The AMA Does NOT Represent Us

What’s up, fam? I hope we’re live. I’m still trying to figure out how to run this garage studio by myself. It’s your boy, Dr. Zubin Damania. This is the ZDoggMD show live Saturday, holiday weekend. I don’t care, by the way, props to everybody who worked this weekend. You guys are heroes because I used to work every single Thanksgiving, and actually, I chose to do it because it was slow. It’s the day after Thanksgiving that really, really sucks because that’s when all the dietary malfeasance comes to roost in the form of CHF, diabetic disasters, etc.

So anyways, welcome. I’ve got your comments pulling up here in just a minute. Josette is here. I want to talk about the AMA, not my show “Against Medical Advice,” which is the superior AMA, but the organization the American Medical Association. Ever since I was a medical student, these guys have been lobbying for me and hundreds of thousands of other physicians to join their organization saying that they’re advocates for physicians, and that they represent us, and that without this collective organization and this voice, we would be run over by insurance companies and government and pharma and everybody else.

How’d that work out for us? We’ve already been destroyed, and I would argue that the AMA, rather than helping, has actually made this problem distinctively worse. There are many reasons for this, but the primary one sort of comes to mind from a tweet they put out today — and I linked to it in the description — but let me just summarize here. The tweet was this: Can medical schools create physicians who are more effective and efficient working in the EHR? Experts tackle the question.

That they would even tweet something this idiotic is a sign of how out of touch our so-called leadership, our organized medicine has become from frontline clinicians. This tweet triggered generalized outrage on Twitter, including from myself, because this is the premise. Why the hell should we adjust and teach and poison the next generation of physicians into training them to work with a user interface that is about billing and compliance, and click, click, click, click, click instead of actually looking our patients in the eye, instead of actually spending time at home with our families, instead of charting, instead of destroying the way we think?

Actually, that’s the worst sin of our current generation of EHR. It has destroyed our cognition so the way we actually think about clinical medicine is altered by the way we have to document it. In the old days, you would actually write. You would physically write notes, and they would be very concise because you have to write, and that mind-physical connection actually changed the way you thought, so when you wrote your note, you actually started to think out, “What am I going to do with this patient?” You spent quite a bit of that encounter actually spending time being present with the patient. You would get on the phone or you would go walk to the lounge to talk to other clinicians or the nurses or the respiratory therapist or the dietitian or whoever it is that you needed to get more information from.

Electronic silos didn’t exist. Humans who evolved, actually, to be together, interact in real-time — not through a screen, not through email, not through staff messages, not through click boxes — would actually exchange ideas. Creativity would emerge, clinical reasoning would flourish, and patients would get taken care of.

Now, was it perfect? Hell, no! Health 1.0 was kind of a mess in that it’s fee-for-service, it’s patriarchal, paternalistic. There are a million problems, inequitable and unsustainable. Sure! Fine, we need technology to help us practice better, to give us the quality improvement, the quality science, and the randomized controlled trials that allow us to practice better. But what’s been sucked away is that human juice, that analog heart of it that makes it a healing, sacred profession.

The AMA, which should have been protecting us from this rape of our profession, instead has enabled it not just with this stupid tweet, which is dumb. They enabled it because the predominant source of their income is the clinical procedural terminology or CPT codes, the very billing codes that they want us to train the next generation of medical students to optimize their ability to work with through the cash register that they helped create: the electronic health record. Let that sink in. AMA makes the predominance of its income through CPT codes and their copyright on CPT codes.

They have a massive building in Chicago. They have a big staff and this is the thing. I know a lot of the doctors who work at AMA. They are good people trying to do good. The organization is rotten and I’ll tell you why. It’s risk-averse. It does stupid shit like tweet stuff like this about, “Maybe we can teach our medical students to adapt to this piece of shit that they call an EHR that’s really a glorified cash register with a little patient stuff tacked on to keep the doctors from openly revolting.” This is our so-called representative, right? These are the people who are supposed to represent us. No. No more.

First of all, they don’t even have a quarter of physicians as members. It’s a tiny membership. They send all kinds of flyers out, at great expense, trying to get doctors to sign up or to buy insurance through them or hock other stuff so that they can pay for their bloated crap and do absolutely no good for us. Our state organizations are much more nimble. There are other organizations, actually. For example, the competitor to the American Board of Internal Medicine, which is a crony organization. Basically, it’s designed to use maintenance of certification to basically torture physicians and enrich themselves. You have NBPAS and other organizations. You have other organizations that represent physicians.

You know what? I would love to see an organization that represents physicians, nurses, housekeepers, environmental engineers, administrators, everybody. You know what that organization is called and it actually doesn’t charge dues? It’s called us. It’s called what we do on social media together. It’s called going and having your voice heard in a group of people that shares a goal. The goal is to make health care sustainable for our patients and for caregivers. We all have different ideas of how we might get there, but the goal is the same, which means we share a common approach and a common tribal identity. We are beholden to no one. We’re not making our money off of the very billing codes that broke the profession.

Let’s read some comments. Thanks for the stars, Josette. “I scribe for my doctor,” says Rhea. “He’s always looking the patients in the eye and he’s able to focus on the exam. There’s usually a special relationship between doctors and the scribe. It’s better when you have two people who scribe for that.” This idea of scribes. Look, you’re making it better in the sense that you’re freeing the doctor to do this thing, but how about this? How about fix the user interface? I’m not saying get rid of EHR. I’m saying fix it so that it’s actually a patient care device instead of the bloated crap.

By the way, I’ve been too nice to people like Epic. They are making a ton of money, knowing full well that this thing does not actually help patient care, period. They need to stop doing that. They need to listen to physicians that their user interface is garbage. It’s actually destroying the way we think, and it’s destroying our relationship with patients and with each other, period. Let’s look over here. Look, when we ran our clinic, our partners, Iora, developed their own electronic medical record, and it involved basically a problem-oriented design where everybody could write in the same note at the same time because guess what? We didn’t use CPT codes. We just did the right thing for the patient because we were capitated. We got a flat fee per patient, per month, and we just have to do the right thing.

When you fix that financial incentive, which, by the way, when is AMA ever going to fix our financial incentives? They’re not because they were weaned and sort of bred on this fee-for-service poison. They’re never going to fix it. Let’s be honest. What are they going to do, too? They’re going to be really, really hierarchical when it comes to other professions. Instead of teamwork, it’s all about siloism, protecting this narrow band of interest which is usually medical specialists. Do you think primary care gets a voice, really, in the AMA? I don’t think so. They don’t get a voice anywhere, except here.

Let’s see where we’re at. This shit gets me so angry. Let’s read some of these tweets because I tweeted back at them. Who cares what I said? It doesn’t matter. Let’s see what actual human beings are saying about this. They’re physicians, because you can just judge how effective the AMA is by its constituents online. Take a look at this. Howard Green says, “Can EHR companies construct a user interface which improves physician efficiency when loading patient health information for sale by the EHR companies?” That’s exactly what they do. It’s all about taking our data. That’s what the EHR companies are really in the business to do, too.

Chris Simoneau says, “It looks like the AMA would prefer medical schools to train coders instead of doctors so they can sell more CPT code paraphernalia. There’s an inherent conflict of interest. AMA should divest the CPT business.” If they divested CPT, if they actually listened to the voices of frontline clinicians, that would be a whole different thing.

Can I tell you guys a quick story? AMA approached us a couple years back about collaborating on some sponsored shows and I said, “This might be interesting. Let’s figure out what the deal is.” I get on the horn with their marketing guys, and it was this quid pro quo like, “We’ll think about working with you.” Like, “Oh, thank you for blessing me, AMA, with your patronage. F*** off!” “We’ll think about working with you if you share these videos that we’ve made on your platform.” I looked at the videos and they were supposed to be about the experience of women in health care, and they were horrible. They were patronizing. They were stupid. I was like, “Are you kidding me? I could make a better video about this and I’m not even a woman.” Imagine if we actually got women to make the video. It was absurd, you guys. It’s a crony organization. Again, I know a lot of docs that work within the org that are really wonderful people, that are trying to do the best they can.

Here’s the last thing I really want to rant about this. What is wrong with doctors? What is wrong with us? We are the worst. We can’t get our shit together. We’re constantly fighting with each other. We’re so f***ing boring all the time. Just such a stick up our ass, constantly. When doctors come up and start speaking truth, oh, my God, the shit they take, man. People like my friend Marty Makary and others that I know that are really out there just saying, “Hey, you know what? Most of what we do is garbage. Maybe we could wake up and do the right thing for each other and for patients.” What happens?

If you go to a medical conference, it is like getting stabbed in the eyes. It’s that aggressively painful. We’re so conditioned and hierarchical and risk-averse. Is it our fault? No. It’s the way we select medical students. It’s the way we train them, and now AMA wants us to train them to optimize their use of Epic early and often, so when they come out are they going to question this f***ng shitstorm that we call an electronic health record? No. They’re going to go, “OK, Boomer,” when people like me go, “This is garbage.” “You’re just a Luddite.” “F*** you. I was programming in f***ing assembly language in the 80s while you were shitting in a diaper.”

We just want a good user interface that focuses on clinical care instead of billing. We want financial incentives where we can do well financially by doing good for our patients and taking care of each other. Is that too much to ask for from our organizations that are supposedly representing us? Come on, you guys. That’s all we’re saying.

Let’s read a couple more of these tweets because they just piss me off. Dude, I put a long-sleeve shirt on in my garage on a Saturday to just go off the rails, I should have just worn a t-shirt. Let me see here. James Smith. “It would be awesome if you would advocate for physicians,” talking about the AMA. “I will not join the AMA because it’s my perception that the association is not serious about improving and advocating for physicians’ work environment. Articles such as these deepen that perception for me.” Brilliant, spot on, very well said without hyperbole. Another person says, “Did Epic write this?” Oh, my God and the amount of money.

Listen, I’ve been to HIMSS and these big health IT conferences. Again, the people who run the things, very good people, but it’s just money is dripping out of the walls. Where is that money coming from? From you, the patient, right? But then in the same breath they’ll say, “Doctors are overpaid and nurses are overpaid, and they need to work harder and be more productive and more efficient, click more boxes.” F*** off. Really? Did you see your booth at HIMSS? It costs like a million dollars. Where’s that money coming from? I’ve been on the phone with these marketing people. It is like getting stabbed in the eye. “We would like to reach frontline clinicians because,” shut the f*** up. Your product is garbage. There’s no way you’re coming on my show. You’re adding no value to the world.

Most of the health IT people out there on Twitter tweeting about stuff are just circle-jerking each other. Seriously. There’s nothing actually getting done. They have whole conferences where people just sit around talking about disruption and innovation, and it’s the same bullshit. You know what? In the end, though, it’s not their fault. It’s because our incentives are all f***ed up. Really, we just have to be paid differently to take care of patients because the current way we’re paid does not actually incentivize. Humans are only as good as their incentives, so of course you’re going to have these big booths and all this stuff because there’s money sloshing around. There’s the incentive to behave like a goddamn jackass that doesn’t really care about patients but pretends to.

F***, I forgot to hit record on this thing so now I can’t put it on YouTube. I just realized that. It’s what happens when I do this shit myself. I don’t know. I just had to get this off my chest. I was going to take a bunch of comments and stuff. Now, I’m just too pissed.

I hope you do me a favor. Leave your thoughts and comments in the thread here. It’s time we gave ourselves a voice. Why are we relying on these dipshits who have financial conflicts to speak for us? We have a tribe. Even just this ZPack. It’s like 1.4 million people on Facebook, 200,000 people on YouTube. Let’s start making noise. We’ve been trying. Let’s ratchet it up. Do me a favor. If you’re brave enough, share this video. If you’re not, leave a comment and quietly tell people never to join the AMA because it’s a garbage organization, and I love you guys.

That’s it. All right? Thank you to everyone who donated stars to support the show. Thank you to our supporters who are members. We have these private conversations and stuff like that. It really helps to pay for all this garbage that I don’t know how to run myself. Now, I got to go walk over there like a jackass and turn it off. So have a great safe weekend. Be grateful and thankful for the things we do have. Be loud and vocal about the things we need to change and I’m out. Peace.