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Medical Organizational Politics

¹ Department of Radiology, Richard L. Roudebush VA Medical Center, Indiana University School of Medicine, 1481 W. Tenth St., Indianapolis, IN 46202.

Received May 8, 2001; accepted after revision May 8, 2001.

 
This is the final installment in a series on noninterpretive skills for residents in diagnostic radiology from the American College of Radiology and the Association of Program Directors in Radiology. Editor: Jannette Collins.

Address correspondence to J. A. Knote.

This is the final installment in the Noninterpretive Skills series. The reader's attention is directed to the earlier articles: Introduction to the Series, which appeared in the December 1999 issue; Job Search and Contracting Issues, December 1999; American College of Radiology Standards, Accreditation Programs, and Appropriateness Criteria, February 2000; Critical Thinking: Deciding Whether to Incorporate the Recommendations of Radiology Publications and Presentations into Practice, April 2000; Practical Business Aspects of Radiology, June 2000; and Customer Service and Satisfaction in Radiology, August 2000.

Introduction

Top Introduction Political Involvement Power of Political Groups Process of Providing Input Predicting Change References

 
All physicians encounter basic challenges as we begin to practice or teach, in addition to learning to apply the knowledge and experience gained in training. These challenges include not only selecting a practice site and home, but also adjusting to new associates (and vice versa), developing relationships with referring physicians and other medical professionals, and learning how to interact with medical care administrators. Although self-motivation usually ensures success during residency or fellowship training, most challenges in the transition from training to practice involve extrinsic influences, including local, state, and national regulatory processes.

Regardless of the excellence of your training program and your professional dedication or talent, your success as a practicing physician will be determined not only by your objective knowledge of your specialty, but also by subjective criteria. No case study—or series of cases or double-blinded studies—can prove that both our success in caring for patients and our reputations ultimately depend on political interaction, but undoubtedly political involvement and the political process are major determinant factors.

The purpose of this article on medical organizational politics in the Association of Program Directors in Radiology series on noninterpretive skills is to alert practitioners to the scope of political involvement necessary to practice successfully. Politics influences medical specialty practices throughout our professional lives.

For this discussion, "politics" is defined as the application of practiced wisdom, personal experience, and diplomacy to promote plans or philosophies through group influences on other interacting groups or individuals. A common misconception exists among radiologists that medical politics begin and end with the American College of Radiology (ACR) and the American Medical Association (AMA). However, professional practice groups, groups that refer patients, hospital boards and administrators, county and state medical societies, and other national organizations are essentially political organizations as well. These state and national groups may represent general medical interests or specialty interests. Moreover, radiologists also interact with officials of municipal, state, and federal governments.

Before graduation, the process of training and certification is governed by regulatory bodies, with input from professional and public political groups. Examples of such groups are the Accreditation Council for Graduate Medical Education, residency review committees, specialty boards, and state licensing boards. Each of these certification—licensing bodies has members appointed or recommended by medical political groups. In short, all of these political groups interact and control much of radiology training and practice.

Political involvement can take several forms: leadership, participation, support, or avoidance. Political leaders guide and direct other people and interact with outside interests to promote the ideals and requirements of their professional organization. Political participants serve on committees, councils, and advisory groups that influence the policies and direction of their professional organization. Political supporters contribute funds or time (allowing others to participate more directly) to their organization. "Avoiders" do none of the above, and thus allow those who do participate in political activity to control their destiny.

Political networking can positively influence the purchasers of medical equipment after other efforts have failed to convince a hospital administrator and board of trustees that an expenditure can be justified. Participation in community activities and personal communication skills reveal personal interests of the administrator and identify influential members of the board. Interpersonal relationships with these individuals establish credibility. Individual credibility convinces the decision-makers that the benefits of the equipment outweigh the costs, and the department obtains the equipment. Not only do patients receive better care, but the respect gained from referring physicians enhances the radiologist's influence in his or her group. By our definition, this is politics, as surely as activity in the ACR or AMA is politics.

Political Involvement

Top Introduction Political Involvement Power of Political Groups Process of Providing Input Predicting Change References

 
One sometimes hears that "those people" in organizations or legislative bodies have "all the power." This is true, because no legislative or regulatory group (from the federal government to the local hospital board) can respond efficiently to each person on all sides of multiple issues. The power is generated by groups who form to resolve issues and who are able to enforce their resolution because of their numerical and monetary resources. Participation in such groups requires people meeting people, serving on committees, taking ethical positions, and voting accordingly— in addition to seeking positions of influence or supporting those who do. One gets involved in organizations by meeting people, understanding issues, and volunteering time or money. Examples of such issues include assisted suicide, tort reform, mandated coverage, managed care, and of course Medicaid and Medicare. In addition, research spending, work-force issues, antitrust reform, and public health issues also affect radiology. Turf battles and the involvement of nonphysician practitioners in our area of expertise must be of serious concern to all radiologists.

Occasionally, one laments that "there are not enough of us to make a difference." Well, one person can make a difference. One person can represent a small county in a small state where there are no metropolitan numbers for voting support. The process involves being available, speaking up, being considerate of other viewpoints, and developing an interpersonal network.

Power of Political Groups

Top Introduction Political Involvement Power of Political Groups Process of Providing Input Predicting Change References

 
Some new physicians are recognizing the importance of political involvement. David H. Miller [1], a first-year radiology resident, wrote that "the health care environment in which we practice medicine is rapidly evolving, and we must speak out if we're going to make a difference." Miller also stated that his "new perspective on involvement in organized medicine," resulting from attending an AMA leadership conference, included the concept that "organizations gain more power as they represent a greater number of physicians." He wrote that "for those interested in political aspects of organized medicine, a letter or telephone call to a member of Congress can have significant effect." He also observed that "most organizations are run democratically; if someone has different ideas and is willing to become active and push for change, these ideas may garner support and eventually become policy." Individual confidence to develop and promote ideas without regard to who gets the credit is a basic tenet of politics that propels an organization. This is similar to the concept embodied in the best-seller The Tipping Point: How Little Things Can Make a Big Difference, by Malcolm Gladwell [2], that "infectious ideas" spread like epidemics of illness and their origins are obscure.

An example of the spread of an idea, and how one person can make a difference, is embodied in an AMA resolution, submitted only a few years ago by a medical student whose organization had recently gained the privilege of voting in the AMA. That resolution called for the AMA to support and strive for a "smoke-free society by the year 2000." (Lest we forget, not many years have passed since a cigarette company touted its product as the one preferred by one out of three doctors.) It is 2001 and America is not smoke-free, but the passage of that resolution meant that everyone now recognizes the AMA to be the leading antitobacco lobby in Washington, DC. This transformation was initiated by a single medical student who recognized that by political activity he could get the AMA to amplify his own thoughts and make them the policy of a powerful organization.

In the ACR, a minority of councilors who wanted more direct involvement in choosing the members of the council steering committee and the board of chancellors introduced a resolution that led to an ad hoc committee study. That study resulted in 11 positions in contested elections, and the transition occurred over only a 3-year period.

Interest and involvement in medical political organizations affects radiology practices and patients. The ACR (Appendix 1) and the AMA (Appendix 2) make recommendations or appointments to numerous committees and regulatory boards that affect radiology practice. The ACR or AMA also make recommendations to some ad hoc committees, such as the Task Force on Evaluation and Management Documentation System, Physicians for Responsible Negotiation (collective bargaining), and the President's Commission on Consumer Protection and Quality in Health Care.

Members of the ACR or AMA are entitled to offer input to representatives concerning various groups and activities that may affect their organization, their day-to-day practice, and the well-being of patients served. A more active role such as service on a committee, commission, or council affords interpersonal relationships with representatives. Leadership involvement on a board of chancellors or board of trustees provides an opportunity to participate in the appointment or nomination of representatives to various groups charged with health care decision making. If one individual does not want to influence organizations that have substantial control over radiologists' careers, another individual will. It has been said that "you'll never get any other self-interest group to fall on your sword of self-interest" (Dunn M, personal communication).

Process of Providing Input

Top Introduction Political Involvement Power of Political Groups Process of Providing Input Predicting Change References

 
The mechanism for policy input starts with submitting a resolution to the appropriate organization (ACR or AMA) through a state or specialty organization. A member can submit such resolutions individually. During reference committee deliberation at national organization meetings, a member may testify in support of his or her resolution and other resolutions. If a resolution passes the Council (ACR) or the House of Delegates (AMA), it becomes policy of that organization (just as the governance resolution became policy of the ACR, and a student's antismoking resolution ultimately led to recognition of the AMA as the leading antitobacco lobby in Washington).

If a proposed policy is not accepted, the educational experience will help make the next resolution more acceptable. In addition to being an opportunity to learn from personal mistakes, politics offers a chance to learn from the mistakes of others (none of us lives long enough to make all the mistakes ourselves).

Predicting Change

Top Introduction Political Involvement Power of Political Groups Process of Providing Input Predicting Change References

 
Being involved politically as a supporter, participant, or leader (not an avoider), however, may not be enough. Success depends on knowing or anticipating future challenges and successes, and recognizing talent in others. Tom Peters [3] in Re-inventing Work: The Work Matters! states that "ninety percent of economics today may be in jeopardy due to developments in information technology, globalization, and deregulation. Upheaval and chaos may prevail for those unprepared." Medicine is not immune to these changes. Peters also writes that "economic value is gravitating to the information technology/information system axis." Gravitation of economic value to this information and technology systems axis appears to be occurring in medical practice, with medical information and quality monitoring data readily available to patients. The relative importance of specialization may decrease as more people have objective medical information. In effect, patients will know more and may be unwilling to pay for information they have obtained from available data systems. Grossly, this is the same phenomenon as in what may be called "the managed care syndrome." Many physicians and patients rushed to "be first" in their community. No thought was given to the reaction of the market-place when everyone is first (i.e., when everyone has the same discounts).

However, in a world where objective medical knowledge and decisions are shared nearly equally by practitioners and recipients, subjective factors will more actively dictate control and application of medical quality and economics, and that is the province of politics. In a recent editorial in Radiology, Brown and Evens [4], by outlining the activities of the Radiology Advocacy Alliance and the Academy of Radiology Research, make the case for lobbying and interest groups as the means to promote a core ideology. Since their editorial was published, the Radiology Political Action Committee has been formed through the alliance. Emerson [5] wrote in the summer 1999 issue of the Ducker Foundation's journal, Leader to Leader, that "the power of advancing technologies to expand the horizon of a local practitioner becomes the glue that connects to the larger world." In that world, where as Somerville and Mills [6] state, "politics is local, power is now global, and the disconnection is explosive," medical practitioners must attempt to minimize the disconnect and maximize the power, for positive results.

We can optimize the results by participating at the appropriate political level, recognizing change and benefiting from its dynamic situations, and knowing the issues. A simple exercise by which to establish perspective on the need for involvement in medical political organizations is to peruse the 1999 ACR Bulletin index, or to review the table of contents in the ACR 2000 Resource Guide. The point is to maintain integrity but also develop a communication network. "Obscure but secure" is no longer an acceptable philosophy. "Backroom politics" are acceptable, but only if done in the front room.

,

References

Top Introduction Political Involvement Power of Political Groups Process of Providing Input Predicting Change References

 

1. Miller DH. The value of involvement in organized medicine. ACR Bulletin 1997;53(5):28
2. Gladwell M. The tipping point: how little things can make a big difference. Boston: Little, Brown, 2000: 7.
3. Peters T. Re-inventing work: the work matters! Boston: Tom Peters, 1999:3 -5
4. Brown JJ, Evens RG. Public policy: the case for lobbying in radiology. (editorial) Radiology 2000;214:321 -324.[Free Full Text]
5. Emerson J. Leadership of the whole: the emerging power of social entrepreneurship. Leader to Leader 1999;13:12 -14
6. Somerville I, Mills QD. Leading in a leaderless world. Leader to Leader 1999;13:30 -38

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