EP. 53: SHAPING AMERICAN MEDICINE
WITH JACK RESNECK JR, MD
The immediate past president of the American Medical Association and Chair of Dermatology at UCSF discusses clinician burnout, physician compensation, racism in the medical profession, how digital health will transform medicine, and more.
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Episode Summary
The American Medical Association, or the AMA, is the oldest and largest professional association of physicians in the United States, comprising more than 270,000 clinicians across all medical specialties. It is involved in all aspects of American medicine, from establishing standards of care, to reforming medical education, to lobbying for health care policies at the highest levels of government. Our guest in this episode is Dr. Jack Resneck Jr., chair of the Department of Dermatology at the University of California San Francisco and President of the AMA from 2022 – 2023. In this conversation, we explore Dr. Resneck's personal journey in medicine, how the AMA is addressing the epidemic of physician burnout, how the AMA is coming to terms with its own complicated history with racism, the ways in which digital health is transforming medicine, how health care reimbursement rates are determined, and how doctors can play a more active role in advocating for their own work.
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Dr. Resneck is the Bruce U. Wintroub Endowed Professor and Chair of the UCSF Department of Dermatology, and holds a joint appointment as an affiliated faculty member at the Philip R. Lee Institute for Health Policy Studies. In earlier roles, Dr. Resneck served as residency training director and then medical director for dermatology at UCSF.
Dr. Resneck became president of the American Medical Association in June 2022. He is a passionate advocate for physicians and patients, a prominent spokesperson for innovation, and a champion for a more equitable health care system. Whether testifying before Congress about removing dysfunction from health care, caring for his patients at UCSF, or advocating for physician values in emerging technology, Dr. Resneck channels his leadership to improve the lives of patients and the working environment for America’s physicians to help build stronger, healthier communities.
Dr. Resneck was elected to the American Medical Association Board of Trustees in 2014 and served as its chair from 2018 to 2019. He is a former member of the board of the American Academy of Dermatology and the former president of the California Society for Dermatology and Dermatologic Surgery. Currently, he is a member of the editorial board of the Journal of the American Academy of Dermatology and serves on the board of directors for the National Quality Forum. He is active in health services research, and his studies on patient access to care, health care delivery, telemedicine and public health have been published in prominent journals and attracted national media attention. He is a sought-after speaker and has given dozens of invited lectureships around the country.
Raised in Louisiana, Dr. Resneck received his BA in public policy from Brown University and his MD from UCSF—where he also completed his internship in internal medicine, residency in dermatology and fellowship in health policy.
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In this episode, you will hear about:
• Dr. Resneck’s early years as a self-described ‘policy nerd’ and growing up in a physician family - 2:10
• How Dr. Resneck first became involved with the AMA - 6:01
• A brief review of the history and mission of the AMA - 8:23
• A discussion of the epidemic of burnout and how the AMA is addressing it - 12:45
• A survey of the AMA’s current policy priorities - 23:42
• A conversation around the incentive discrepancies around primary care medicine and how the AMA’s Relative Value Update Committee (RUC) is addressing this - 29:26
• How artificial intelligence and other new technologies are shaping the future of medicine, and why physicians must take an active role in their development - 36:25
• Reflections on the history of the AMA’s race relations and what the modern medical establishment must do to remedy health discrepancies, including The AMA’s Strategic Plan to Embed Racial Justice and Advance Health Equity - 47:15
• Dr. Resneck’s optimistic view of the future of the profession - 55:08
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Henry Bair: [00:00:01] Hi, I'm Henry Bair.
Tyler Johnson: [00:00:02] And I'm Tyler Johnson.
Henry Bair: [00:00:04] And you're listening to The Doctor's Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build healthcare institutions that nurture the doctor-patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?
Tyler Johnson: [00:00:27] In seeking answers to these questions, we meet with deep thinkers working across healthcare, from doctors and nurses to patients and health care executives; those who have collected a career's worth of hard earned wisdom probing the moral heart that beats at the core of medicine. We will hear stories that are by turns heartbreaking, amusing, inspiring, challenging and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.
Henry Bair: [00:01:03] The American Medical Association, or the AMA, is the oldest and largest professional association of physicians in the United States, comprising more than 270,000 clinicians across all medical specialties. It is involved in all aspects of American medicine, from establishing standards of care to reforming medical education, to lobbying for health care policies at the highest levels of government. Our guest in this episode is Dr. Jack Resneck, chair of the Department of Dermatology at the University of California San Francisco, and the current president of the AMA. The diversity of the issues we cover in our conversation reflects the diversity of the AMA's activities. Among other things, we explore Dr. Resneck's personal journey in medicine, how the AMA is addressing the epidemic of physician burnout, how the AMA is coming to terms with its own complicated history with racism, the ways in which digital health is transforming medicine, and the intricacies of how health care reimbursement rates are determined, as well as how doctors can play a more active role in advocating for their own work. Dr. Resneck, thank you for taking the time to join us. To start, can you tell us what drew you to a career in dermatology and how you got involved in health policy?
Jack Resneck: [00:02:18] That is a great question and I'm still not 100% sure how I got here, but I did. I grew up in a house where my father happened to be a physician and actually happened to be a dermatologist. So I'm sure that had some impact. But frankly, as a kid, I was a little bit more of a of a policy nerd. And, you know, it sort of dominated conversations at the dinner table. And my family had a history of a couple of uncles who were very involved in the civil rights movement in Mississippi in the 1950s and 60s. So it was a part of the thread of our family. And so when I went to college, I actually majored in public policy as an undergrad. I went to DC for a little while after that, but I think I recognized during that time in DC that I was missing something and that it was that one on one face to face interaction that you get to have with a patient. And it's it's really fun at the big national level to get to do things that influence lots of people and improve health care for for large numbers of people.
Jack Resneck: [00:03:16] But there's something also really special about sitting down with a patient. And I think I craved that. As I said, my my dad was a dermatologist, but when I did decide, okay, okay, I'm going to go to medical school and take a little time off of this policy work. I said, I'm going to go to medical school, but I swear I am not going to become a dermatologist. Even though we had a great relationship, somehow here I am. And I think partially that was just the impact of seeing somebody get up every morning in my household as a kid who loved their job, he actually was excited to go to work every day as a physician. He loved taking care of his patients and that had a real impact. And derm has been a wonderful specialty for me. I love the mix of getting to do sort of the more medical cognitive work of solving complex rashes and also getting to do a lot of surgical procedures for skin cancer. So I've really enjoyed it.
Tyler Johnson: [00:04:09] So I'm struck by the fact that you mentioned that even when you were growing up, I sort of imagined from what you were saying, you seated around the dinner table with your family or whatever, and that even as a teenager you self identified as what you called a "policy nerd." I don't think most teenagers probably self-identify as policy nerds.
Jack Resneck: [00:04:28] Probably didn't win me a lot of friends and popularity either.
Tyler Johnson: [00:04:31] Yeah, probably not. But. But I'm curious. Like, I'm not even sure exactly what that means as a teenager, but like, what was it that sparked your interest early on in policy work or what did that even mean for you, especially when you were young?
Jack Resneck: [00:04:45] Yeah, I don't know. I think it's probably genetic, but I you know, I loved looking at editorial pages and thinking about things from that viewpoint. Mostly in middle school and high school, I would say. And I was seeing things in my own environment. I live in California now, but happened to grow up in Louisiana and seeing the unfairness of racism in my community, which is certainly not unique to that part of the country. But there were just a lot of things that drove me to feel like we need to use systems and levers of power to try to make things better. And I think some people have more of an outsider orientation and some people largely, if you have the privilege to get to sit at tables and have influence and this is probably not as a kid, but later in life, sort of a more institutionalist and like to try to change institutions from the inside and find levers of power to make positive change. My parents were pretty nervous when I was growing up in middle school and high school that I was going to end up running for public office and that they would be handing out leaflets in grocery store parking lots, trying to raise money for a congressional run or something. And I'm I think they're relieved that that didn't quite go that path and that I've combined medicine and policy work in the way that I have. But it's it's been really fun to get to wear both of those hats.
Henry Bair: [00:06:01] So talk to us more about that journey. How did you go from finishing residency and then now to leading the American Medical Association?
Jack Resneck: [00:06:10] That's a good question. When I was a medical student, I actually think I wasn't even a member of the American Medical Association yet. Shame on me. But I really got sent as a resident by my specialty society to represent my specialty in the Resident and Fellows section of the American Medical Association. And I pretty quickly realized that policy is made, whether it's in the AMA or anywhere else, by people who show up. And I looked around at other people who were doing the same thing, and I was pretty impressed by the dedication and the values of other people who were who were increasingly showing up. And I sort of got romanticized by the whole notion of how that worked. And the AMA is quite unique in some ways in the way that our policy is set. So as compared to some other just advocacy organizations that have a particular policy goal, the AMA is different in that it represents the profession and that our policy is actually not set by me as president. I don't get to go out and decide I'm going to be for this or against that. It's not set by our board or our management team. But we gather this really large house of delegates, hundreds, even thousands of people twice a year who come together and basically have open public evidence-based, science-based debate around hundreds of resolutions each time about what the AMA should have as its policy, what we should be doing in the advocacy space or in other arenas, public health arena.
Jack Resneck: [00:07:38] And minds actually get changed and the debates are tend to be evidence based and and we come to consensus and vote and that's how our policy gets set. It's it's sort of how I wish Congress would function sometimes. It's it's actually quite fun to watch that sausage get made. And we're gathering people from docs who are in big urban areas, who are in rural areas, people who are employed, people who are in tiny, independent practices, people from all across the political spectrum, I know because they all send me emails every day when they're happy or mad about something, and nobody's going to agree with every single policy that comes out of that House of Delegates. But it's pretty special, I think, the way that we make that policy so that we can go forth and really represent the profession.
Henry Bair: [00:08:23] Given that our listeners include not only clinicians but also pre-medical students and patients as well as those not affiliated with the medical profession. I think it would be helpful if you could describe the history of the AMA and what its mission is, just to give us some context.
Jack Resneck: [00:08:44] So the American Medical Association has been around for 176 years. So that's a that's a fairly long time. And I would first say there's a lot of great things that have come out of the American Medical Association that we're quite proud of during that time. So really, the AMA was founded around a couple of things, one of which was the creation of a code of medical ethics. And ever since then we have a group that is very sheltered actually from our political process that our AMA and our House of Delegates, the Council on Ethical and Judicial Affairs that updates and maintains that code of medical ethics, which is really the the moral basis and ethical basis for our profession. It's used by licensing boards around the country and courts. So that's something I'm quite proud of. And also we were founded around pushing a lot of snake oil and unproven cures and range of what sort of was considered even being a doctor that existed in the time of the creation of AMA. And even to this day we speak up on on those issues. It was also really founded around reforming medical education. And at that time, medical schools meant very different things in different places. And creating standards for medical education was was a big, important piece of that as well.
Jack Resneck: [00:09:57] There are also pieces of our history in those 176 years that I'm not proud of. And any organization that's been around that long is going to have that be the case. And one of the things we've been doing a great deal of in the last decade is reckoning with some of that history, particularly around race and racism. There are countless examples we've been talking about where we've actually done harm. Early in the creation of our organization, some of the founding folks who at some point we had awards named after were racist and worked to keep blacks, women and other marginalized groups out of being physicians. And so we've been talking about that unfortunate history and painful history. The Flexner Report, which some of your viewers may know about in the 1920s, which was commissioned by the Carnegie Foundation, on the one hand really advanced the standardization of curricula in medical schools and created a lot of what we consider pretty standard stuff today about starting with basic science and then moving on to clinical education. But the Flexner Report also, which the AMA was involved with, led to the closure of many of the historically black medical schools in the country at a time where blacks did not have another option of a place to go to medical school and had devastating consequences on that front. All the way to the 1960s, where our House of Delegates allowed some state medical delegations that had white-only delegations to come and be represented in the House of Delegates at a time where we should have done otherwise.
Jack Resneck: [00:11:31] While the reckoning is an important first step to rebuild trust with harmed communities, we've created a large center for health equity, which I hope we get some time to talk about later, which is doing really important work around actually fighting some of the appalling inequities that we see in health care. You asked about the purpose of the AMA. We sort of broadly think of our mission statement is promoting the art and science of medicine and the advancement of public health. And that's a broad mission statement. It really impacts us across several business units, whether it's our advocacy team, which is probably what people see more of in terms of reading in the newspapers, what we do in front of Congress or with the administration or with state legislatures around the country. We have a large litigation center which at any time is engaged in a large number of lawsuits around the country defending health care and doctors and patients, an innovation center that really thinks about the future of innovation, a unit that focuses on chronic disease, a large unit on medical education. So it's a it's a large, complex organization. But at the end of the day, it is all driven by the profession and the policy that comes out of that House of Delegates.
Tyler Johnson: [00:12:45] You're in an unusual position because as the you know, as the leader of the AMA, you are sort of the point person who to the degree that, you know, doctors in the United States have an organization that tries to represent all of them and that tries to use this deliberative process to come to a consensus about what we want, which obviously that's complicated, but whatever, to the degree that that exists, the AMA is probably the closest fit, right? And and so that gives you this really fascinating sort of 30,000 foot view on what's happening in health care in the United States, what the problems are and sort of what we should do, where we should go to try to fix them. And as you may be aware, if you've heard any of our episodes, the animating discussion that we are having in various forms on the podcast in all of our episodes turns on the fact that it's a well-recognized problem in American- and everywhere but American health care, that there is an epidemic of burnout, right? We often have conversations with our guests on a more personal ten foot view level about what do you do in your practice day to day to try to help battle this epidemic? Just on a you know, as you're practicing, you know, wherever wherever you are, a doctor or a nurse or what have you. But I'm curious from your 30,000 foot view, as you look at the policy implications, the bureaucratization, corporatization, all of these things of medicine, like what do you see as the biggest drivers of the epidemic of burnout and what are your thoughts about how those need to be approached?
Jack Resneck: [00:14:31] This is what keeps me up at night right now, and I can give you the 30,000 foot view and the ten foot view because I happen to still be a practicing physician. I think that's important to have street cred as I represent the profession and to have my colleagues knowing that I'm living the challenges and the joys of being a physician on a regular basis. So I was just in clinic yesterday afternoon before I'm headed off to DC tomorrow and burnout has really been my framing narrative. I think of my year as as a president. And, you know, the numbers are just overwhelming. At the beginning of the pandemic, there was too much burnout. We had 38% of physicians reporting some major symptoms of burnout, but now it's 63. That's an astonishing change. We have 1 in 5 physicians who are telling us that they're likely to retire from medicine or do something else other than patient care in the next two years. That's not okay. And it's especially not okay at a time when we have a real workforce challenge. We don't have enough physicians as it is. We've been advocating for decades to get more physicians trained. As Congress contemplates that and to to be losing people on the back end because of burnout is a problem.
Jack Resneck: [00:15:40] We know that that patients don't do as well when their physicians are burnout, and it actually affects quality of care. So as I think about drivers, I think there are a lot of confluent things happening at the same time. So obviously, living through this pandemic the last three years and having doctors put their lives on the line and run towards the fire and take care of this nation during this difficult time; the workforce is tired. And here we are having another winter with at least a triple-demic of multiple respiratory viruses filling our ICUs and our emergency departments again. And I think we went from a point in that first year of the pandemic, everybody probably remembers people hanging out their windows, banging pots and pans in support of physicians and howling. And a few months later, due to the politicization of science, we started to have people actually turning on physicians and just rampant disinformation and misinformation in social media and real media and seeing it in politics. So physicians were spending a lot of their energy and bandwidth, I think, pushing back against a lot of that. And then I'm guessing what you hear from a lot of colleagues who you talk to 1 to 1 on this podcast is also just the daily burdens that get in the way of what drew us all to medicine in the first place, which is taking great care of patients.
Jack Resneck: [00:16:58] That's the common theme that we all have as physicians. So whether it's filling out an average of 41 prior authorizations a week on paper sometimes and sending them via fax machines and then having to have arguments, several phone calls, one after the next, with health plans just trying to get medications approved for our patients that are evidence-based and we know we're doing the right thing. Whether it's clunky digital tools and other things that we deal with in our practice, whether it's things going on in our health systems and practices that cause non-physician work to kind of roll uphill to physicians. I think those burdens play a big part. So I am worried about our workforce. And I really what's important to me in this role is that is that I and we as an AMA do everything we can to preserve and renew this profession for the next generation. So a lot of our work and my priorities really center around that framing.
Tyler Johnson: [00:17:54] To highlight the point that you're making. I just wanted to read very briefly -I've never forgotten this because the name is so provocative- This is a Daily Beast article that was written now very nearly ten years ago in 2014. And the name of the article is How being a doctor Became the Most Miserable Profession. And it opens like this "by the end of this year (This is in 2014) it is estimated that 300 physicians will commit suicide. While depression amongst physicians is not new -A few years back, it was named the second most suicidal occupation- the level of sheer unhappiness amongst physicians is on the rise. Simply put, being a doctor has become a miserable and humiliating undertaking. Indeed, many doctors feel that America has declared war on physicians, and both physicians and patients are the losers." And that, as I say, is from ten years ago.
Jack Resneck: [00:18:48] That's intense. And I mean, I will say I still love my job despite all these burdens. And I know a lot of my colleagues do. So I won't describe my daily life as a physician as miserable. But but those statistics are real. And there are real challenges that have made our jobs harder. And you mentioned depression and suicide among our workforce. And one suicide is too many among our physicians and among the health care workforce. And so depression is a real problem. And we have issues where, you know, that in our profession, mental health issues are stigmatized. Right? And we have physicians not coming forward when they need help. That is something we are working to change. We are working, for example, when you fill out credentialing forms or state licensure forms every year, it's silly and unacceptable actually, that they ask, "Have you ever in your life had an impairment or a mental health issue?" They should be asking about current impairments and it's things like that that actually keep physicians in training and physicians from seeking the help they need when they do have depression or at risk of harming themselves. We helped get the Lorna Breen Health Care Act over the finish line in Congress, which actually is going to pump resources into making sure physicians who are at risk get help that they need. But yes, it is also about making the systemic changes to get those burdens out of the way.
Jack Resneck: [00:20:15] You know, I think back about sort of early work at about the time of that quote that you read me. Health systems started to recognize that burnout was a problem. And some of them for the right reasons, some of them just because they recognized it was costing them a lot of money to have turnover when people left their health systems, but partly because they recognized that they actually cared about physician well-being. And a lot of those early efforts were really focused on wellness. And wellness is important, but in a way, focusing on the resilience of the doctor kind of blames the victim and says you just need to buck up more and we need to do things to help you to tolerate all of what's challenging in the system. So we saw health systems providing yoga classes in the hospital and free gift certificates to go have dinner with the CEO. And that's lovely. Yoga is wonderful, but it's not going to you can't yoga your way out of burnout. Right. So I was giving a speech recently and I said, you know, we have we have to fix what's broken in health care and it's not the doctor. So I'm really pleased with the work that's happening both at the system level and at the institutional level to try to address this.
Tyler Johnson: [00:21:26] I just remember and as I'm sure you've seen on Twitter, so-called Dr. Glaucomflecken does a lot of riffs on this. But I remember when I was an intern, right? So I'm like two thirds of the way through this year where I'm this was many years ago, so it was still Q4 30-hour call, right? So I haven't had a good night's sleep in however long. And one day in like February, someone from the hospital administration comes by with this great big smile on their face and this sort of bearing like they're bringing the solution to our problems, right? And they come to an intern meeting and they say, Guys, we know that you're working so hard, you're getting so little sleep. Et cetera. Et cetera. And we really we wanted to let you know how important you are to the hospital and give you something that would really be a token of our thanks and then passed out $5 gift certificates to the coffee cart. And I just remember looking at it and being like What? Like this is a symbol of how much we mean to you as a $5 gift certificate to the coffee cart.
Jack Resneck: [00:22:29] Yeah. So fortunately we are seeing and stuff like that still happens, but we are seeing increasing numbers of health systems and multi-specialty group practices and hospitals and others who have actually figured out what is involved in supporting physicians and what it takes to build teams that actually take care of non physician work and support physicians in that work. How do you create time in a physician's day to deal with some of the new burdens like the overwhelming in-basket load and all the messages that we get and what it really takes to support physicians. One of the things that's important is actually having leadership that gets this and communicates that they get it in ways other than the $5 gift certificate. It's, as we look at data around burnout, one of the primary predictors in a health system is a question on on sort of the quality of leadership in your setting. So we actually are partnering with a lot of health systems at AMA to teach them how to do this work when they're motivated to do so. It also is just about measuring things. So like sort of until you know what the nature of the problem. So we come in and help health systems and hospitals measure levels of burnout and what their physicians actually need and then follow up on how much they're improving.
Henry Bair: [00:23:42] Thank you for this interesting discussion on burnout and for highlighting the many concrete things the AMA is working on to address this. I'd like to zoom out and ask you what are some of your other current priorities as leader of the AMA?
Jack Resneck: [00:23:56] Well. So a big part of my work this year as we think about coming out of the early phases of the pandemic and looking at practices around the country where, yes, physicians are burnt out, yes, practices are actually have had enormous financial strains during the pandemic as they lost all of their revenue for some period of time when patients weren't able to come in and then also had to really invest in retooling their practices. I have and the AMA has framed some of that work under what we're calling a recovery plan for America's physicians. And we've heard a lot about recovery plans during the pandemic and economic recovery plans. But I really feel like as physicians put their lives on the line these last few years, that the nation really owes them some work to reinvest in our profession. There are some pillars to that, and this is not the totality of our work. This is really the work that's congressionally focused largely and on some state legislatures and with the administration to sort of help practices and physicians recover after these worst years of the pandemic. A piece of that is around Medicare payment. And this is not really about doctor compensation or doctor salaries, but it's about how we fund the work that physicians do so that they can fund their staffs and their practices and fund innovation. Many physicians who are in practice watching your podcast already know this, but some who are in training may not, so that Medicare payments to physicians are basically on a fee schedule, and that fee schedule has been frozen by Congress basically for two decades.
Jack Resneck: [00:25:28] So while inflation cranks away every year and physician expenses go up, it's just been a flat line in terms of payments. So physicians have really had a 20 to 25% cut in their inflation-adjusted payments. And it's just making it harder and harder as people are having to invest in all the new things we're doing around quality improvement and quality reporting and new technologies and AI and even electronic health records, it's a big problem. And if you look at hospitals or skilled nursing facilities or hospices or every other group that gets paid under Medicare, they all are on systems where every year they just get an automatic cost of living, inflation based update and physicians don't get that. And even worse, Congress just let a 2% across the board cut in the middle of this pandemic go into effect this year for physicians. So that's pretty demoralizing at this moment. And it's not just about traditional Medicare payment. We are also very engaged on making sure physicians have a diversity of options and alternative payment models, probably a whole other seminar and itself too, but so that people can reinvent their work. Prior auth is another pillar of that recovery plan. I mentioned this a little bit earlier with you guys. This is my number one pet peeve. And when I travel the country talking to physicians, this is probably the most common thing that I hear about that has just become the biggest thorn in our side.
Jack Resneck: [00:26:47] When I was in training 20 years ago, prior auth was basically something that applied to brand new, really expensive medications and procedures that had just been created and were really expensive and they were trying to sort of control utilization while the evidence base was being built. And when I travel around, every specialty pretty much has their nadir, their low moment when they realized like, this has gotten really out of control in dermatology. My low moment was when I started having to fill out prior authorizations for generic topical cortisone creams invented in the 1960s. It's just it's outrageous. And I'm literally filling out all these forms. Not only that, they almost always get rejected. The patient goes to the pharmacy ready to start their treatment. They're frustrated. They have to go home and wait while I argue with the health plan. Eventually, after the first few fax rejections, I end up on something called a peer to peer, which is a phone call with somebody at the health plan. But it's almost never a peer. It's typically not a physician. If it is a physician, it's not the same specialty. Often they haven't heard of the disease I'm treating or the medication I'm recommending. They're just looking at their computer screen and hoping I'll say or won't say the magic words to get that that drug approved. And I'm guessing what they want to hear. It's really, really frustrating and unfair for the patients. And not only is it a burden on docs. It's harming patients.
Jack Resneck: [00:28:10] We know that somewhere around a quarter or a third of patients never show back up at the pharmacy. After that week of me battling their health plan, getting the drug approved. And so their chronic disease just gets worse and gets more expensive and more difficult to treat later. We see this in diabetes and hypertension and mental health and all kinds of areas where not treating somebody really has harm. So we've been pushing Congress. The administration I just was at Center for Medicare and Medicaid Services, and they put out some great proposed rules to really rein in prior auth and Medicaid, Medicare Advantage plans. We're getting some wins in states around the country. Texas a couple of years ago passed a thing called gold carding. It's like TSA precheck for prior auth and says, hey, if you're a good doc practicing evidence based medicine and you ultimately are getting most of your prior offs approved, why on earth should you continue to even have to deal with these? You should be excluded. So those are a couple of the pillars. I probably don't have time to get to all of them. But you know, you mentioned earlier burnout and mental health. That's that's a big pillar as well. And then there are a lot of things that we're working on I suspect we'll get to in the conversation outside of that, government interference in health care has been really out of control, I think, in the last couple of years, health equity work that we're doing or other passions as well.
Tyler Johnson: [00:29:26] Before we get off of the the payment schedule piece. And we've asked this to a few of our other guests who are involved in policy. I recognize that it's controversial, but I think it's an important question to ask. You know, you mentioned the fact that one of the things that is counterintuitive about the way that physicians are paid is that even those who maybe don't have the bulk of their patients on Medicare, everything is sort of structured around Medicare payments as kind of the reference point, right? So a lot of private insurers kind of look to those to figure out kind of how they're going to how they're going to build out their payment schedules and whatnot. And I have spoken to many physicians over the years who feel that the way that the Medicare work RVU payment structure system is set up right awards proceduralists and penalizes thinkers and coordinators and people who have, you know, we might call them, I don't really like this term because it sounds sort of pejorative but softer skills, right? So, for example, a person who does procedures in the office all day or who is a surgeon working in an operating room gets paid very, very handsomely.
Tyler Johnson: [00:30:31] Whereas a primary care doctor who spends just as much time and does work, that's just as complicated as and hard, but it's maybe more about care coordination and sort of answering patient questions and whatever, rather than doing procedures in the office gets paid a quarter or a third as much as the person who does procedures, largely based on the fact that that's sort of how these what a lot of people would consider to be antiquated payment structures are set up and people have just come to sort of accept that as the de facto reality. Do you personally or does the AMA have any thoughts about how to get to a more equitable payment structure? Because I think a lot of people would point to that and say, look, the reason that there's a crisis of people going into primary care is because we don't really incentivize primary care. We say everybody says, Oh, we care about primary care doctors. We really like them a lot. But if we don't pay them to reflect how much we. Quote unquote, like them, it's hard for them to believe that that's really true.
Jack Resneck: [00:31:28] Well, let me first just go back to the higher level thing about overall payment. And while our work at the congressional level around Medicare, which, as you stated, affects commercial payments as well, because they're all based off of that pay schedule, is not, at the end of the day, focused on physician compensation. It is important to me that we continue to be able to attract great people into medicine as we have been for the last several decades. And comp is not the primary driver of what brings people into medicine or else. There's a lot of other things people would choose to do, but it has to be still a level where we can do that. And I live in the San Francisco Bay Area. Bay Area. We've got kids straight out of college going to work as coders for tech companies, making more than a lot of our physicians in the area. So I do worry about that. And so it is important to me and I'm perfectly comfortable talking openly about that in terms of sort of thinking about different particular specialties. Let me first say, so there's this this group called the relative Value Update Committee that actually the RUC, which does make recommendations to the Center for Medicare and Medicaid Services and HHS about relative payments, you should go to one of those meetings and actually watch some time. It's it's actually all the specialties sitting down in a room.
Jack Resneck: [00:32:42] And when codes come up for review or new codes are getting valued, it's pretty intense down to the level of like arguments about how many Kleenexes get used and how many boxes per day and a psychiatry office or, you know, does this procedure require clean gloves or sterile gloves because they have different prices? Does this thing really take eight minutes or does it take 16 minutes? And and any specialty that uses a particular code finds themselves questioned by all the other specialties who are going to be voting on that. And it's a it's sort of a zero sum game the way Medicare is set up. So if one thing goes up, other things come down. And so I think it's fairly different than a lot of people imagine it is. It is also very evidence based and data based. I do think there have been challenges with with primary care and primary care compensation and I'm actually quite proud that that group of people over the last few years who gets together to have that discussion. And let me say the Center for Medicare and Medicaid Services doesn't always accept the recommendations of the RUC. So it is not the end all, be all. I think it's more than 20% of the time Medicare that sits in on these meetings changes those values. That group decided to do a couple of things related to office visits, which or hospital consults now as well, which is how the codes that we use for a lot of that cognitive work that you were that you were describing.
Jack Resneck: [00:33:59] And they said the nature of office visits has changed a lot in the last few years. So first of all, they changed the way that we document and bill for those. So we no longer count up how many parts of the body somebody examined and how many systems somebody reviewed. So doctors can actually get back to writing notes that are what you need to know about your patient and doctor needs to know. So that's been a huge advancement that was brought about by the CPT editorial panel and accepted by Medicare and the commercial payers. But the other thing that they did when they did that was to just revalue those codes. And a lot of people may not know this, but that same RUC group basically recommended substantial increases in the valuation of office visits because of the fact that patients are sicker, because of the fact that doctors now have to spend two hours of pajama time with their electronic health records or time on the phone arguing about prior auth. For every one hour they spend face to face with patients, which is just an appalling number. And recognizing that complexity, they raised the value of many of those office visit codes not by 5% or 6%, but by like 20% or 30% in some cases. And that led to a compensatory decrease in a lot of the procedural codes, and that was voted on by all the specialties and approved and acknowledgment of the incredible difficulty of the cognitive work.
Jack Resneck: [00:35:22] Now has that, you know, do we still have compensation issues? Sure. And is there more work to be done? Of course, my wife was trained as a family physician, so we sort of cover the primary care specialty spectrum in our in our household. And I talk to primary care physicians all the time. Payment is an issue, but it's not the only issue in terms of the future of primary care. As I talk to primary care physicians, they also talk about existential questions about what is the future of our specialty and what does it look like. There's been a movement that that primary care physicians should increasingly take care of the sickest patients and work in teams so that they're not always taking care of the routine care, which has some advantages. But it also a lot of people went into primary care because they love developing longitudinal relationships with their patients so that when they do get sick, they actually know them really well and have that relationship with them. And in some ways that new model is a threat to that. And so there there are a whole lot of other issues that I think are important, but it's important that we talk about all of them.
Tyler Johnson: [00:36:25] Yeah. So I wanted to ask you one question that I think you were just mentioning this these existential questions about what? Particularly about the future for primary care doctors. But I wanted to talk for a minute about what I think is an existential question for really all occupations right now, including medicine. So, you know, the big thing over the last few weeks in the news has been chatgpt bots, right? And the sort of the rise of artificial intelligence. And we've discussed with some of our guests before the fact that so in my world of oncology, 5 or 10 years ago, there was this huge thing about that there was going to be a partnership between MD Anderson and an artificial intelligence company to try to bring artificial intelligence to the diagnosis and treatment of cancers. That ended up being a total flop, right? And so which is just to say that just because there's a promise of artificial intelligence in health care doesn't mean that the reality is there yet. But nonetheless, I think that everybody agrees that AI and other health technologies are going to change things. We just don't know how much and in which ways. But I guess as as the head of the AMA, how are you thinking about that coming digital revolution and where do you see the field going as far as our the way that we incorporate technology into the work that we do?
Jack Resneck: [00:37:46] We spend a lot of time thinking about this. We actually have a large cadre of of experts in the organization. We are showing up everywhere that people are gathering to talk about the future of digital technologies in health care. And part of what drives us is a recognition that if you ask most physicians when their electronic health records first came out -and EHRs are a great thing, I don't want to go back to paper- but if you ask talks about what it was like those first couple of years, most of them will tell you there is no way that a physician was involved in designing this particular tool. It does not address our daily needs. And there they were really difficult. And in the same way that that prior auth is the loudest thing I hear about now. A few years ago it was the number one complaint of physicians in practice was lousy HR tools and we don't want to see that repeated with e-health apps, with augmented intelligence, with other things. So we're really trying to make sure that physicians and physician value sets get get inserted early in the innovation process.
Jack Resneck: [00:38:47] So. So what does that mean? Well, first of all, I would say physicians sometimes are getting painted in the entrepreneurial world as sort of fuddy-duddies who don't want to see innovation or threatened by it. To the contrary, like docs have been pretty engaged in innovation throughout the history of medicine, and we're pretty excited about some of the cool things that can happen. In health care, we just get a little bit more nervous about the sort of "move fast and break things" approach from the technology sector because when something doesn't work and actually gets deployed, we hurt people and we have higher standards about the evidence base that we need before we do that.
Jack Resneck: [00:39:23] So let me talk a little bit about what we're doing. So for any of these digital tools, we ask a very similar set of questions. The most important one is, does it work? Because in this space it is possible to get things funded and sometimes sold based on a whole lot of hype because a tool sounds really cool.
Henry Bair: [00:39:45] Theranos.
Tyler Johnson: [00:39:46] We're looking at you, Theranos.
Jack Resneck: [00:39:47] Okay, so you've got the big example and but we see small examples every day of things that get deployed. And and it's not just does it work, but it was shown to work in one place or in one population. But has it actually been tested in the venues where it's going to be deployed? Because we see things that get developed in one health system or at one company and they're very brittle when they go out in the world and you discover that based on the learning set, it's not applicable everywhere. And then there are questions just does it actually advance health care? Is it addressing a big gap in care or is it addressing some non-need that we don't even have if we're going to be investing in it? And does it work in my practice? Right. So a cool tool that like measures somebody's blood pressure 45 times a day, but reports it in a giant Excel spreadsheet that gets uploaded. We don't have doctors twiddling their thumbs ready to look at that. It needs to sort of analyze is there a problem here? And notify the doctor when they need to know or analyze the data and useful ways. So, you know, if you go to your if you pick up your iPhone right now and go to the App store and put in blood pressure monitor, you'll find a lot of apps that actually say put your finger on the camera and we'll give you a blood pressure reading. And someday that actually might even work. But right now that tool is most useful. If you need a random number generator for your research, it's not useful to actually determine blood pressures.
Jack Resneck: [00:41:04] In my field of dermatology, we had a great tool and we're not threatened by this, I would love the help of an AI tool to actually look at moles and pigmented lesions and help me determine for some of the ones on the edge whether they need a biopsy or not. And that's a great deployment of AI. But one of those tools that was created shown to have great sensitivity and great specific. He actually put out into the world. Some enterprising young person decided to ask like, what were the training sets that this tool learned on? And they hypothesized because they couldn't actually get the training sets which were proprietary, which is a whole nother problem in this space that the melanomas that the AI tool learned from were probably preoperative melanomas that had been biopsied. And when you're going to take out a big chunk of somebody's skin to get a safety margin around a melanoma, you often draw surgical markings to plan your closure or your flap or anything. And when you're just biopsying a little non-melanoma pigmented lesion that turns out to be benign, those are pre biopsy photos that don't have surgical markings.
Jack Resneck: [00:42:05] So they took this tool and submitted a bunch of moles and the exact same picture with and without like a purple oval line around it. And sure enough, the tool had learned that the surgical markings were predictive of melanoma, and it came out with different results. We see the same thing in the health equity space, where another fear of ours is that AI tools, if you don't go into them thinking about solving health inequities or not cementing those health inequities at the ground level, when you create the tool, you actually can do real harm. A large health insurance company, you may have seen this reported in the media, came out with a tool a few years ago with good intention, and it was supposed to comb through tons of claims data and the medical records that this insurer had access to, to look at patients with chronic diseases, diabetes, COPD and predict which ones in the next year might have big exacerbations that would lead to hospitalizations so that they could divert more resources to those patients to try to prevent their chronic diseases from running off the rails. Well-intentioned. Good idea. But the system was taught based on a proxy for health care needs, and that proxy was looking back at people and what was actually spent on them in the year ahead. And not surprisingly, if you think about this, minoritized marginalized patients have less access to health care and end up getting less spent on them because they're less likely to be as well insured.
Jack Resneck: [00:43:30] They might have higher deductibles or co-pays. They might not seek care because of those deductibles or co-pays. So again, after the tool was out in use, being being used in this case on millions of people to make resource allocation decisions, somebody decided to feed the AI tool the exact same patients, only changing the race of the patient. So exact same medical history, everything else. And what did it do? The tool flagged the white patients as needing more resources than the black patients. So I just think while we're excited about these tools, we just want a lot more work at the front end to make sure that they're being designed in ways that advance the health of the nation, that do so in ways that are useful, that deal with health inequities. So we're sending physicians to be engaged in this innovation cycle alongside entrepreneurs and alongside their funders. We're thinking about regulation and what the FDA needs to do to make sure that these tools are treated not that differently than drugs, when they're going to be making health care decisions and actually have created our own unit in Silicon Valley called Health 2047, where we're spinning out companies that have more of that sort of health physician value angle on them.
Henry Bair: [00:44:38] Yeah, that's really fascinating. There's a there's plenty of robust data studies that have looked at the time it takes for a new innovation to be developed and then actually implemented in health care practice. And that number based off of a lot of estimates, is around 17 years. This is not just digital health. This is just innovation in general, like a new treatment, a new drug or something. For the moment, it's first discovered until actual widespread use. It's about 17 years. And if you think about that in in the time frame for digital technologies in particular, that is 17 years is like eons. 17 years ago we didn't even have iPhones. So my thinking is if medicine doesn't keep up with the ways that digital tools are changing, potentially changing the ways we practice, by the time we're trying to validate things five years down the line, six years down the line, the cutting edge of technology has moved so far beyond what was being worked on five years ago that will always be playing catch up. So I think your idea of encouraging more physicians to be involved at the outset is actually a fantastic idea.
Jack Resneck: [00:45:42] Yeah, I would say, though, the difference between validating something well and validating it poorly actually doesn't take that much longer. So if you design things right up front and you actually think about this before you start down the entrepreneurial path, it doesn't need to lengthen things. And a lot of what you see in that 17 year lag is actually an uptake lag. And and part of that is, you know, physicians in this AI space are going to be facing thousands of tools and all kinds of options that are out there. And if you happen to work at a big health system like I do at UCSF, we have teams of people in the technology and digital innovation space who actually can evaluate tools for us and try and decide what works and what's dangerous. But imagine for the individual physician in practice trying to choose among all these tools and trying to look at an evidence base and what's going to help their patients, what might endanger their patients, what might they get sued for using, What might they get sued for not using? What's going to be reimbursed and compensated so that they can afford to use it. And so I think at our level, at the AMA level, thinking about what is it going to take so that when tools come out, physicians actually have what they need to make those decisions in the same way that with a new medication, an oncology or whatever else, there's an RCT, a randomized controlled trial. The data are in a big journal. You can actually see the demographics of the patients in whom it was tested and make reasonable decisions. We're seeing a lot more proprietary stuff that's not put out for the same level of study in the technology space. And if we can convince those companies to do that work, physicians will take the plunge and utilize them more quickly.
Tyler Johnson: [00:47:15] So we know that our time is running short. I want to make one final pivot. We've alluded to this multiple times, but I did want to give you a chance to address it more directly, both the AMA specifically and just sort of the medical establishment in general, obviously has a very fraught history in the United States with race relations, Right. So whether you want to look, as you mentioned, the Flexner report or if you want to look at the Tuskegee study or whatever, we could go through and tick off all the things. But I think what what is dispiriting to many people is that in an era where we, you know, talk freely about things like Black Lives Matter and anti racism and all the rest of it, there is still clear evidence that patients receive disparate care based on the color of their skin and also that the medical establishment itself. Does not yet reflect the full diversity of the country, which, if anything, is going to be thrown into an even more fraught position. If what seems likely holds in June when the Supreme Court may rule that affirmative action in any form is is illegal. Right. So I guess given the multiple layers of that problem within medicine, everything from establishing the workforce to the way that the workforce then delivers care to the to patients. How are you as head of the AMA, thinking about engaging with that very complex, fraught, you know, emotionally charged problem?
Jack Resneck: [00:48:48] It's a real problem and an issue that, again, is very high on our list. It was just on a webinar with Harriet Washington and several others on health equity and racial justice a couple of days ago. The evidence is overwhelming, as you noted. Right. So we have appallingly different outcomes for patients based on their zip code, based on their race, ethnicity. And we know that there are a lot of things built into the system that lead to those things. So a lot of that is upstream public health issues. And that's why physicians have increasingly engaged around food insecurity and housing insecurity and education and things that actually end up driving those consequences that we see in our office. And we also know that there's unconscious bias and their data are very clear on this among physicians. And I think this has gotten so politicized that it sometimes gets pushback from physicians who feel it as an individual judgment about individual racism. But it really is about unconscious things that that cause physicians who think of themselves as really trying to provide the same care to everybody to somehow end up being differentially likely to give pain medicine to a black patient in an emergency department versus a white patient in an emergency department. So so we live on data and evidence in medicine, and those data and evidence are clear. And I think that's one of the reasons why our House of Delegates at the AMA has been very clear in the last few years that this racism is a public health threat and that we have an ethical and moral responsibility as physicians to work to solve that problem.
Jack Resneck: [00:50:22] So we put out a couple of years ago a very comprehensive plan. People can look it up on the Internet to Embed Racial Justice and Advance Equity in Medicine. It's grounded in science and evidence, and it is aligned with policies from our House of Delegates that the profession told us to to move forward with. You know, eventually it will be successful when it solves those zip code and race problems in terms of different outcomes. But in the shorter term, and I was chair of the board when we were first implementing this and a huge team of people have been involved and we've had Aletha Maybank leading the Center for Health Equity at AMA, which now has over 50 employees and has been partnering with other groups around the country to do some really amazing work that I am proud of. And my sense at that time was this will be successful in the short to medium term if we see it not as siloed work. Okay, we've created a center all good, but as work that should impact everything we do across business units in the association. Right? So whether it's affecting our litigation center and the fact that we went and sued the FDA for failing to do its job for so long to get menthol out of cigarettes, which was clearly targeted at young black men for for generations with devastating health consequences, whether it's our chronic disease unit that's focusing on really unacceptable differences in outcomes for pre diabetes and hypertension and black and brown communities.
Jack Resneck: [00:51:45] Our medical education group, which is focused on a lot of things, a changing the curricula of medical schools and the environment in medical schools so that we train a new generation of physicians who actually have the skills they need to go out in their communities and affect health equity locally. And then you mentioned pipeline. We still have physicians who are nowhere close to representing the diversity of patients who we take care of. We did brief in that Supreme Court decision, Supreme Court case that you mentioned. They may have a lot of activity in the federal courts, and that is a case where we spoke up that we think we need to continue to be able to take account of race, among many other things, as we choose among large pools of qualified, highly qualified applicants to medical school. We it's not that every visit needs to be race concordant. While some patients may want that and choose that, it's also just that having diverse colleagues during your training completely affects your understanding of health inequities and your ability to deal with those and the conversations that take place in medical school. I mentioned our innovation group and how much it's affected by its work around health equity and making sure that that new tools don't worsen them. It affects our advocacy team every day. We were involved recently in discussions about extending telemedicine beyond the pandemic and making sure that the government continues to pay for telephone only as an option and not just video.
Jack Resneck: [00:53:07] Because I have patients in California who are farmworkers who don't have a high speed Internet connection, who literally call me on a break from the fields in California, and we need that to continue to be an option. So in terms of the way our advocacy team thinks. We're invested in Chicago, our headquarters are in an area called the Loop downtown. Lots of fancy buildings, beautiful architecture, but just a couple of miles away on the west side of Chicago, there's an appalling I forget the exact number, but I think it's about a 14 year life expectancy gap between people who live in that area and where our office is. So we've invested in a large microloan program that's that's actually trying to bring up that neighborhood and improve the health of that neighborhood. So I think if you don't sort of invest in your own backyard, you can't be an example to the nation. So this is really important work to us. There is pushback because like many other things in the last few years, it's unfortunately been politicized. We saw neo-Nazis protesting outside of a Boston children's hospital recently against physicians who were actually doing this health equity work and making threats against them. Very similar to threats we've seen against other physicians doing equity work for transgender patients and many other situations. So it's so important to me that we protect people who are doing this work and that we really work to bring science back to the fore and to depoliticize these efforts.
Henry Bair: [00:54:34] Thank you so much for going into all of that with us. You know, one of the one of the best things about talking to someone in your position in the AMA is that you are involved in so many aspects of American medicine. And it is impossible for us to talk about all the things that we would love to talk about in the confines of an hour. But I think given the time we had, I think we definitely delved into some things that that were really thought provoking. And we want to thank you so much, Dr. Resneck, for taking the time to join us and to share your reflections and your experiences and the work that the AMA is engaged in right now.
Jack Resneck: [00:55:08] Thanks, Henry. Thanks, Tyler. I have to squeeze in one more thing, if I can, which is, you know, we talked a lot about burnout and challenges, and Tyler read that one kind of alarming quote from a few years ago. I just want to say that I'm not discouraged. I do love my job. And I think that what we get to do as physicians and medical students is a real privilege to actually get to walk in a room and sit down with a patient, try and solve their puzzles of their problems and offer help and advance their health with informed consent and kind of sharing what their values are and what that adds to the equation. And as I said earlier, we really want to preserve and renew this profession for the next generation. And I'm hopeful and I'm optimistic because of AMA's work and because of the amazing students and residents I see coming into the into the profession. And for me personally, I have loved getting to wear two hats of both coming home and sitting in that exam room with individual patients and also getting to be president of the American Medical Association and try and drive policy forward so that we can advance the health of the nation.
Tyler Johnson: [00:56:09] I really appreciate that optimistic note to finish on. And I think that although our way of going about things obviously is very different, right. You're working at this 30,000 foot view, not that you only do that. I know you also see patients in clinic, but when you're wearing your AMA hat, you're working from the 30,000 foot view and trying to rally colleagues around complicated policy initiatives and then trying to work with Congress and the president and and state legislatures and whatever to enact things. I think that Henry and I join with you in your vision of a renewal of American health care. Right. Like, I mean, we spend a lot of time talking about problems on this podcast and we spend a lot of time delving both into the 30,000 foot view problem and also into the just the great difficulty of being witnesses to the suffering of individual humans. And yet the overall bent of the podcast is optimistic because our hope is that we can help to renew the sense of meaning that I think drives just about everybody who writes that first essay about why they want to get into med school. So at least insofar as that goes, we we we find common cause with you. And really thank you for coming on the program.
Jack Resneck: [00:57:23] Well, thanks so much for having me and thanks for your work and for shining a light on all these really important issues.
Henry Bair: [00:57:31] Thank you for joining our conversation on this week's episode of The Doctor's Art. You can find program notes and transcripts of all episodes at www.thedoctorsArt.com. If you enjoyed the episode, please subscribe rate and review our show available for free on Spotify, Apple Podcasts or wherever you get your podcasts.
Tyler Johnson: [00:57:50] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor, patient or anyone working in health care who would love to explore meaning in medicine with us on the show, feel free to leave a suggestion in the comments.
Henry Bair: [00:58:04] I'm Henry Bair.
Tyler Johnson: [00:58:05] And I'm Tyler Johnson. We hope you can join us next time. Until then, be well.
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LINKS
In this episode we discussed several reports and articles, including:
The Flexner Report, a 1910 survey of the medical profession that was used to standardize medical education and practices but unfortunately also embedded bigotry within the field’s protocols.
How Being a Doctor Became the Most Miserable Profession by Daniela Drake for Daily Beast, an article about burnout.
The Lorna Breen Health Care Provider Protection Act, a recently-passed legislation aimed at helping physicians.
Follow Dr. Jack Resneck on Twitter @JackResneckMD.
