicians get personally frustrated, but one of the ways to harness that frustration and channel it into something positive is to work with people who are trying to change things, to advocate for the right things,” says Arora. “It can be a very rewarding experience. You feel like you have a voice, and people are hearing the opinions you have.”
Learning to take the long view
As medical practitioners, physicians are accustomed to observing the results of their treatments and their counsel in a timely manner; they are rightly focused on outcomes more than processes. That may be one reason why some docs shy away from engaging in political or reform movements, in which progress can be slow, process is critical, and success is measured by small gains.
“There are so few, single landmark victories that you can point to and say, ‘This is where the tide turned,’” says Troy Tippett, a neurosurgeon and president of the Florida Medical Association (FMA). “It’s more of an incremental thing. This is a marathon and not a race. You have to keep working.
“Physicians tend to not want to be bothered. They went into medicine to take care of patients. The general premise is, ‘Just leave me alone. I shouldn’t have to mess with this.’ And in fact, you have to. Everything in politics affects how we practice medicine. There is a direct effect on patient care.”
Another obstacle to docs organizing and involving themselves in public affairs is an ongoing lack of unity within the medical profession as a whole. Sometimes medical societies stake out positions opposed to others, or they cannot agree on the solutions they seek.
But that may be changing.
Larry Stein, a pulmonologist with Pulmonary and Medical Associates in Arlington, Va., thinks the problems in medicine have gone so long untended that now there is far more unanimity than once existed, especially regarding universal healthcare, malpractice, and payment. “There are a lot of issues that physicians clearly agree on, whether you are from the ACP or the AMA,” he says.
So what motivates politically active and reform-minded docs?
For Arora, activism satisfies her desire to address systemic issues within the healthcare system. “I have always loved medicine and patient care, and I think it is very rewarding because you get to interact on a one-on-one level,” she explains. “But I am also a problem-solver, and I like to work on big problems of a larger scale that affect many people.”
Arora also says her involvement keeps her up-to-date with current healthcare policy trends, something she says is lacking among her peers. When she conducts informal polls among her colleagues and residents on topics she knows will grow increasingly significant as time passes, she is often disappointed with the responses she hears. “I ask if they have heard of pay for performance, and universally the answer is ‘no.’ That’s frightening to me.”
The need for new recruits
Inspired to political activism by a now-retired colleague, Stein hopes his involvement will spur others to do the same. “Sometimes you do things because you think it is important as an example to other people,” Stein explains. “It isn’t hopeless. We just have to keep pushing on.”
For the past 10 years, Stein has visited Capitol Hill for “Leadership Day,” an annual event hosted by the ACP. Physicians gather in Washington for two days. First, they are versed on the issues of concern to physicians, and they receive advice on how to effectively speak to the media and members of Congress on those issues. Then they’re off to meet with Senators, members of the House, and their top healthcare legislative aides.
“I think we have an impact because it puts [issues] on peoples’ radar,” says Stein. “Whatever victories we have had are due to the fact that we can get people out. We don’t give people tons and tons of money. We take a day away from our practice; we show that we care.”
He adds that it can be easy to get frustrated with the pace of political reform. “What’s really important is getting people to understand that we don’t win every time. Getting people to go [to Capitol Hill] every year is important. Even when you talk about winning, what are you winning? A flat [payment] or a 1 percent increase? It’s hard to celebrate that, but it’s better than what we were going to get.”
Although he enjoys it, Stein says he has had to cut back on some of his activism, citing work and family pressures. “I have two kids and a busy practice; it is difficult to find the time to do what you want to do,” says Stein. “Part of me wishes I could do more, but part of me wishes more people were involved.”
Wilfred Watkins, a urologist in Napa, Idaho, and former president of that state’s medical association, says he has found his involvement to be “very challenging, rewarding, and interesting,” even though fundraising among his peers is very difficult.
“I guess the most consistent disappointment is that even though physicians complain loudly and bitterly about their fate, they won’t loosen up when it comes to contributions,” says Watkins, who has served on the board of directors of the AMA’s PAC.
Eugene Ogrod, an internist and former president of the California Medical Association, has focused on a number of issues near and dear to him, including providing healthcare access to the poor and retooling the Resource-Based Relative Value Scale (RBRVS) payment system. Early in his career, he was instrumental in developing the AMA’s program for representation by medical residents.
“You can make a difference, and it’s never too late to get involved,” says Ogrod, who also has a law degree. “You may not see the results until late in your career. It will not be instant. [But] on some issues an individual can make a difference if you can stay involved.”
Troy Tippett is living proof of that.
Tippett says he can’t recall the specific issue that propelled him to engage in organized medicine for political change; he does recall being upset about an “unfunded mandate” of some sort being before the state legislature a while back. He recalls thinking at the time, “I could either complain about it in the doctors’ lounge or do something about it.”
Tippett has been a member of the FMA since 1993, and a Florida delegate to the AMA since 1998. He has been involved in successful efforts to enact patient-safety legislation, and he worked on the passage of a 2004 state constitutional amendment limiting plaintiffs’ attorney fees, which he calls “one of the best things we’ve ever done.”
The amendment prohibits lawyers from getting more than 30 percent of the first $250,000 of any malpractice award, and only 10 percent after that.
Proponents of the amendment, including the FMA, raised $6 million to fight for its passage, while opponents, including the Association of Trial Lawyers of America, raised $25 million. The amendment passed with 64 percent of the vote.
In the Internet age, getting involved in issues you care about can be easy and painless. Like other medical societies, the ACP has an e-mail alert system activated when there is a need for immediate physician action. This “key contact” system may ask members to call or e-mail their congressional representatives. The ACP provides talking points and ideas for influencing the debate at hand, says Elizabeth Prewitt, ACP’s director of governmental affairs and public policy.
The number of the ACP’s “key contacts” has grown to roughly 5,000, still a small fraction of the society’s 110,000 members. But don’t let that number give you the impression that this group is unimportant or that they don’t have an impact, says Prewitt. “When members of Congress have all sort of pressures and groups coming at them, if they only hear from the [medical societies’] Washington staff, it is not that effective. It is essential to have a strong grassroots group of people. I don’t think you can overestimate their importance. Over the last few years we’ve had looming Medicare cuts, and we’ve been able to turn that around. We were able to get over 1,000 calls and letters into
Congress,” she affirms.
Prewitt stresses that the need for involvement is ongoing. ACP members’ “interest isn’t just Medicare cuts. Our advocacy agenda is as broad as it can be and still be effective ... graduate medical education, the uninsured, the hassle factor in medicine. … Two big issues are transitioning to electronic health records and pay for performance.”
No one expects every physician to line up to testify before Congress. But Peter Moskowitz, MD, founder and executive director of the Center for Professional and Personal Renewal in Palo Alto, Calif., says that personal activism doesn’t have to be dramatic to be effective: “All you have to do is take on a little bit ... something reasonably small and see how it goes. People who enjoy it will continue to do it and hopefully seek leadership roles. State and county medical societies offer perhaps the greatest number of opportunities for involvement. Most people start with their own medical society and then once they are engaged, they find ways to move to bigger organizations and issues.”
And don’t worry if you’re a neophyte. “Usually the staffs of these organizations are more than willing to help you,” Ogrod says. He suggests seeking out past presidents and senior leaders for guidance.
These days, it may actually be more important to be active on the state level, Tippett and others say. For example, Congress is booting many of the tougher issues to the states to settle - like whether “Plan B” emergency contraception should be available over the counter, and many states are tackling national problems like rising malpractice premiums on their own.
Tippett advises aligning with political figures with agendas similar to your own: “Not only must you go to speak to your legislators, you must get to know them, raise money for them, help them get elected. That assures that you have an audience to make your case alongside someone else who is making their case. If you are not at the table, for sure the other side is most likely going to convince that legislator to do what they want, more than what you want.”
Consider lending your support to a local or regional candidate who you like, “especially if the candidate is a doctor,” Moskowitz adds. “We can’t rely on others to lead us or represent us. The best people to do those jobs are physicians themselves.”
If you want to contribute financially, do your homework and find out which organizations and candidates reflect your personal concerns. The Web site Opensecrets.org lists campaign contributions by industry, including healthcare. Another good source of information is vote-smart.org. Here you can enter the name of any elected member of Congress or state legislative office and see their biggest donors and how often they supported positions that were favorable to them. For more specific details on state races, visit www.followthemoney.org.
Running for office … and winning
And if you like politics enough, well, you might even decide to run for office. Richmond, Va.-based neurologist John O’Bannon ticks off the qualities that doctors possess that would also serve them well in politics: discipline, self-control, good interpersonal skills. “Each voter is like a new patient, so to the extent that you have spent your life meeting patients, you have a lot of experiences which can help you in the political arena,” he says.
O’Bannon knows his stuff: He has been an elected member of the Virginia House of Delegates since 2000, winning office after a long career of representing Virginia physicians before the state legislature. He has served as the chief of staff for two area hospitals, is active in the AMA, and has held executive-level positions with his state medical society.
Homeland security, healthcare information technology, and malpractice are among the many issues O’Bannon has tackled. “We just rewrote the quarantine laws, killed a bill that the bikers wanted to do away with helmet laws. We had a bill today on nurse-midwives and giving physicians some immunity for seeing their patients.”
This physician politician learned from his days schmoozing with state legislators that politics is “not rocket science,” and he also found that he enjoyed his involvement. He counts the support of the medical community as one of the keys to his successful campaigns.
“I really … thank the doctors who supported me. They have been generous and gracious. I would never have been able to win without the medical community supporting me,” O’Bannon says. “I was able to raise a substantial amount of money. You need many things to win an election. You need good planning, good direct mail, good door-to-door [campaigning] ... but at the end of the day you have to have money.” O’Bannon has typically raised $100,000 for each of the three races in which he was challenged, and he won them all.
O’Bannon has tried to minimize the effect of his political activism on his medical practice. In contrast to members of the United States Congress, he misses just six to eight weeks of work each year by serving in the Virginia legislature. O’Bannon maintains a constituent office in the same building in which his practice is located, and the Richmond Capitol is only a 15-minute drive from his office, allowing him to attend committee meetings when the Virginia legislature is not in session.
Of mixing medical practice and politics, O’Bannon says, “Patients are afraid of being abandoned. I’ve told them they will not be. I am in practice with 14 neurologists, and my patients know who will take care of them in January and February; they know I will be back to see them when the session is over.”
He says his political post has not had a negative effect on his doctor-patient relationships: “A lot of my patients are my constituents. I have relationships with many of them, and they feel quite comfortable giving me an earful about what their concerns are. I don’t think [my election] has affected the doctor-patient relationship in a negative way at all. We can talk about it in the part of the encounter that is for small talk.”
Before he ran for office, O’Bannon attended AMA sessions on campaigning; now both he and his wife, Pat - an elected member of their local county board of supervisors - speak at these seminars to potential physician candidates.
“Probably the things that [the AMA’s] campaign school were most helpful with were media training, how to respond to a reporter, fundraising, message, targeting and segmenting in campaigns, and ways to learn more about your opponent, like opposition research. You can learn the skills to get elected to public office. It’s not harder than practicing medicine; it’s just a different skill set,” says O’Bannon.
“Being a physician, you bring a lot to the table,” he adds. “You have stature in your community; you are recognized as a professional. What physicians need to realize is being a doctor does not give you a strategic advantage over any other professional. You have to go and participate the same way a teacher or a realtor or a banker does.”
O’Bannon does not feel he has given up much to hold state office. “I do work fewer hours and make less money. But the house is paid for and the kids are grown,” he says. “There was a financial sacrifice, but it was doable. And I think what we are doing is important.”
Theresa Defino, editor of Physicians Practice, can be reached at Tdefino@physicianspractice.com.
This article originally appeared in the May 2006 issue of Physicians Practice.