In delivering his penultimate address before the AMA House of Delegates (HOD), outgoing CEO James L. Madara, MD, reviewed the closing remarks that American presidents have offered at the end of their terms.
Such speeches, Dr. Madara said during the 2024 AMA Interim Meeting in Orlando, Florida, generally fall into two categories. The first focuses on celebrating one’s achievements. The second concentrates on offering a view toward the future—Dwight Eisenhower’s prescient warning about the “military-industrial complex” is a notable example.
Finding it more useful to look ahead, Dr. Madara tailored his remarks to a challenge he believes the AMA must address in the years ahead: governance.
Streamlining strategy
When Dr. Madara was a candidate for the position of AMA CEO 14 years ago, his conversations with the search committee indicated a dissatisfaction with the execution and short-term nature of organizational initiatives.
“The search committee indicated that the AMA was not satisfied with the way strategy was done—that there were too many small projects of limited duration that did not amplify each other for impact,” Dr. Madara said. “Additionally, the committee wanted an approach that, building on our policies, would bring our mission statement more to life. And then there was a sense that dealing with those things could mitigate the bleeding in membership, reversing the downward membership trend that had then existed for 40 years.” (Read Dr. Madara’s full speech.)
Once he took on the role as CEO, Dr. Madara implemented dynamic priorities as part of the AMA strategy. The mission-aligned strategic focus includes:
- Removing obstacles that interfere with patient care.
- Confronting chronic disease and eliminating health inequities.
- Driving the future of medicine by reimagining medical education and lifelong learning.
“From that, flowed elements such as our medical education consortium, the Center for Health Equity, our Health2047 innovation studio in Silicon Valley and several other amplifying programs and initiatives that I highlight in my regular remarks to the House,” Dr. Madara said. “Now, along the way, AMA membership not only stabilized from its decades of decline, it grew by 30%.”
Learn more about Dr. Madara’s accomplishments as CEO.
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A longstanding consideration
During Dr. Madara's interviews for the CEO position, the search committee highlighted governance and strategy execution as areas needing a fresh approach. Taking on both was a weighty task, so Dr. Madara decided to focus on creating programming that aligns with and amplifies the AMA’s mission.
The AMA that Dr. Madara inherited in 2011 was much different than the one that exists today—yet governance issues persist.
Perhaps the biggest challenge is the growth of the AMA House of Delegates. In his first address to the HOD, the House had a bit more than 500 delegates. Today, the number stands at more than 700.
That growth can be attributed to factors such as membership growth and a decision to balance representation between state and specialty societies.
“A House of substantial size provides both opportunity and challenge,” Dr. Madara said “Opportunity in adding yet more diverse opinions, experiences and contributions. On the other side of that coin, large deliberative bodies can be cumbersome and inefficient.”
Madara noted that the U.S. House of Representatives has been capped since the early 20th Century with 435 members representing states across the nation. Finding the right size is a challenge that will need to be addressed by the House of Delegates and by the AMA’s next CEO.
“The bottom line is that if we plan on continued growth in membership, but don’t consider the downstream effects on the size of this House, we could eventually find our functionality challenged,” he said.
Fighting for doctors in all practice settings
While the HOD’s growth may create challenges, a restructuring would need to ensure that physicians from all practice settings have voice.
When Dr. Madara assumed the CEO position, about 42% of physicians worked in an employed practice setting. That figure is now greater than 50%. As of 2022, about 44% of physicians owned their practice. That represents a decline of more than 50 percentage points from the 1970s.
“My sense is that there will always be a critical physician segment in private independent practice—though shrinking in size—but this population will need be supported, and indeed the need for support is greater than it has ever been,” Dr. Madara said. “But with a growing number of physicians employed in groups, we must be equally attentive to these voices and needs as well.”
The mechanisms through which employed physicians working in group practices can earn a voice in the HOD also need adjusting, Dr. Madara argued. Now, those physicians can work with the AMA Integrated Physician Practice Section, which provides a pathway to submit resolutions and thus influence policy.
Addressing these governance questions falls upon those in the audience and those who will come after them as members of the House of Medicine.
“The two questions I raise—the size of the House and the representation of employed physician groups—are governance questions and thus the purview of this House, acting with the fiduciary oversight of our Board” of Trustees, Dr. Madara said. “These are not questions that can be resolved by your management team.
“I simply highlight these questions simply feeling duty-bound to do so as these are likely fundamental challenges for the future,” he said.
In the closing moments of his 27th address to the House of Delegates, Dr. Madara offered gratitude to the AMA and its membership. Together, he said, they have achieved great things.
Michael Suk, MD, JD, MPH, MBA, the chair of the AMA Board of Trustees, is organizing the search for Dr. Madara’s successor.
Read about the other highlights from the 2024 AMA Interim Meeting.
