Political or Practical (Fishbone Diagram)

In his recent post, David shared reactions to the recent AMA Annual Meeting in Chicago. Its dwindling membership has led us to question the direction the organization is heading. While we at Two Directions agree there are numbers in healthcare which should not rise, we look to reduce costs and would prefer to increase participation.

To analyze the problem we’ll use the Fishbone Diagram tool, and hope to accomplish the aim of this blog: to demonstrate how QI tools are used so they can be more widely applied to healthcare. In doing so, we also hope to consider solutions to the AMA’s dwindling membership. Given that several of us writing are members, we hope this process can inform our own engagement with organized medicine.

Fishbone Diagrams are a tool to conduct root cause analysis. Here, we’ll look for the root cause of the problem: why do so many doctors not participate in their main professional organization? To analyze this problem, we will organize our brainstorming into categories. This structured approach to problem solving is a technique for physicians to approach QI. To be not only creative, but effective, brainstorming often needs to follow a method; especially when working with a group. Because the AMA is essentially offering services to members, we will seek root causes by organizing our thoughts into the following service oriented groups.

Product Place and time Price Promotion Process People Productivity Purpose

As a happy coincidence, each group starts with P. A few notes about them:

• The first 4 P’s listed above are the classic 4 P’s of marketing
• While QI analysis usually considers “Process” in the scope of a product delivery or manufacturing, in this post we want to focus on the AMA’s legislative process. In a sense, it is a manufacturing process for crafting its organizational objectives
• Since the AMA acts as an advocacy organization, its Purpose is an important factor in determining its quality

To begin filling out this bare-bones diagram, consider how the AMA’s products alienate or fail to meet the needs of potential physician members. As we begin to fill an empty white board, we'll recognize that the product faults we identify are better categorized into another group, such as Place and Time.

CPT Codes. The use of the Current Procedural Terminonology codes to bill insurers is responsible for a large part of back office overhead. Physicians are often required to use these codes to receive reimbursement. Since the coding system changes often, physicians must hire employees who maintain this specialized skill.

Yet, the process adds no value to the Patient-Physician relationship nor does it improve patient health. Sometimes regarded as a cozy monopoly fostered by the AMA and insurers, CPT codes complicate the relationship between physicians and patients. The complexity of the coding system edifies the overhead expense of a medical coder, and facilitates the insurer practice of holding up or denying legitimate claims. Despite this detriment to physicians and the practice of medicine, CPT licensing generates annual revenue on the magnitude of tens of millions of dollars for the AMA.

Advocacy. Many physicians feel the AMA advocates for positions which they don’t agree with. Rather than advocate, the AMA may do better to inform. Individual physicians could then better assess how the actions of Congress fit with their personal views. Rather than pay professional lobbyists millions of dollars, the AMA could further shift its focus towards empowering physician's to use their voice in public forums. Again, the AMA's current approach fails to add value for physicians but does reward the lobbying firms the AMA retains. (Product)

Development.The AMA purports to be a professional organization, but has been overtaken by physicians with a fetish for politics. My own experience at A-11 had few opportunities for professional development. The main event was the legislative process. Medical students were exposed to JAMA, AMPAC, pomp and circumstance, but essentially no guidance on the transition from medical education to medical professionalism. A review of the AMA website points to some professional guidance. However, much of it seems to reinforce other AMA products such as the CPT codes. Google is appreciated by its users because the new technologies it offers are designed with the intention of making Google more useful. The AMA is unappreciated as its products seem to only reinforce its necessity.(Product)

The AMA does provide a generous experience to get involved with politics. Participation would likely bolster professional skills; politics and marketing have much in common. However an intensive course, set in Washington, D.C. is impractical to the demands of medical training and practice. (Place/Time)

Continuing Medical Education is a component of a physician's ongoing training which does have the potential to add value to the Patient-Physician relationship. CME offerings compete in a crowded market. The AMA offers CME credits through JAMA and via its Annual and Interim Meeting. Overall, a physician's specialty is typically more successful at meeting educational needs by offering more relevant CME topics. (Product & Place).

A fishbone diagram could capture and portray this analysis as: