Jan 24 2007

The AMA Bogeyman

On the SGU boards I was recently asked to comment on some claims made regarding the American Medical Association (AMA). Here is an excerpt:

“In the U.S., science and the American Medical Association (AMA) are not completely congruent in the realm of health care as a result of an effective monopoly with regard to competing practices. This is not to say the AMA recommends non-scientific solutions, but they tend to rule out less profitable ones and they may recommend scientific, but also needlessly dangerous, solutions. Some of that is done by necessity, or at least by the necessity of profit in the private practice of medicine.”

That the AMA exerts a Big Brother degree of control over the practice of medicine is a common misconception. It is especially popular among proponents of so-called complementary and alternative medicine (CAM) or just critics of established medicine. Such criticism of mainstream science often takes the form of conspiracy mongering, and conspiracies need a villain – the more powerful and cold-hearted the better.

People are often surprised when I tell them that the AMA has no control over the practice of medicine. None. The AMA is a professional organization. Their primary job is to politically represent the interests of their physician members. They also take it upon themselves to promote public health and to publish various medical journals, such as JAMA. But they don’t regulate the practice of medicine, and they have zero power over physicians. Most doctors are not even members.

In this country the practice of medicine (and in fact all healthcare) is regulated by the states. States issue licenses and they set the rules. Only a state can take away a doctor’s license. But states don’t really control the practice of medicine either. They typically will take action against a doctor’s license for one of two types of reasons – violations of professional ethics or practicing demonstrably below the standard of care. But states don’t determine what the standard of care is. That is determined by the medical community.

The standard of care is a constantly evolving thing. It is based upon what is published in the literature and what most doctors are currently doing. Sometimes a professional organization (usually specialty organizations and not the AMA) will publish practice guidelines, and this can serve as a reference to establish standard of care. For example, the American Academy of Neurology may put together a panel of experts to review the current literature and determine what the standards are for headache management. This may include recommendations about specific treatments.

In the last ten year there has been a movement within scientific medicine called Evidence Based Medicine (EBM). This is a complex topic I am sure to blog about in the future, but basically it is a standardized set of methods for reviewing the published literature and rating the evidence for or against any aspect of medical care. It is now common for there to be published EBM reviews of specific treatments. No one organization has a monopoly on reviewing any topic – so often there are multiple competing reviews from different groups.

Membership on an expert panel, on an editorial board, or an invitation to author a review article in a major journal are all highly prestigious. They are both based upon and used to promote one’s academic reputation and career. But opinions are expected to be based upon solid evidence and reasoning. Any departure from this, or apparent bias, will harm – even destroy – a member’s academic reputation. I’ve seen it happen.

Further, doctors are not obligated to abide by any published guidelines. They can essentially do whatever they want, and then take the chance of getting sued (the threat of malpractice is an independent mechanism by which the practice of medicine is regulated) or having action taken against their license if there is a pattern of violating the standard of care. But if they feel their practice is based upon solid clinical reasoning and published evidence, and they can make a reasonable defense of their practice, they are free to do what they will. Ultimately each doctor is left to their own clinical judgment.

Actually, the closest thing to an organization that imposes control on the practice of medicine are insurance companies. They control the money, so they can restrict a practice by refusing to pay for it. But insurance companies have to defend their decisions also. They can be sued. Doctors can appeal their decisions to third party reviewers in many cases. And if one insurance company gets too restrictive, doctors can refuse to take their patients, and patients can choose a different insurance. This is a very imperfect system, and I am not defending it – but the point is that even with insurance companies there are some checks and balances.

The bottom line is that there is no monolithic all-controlling entity that decides what treatments are mainstream or accepted and which are condemned. Medicine is not a top-down dictatorship. It is a bottom-up messy applied science. Those with the most influence on the practice of medicine are actually salaried researchers and academics (they are the ones publishing articles and sitting on committees). They keep each other honest. Biases are easily detectable, because everyone can look at the evidence for themselves.

As always, I need to add the obligatory disclaimers. None of this is to suggest that the practice of medicine is free from bias, fraud, greed, corruption, or simple stupidity. It is a human institution, with all the frailty that implies. But it is largely transparent, like science in general – and that is the key. There is no Big Brother.

But critics and conspiracy theorists need a bogeyman. For them the AMA works nicely.

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