On June 9, 2015, Steven J. Stack, MD, FACEP, was sworn in as President of the American Medical Association (AMA)—the first emergency physician to hold that office. Dr. Stack recently spoke with ACEP Now Medical Editor-in-Chief Kevin Klauer, DO, EJD, FACEP, about the projected physician shortage, the role of advanced practice providers, and how he developed his speaking skills.
Dr. Kevin Klauer: What are your thoughts on where the AMA thinks the physician shortage is going and what it might be able to do to impact that? As a related question, has the AMA really taken a position on advanced practice providers, such as advanced practice nurses who are pushing for autonomous practice? There are physicians who are threatened by that in particular when there are initiatives to have advanced practice nurses who have completed doctoral programs claim the title of doctor.
Dr. Steven Stack: There are three parts here. The first one is there is a physician shortage. The physician shortage will get worse, and it’s unacceptable. Apart from the other explanations in the system, there is a dire need for more doctors, real doctors, physicians, and doctors of osteopathic medicine. I believe it was the Association of American Medical Colleges that just came out with a research piece that projected—even in a rosy case scenario where other clinicians, nurse practitioners (NPs), physician assistants (PAs), and others play a bigger role—over the next decade a shortage of 45,000 or more physicians.1 That’s even with all of these other clinicians coming into the system and doing more. We’re creating more medical schools, and we’re graduating more medical students, but the federal government is the funder for graduate medical education and residencies, and they refuse to add more money to the pool to create more slots. It’s been frozen for a very long time, and in fact, both parties have introduced cuts to graduate medical education funding. They are not only not adding to it, they are 180 degrees in the wrong direction and ready to cut. Unfortunately, there is no interest from other participants. Thus far, the graduate medical education community has been unable to come up with a new approach to fix that, and it has to be fixed. The AMA, through its advocacy, continues to press for the need to expand residency slots because, in this year’s match we just finished, around 1,100 U.S. medical grads did not match. I’ll give you a story to make that even worse. There are young adults who have graduated from schools like Johns Hopkins, which is ranked as the best medical school in the country most years, who did not match. Now, if you can get into college and get into the best medical school in the United States after college and you can’t match at the end of that, we’ve got a problem. If the smartest people in the nation can’t finish their training and have to go to work at a restaurant waiting tables or drive a taxi to get through their next year while they hope they can match the following year, it’s really a horrible situation. It is utterly unacceptable, but it’s not been easy to find a way to fix that structure. Something every bit as profound as what we’re doing for reforming medical schools will probably need to happen in the residency and fellowship training world, but it’s a difficulty where a path to do so has not yet materialized.
When we talk about the other clinicians, it is a problem, and patients should never be confused in the clinical setting about the qualifications of the people caring for them. It’s not offensive to say that it’s an undeniable truth that physicians, by the duration and intensity of their training, are the most highly educated and trained clinicians in the health care system. That’s just a reality. In terms of years spent in study and hours spent during those years in study and experience, we are the most highly trained. Patients should not have someone else come into their room or be at their bedside and hold themselves out in a way that is confusing to them, that a clinician who might otherwise be a very intelligent and capable person is somehow a doctor in the parlance that patients understand to be an MD or DO as a medical doctor. We have had a campaign in place for a number of years called Truth in Advertising and have enacted laws in various states to require that every clinician providing bedside patient care is required to wear a visible photo identification badge that displays their credentials and that, in all advertisements, they have to clearly display their proper credentials. They can’t have false or misleading representation that they are physicians in the context that you or I understand it as an MD or DO. That would confuse patients. There are 19 states that have enacted legislation consistent with the AMA’s Truth in Advertising campaign. There’s a long way to go, but that’s not bad so far for a six-year process.
Because the application didn’t ask for a date of birth, they just signed me up. By the end of my four years, they had already made me secretary of the chapter before I was even 18 and technically allowed to be a member of the Toastmasters. Due to an illness, the district president invited me to step in as the district secretary in northeastern Ohio. By doing that, I went every other week and associated with people multiple decades older than me who did public speaking on a regular basis.”
So what is their role? You and I work with PAs, PharmDs [doctors of pharmacy], advanced practice nurses, and others. It’s not that we don’t have respect for our colleagues and do not work well with them, but their professional societies’ push for enhanced autonomy flies in the face of everything in the modern era that supports team-based care. It’s all well and good to say that they’re part of a team, but some are pushing to go out and hold themselves as independent, and that is inconsistent with all of the current thinking about the value of team-based care, of which physicians are a part and from whose participation all of them benefit. We are not supportive of progressively more expanded autonomy because we feel this would expose patients to risks if not done in a very thoughtful and careful way.
KK: It’s nice to know that the AMA has taken a specific, fairly hard line on this and is really focused on supporting its membership. Steve, it always amazes me how well-thought-out your responses are. You deliver a message with a significant amount of intellectual detail even when you have a limited amount of background information. How were you able to become such a great orator, such a great speaker, and deliver an award-winning message every time?
SS: When I was in eighth grade, I got the opportunity to participate in a community outreach program by Toastmasters International, which is a nonprofit organization committed to advancing people’s public speaking and leadership skills. I guess I’ve always been precocious, and I asked, “Hey, I like this. Can I be involved more? Can I do more?” One thing lead to the next, and the chapter sponsored me when I was in high school for all four years to be part of the chapter. They had to do it that way because the bylaws said I was not allowed to be a member until I was 18, and so they had to sneak me in at the age of 14. Because the application didn’t ask for a date of birth, they just signed me up. By the end of my four years, they had already made me secretary of the chapter before I was even 18 and technically allowed to be a member of the Toastmasters. Due to an illness, the district president invited me to step in as the district secretary in northeastern Ohio. By doing that, I went every other week and associated with people multiple decades older than me who did public speaking on a regular basis.
It’s very kind of you to be complimentary of the way I communicate. I would like to be better at what I do, but if it’s effective in some small measure, I owe a lot of that to the Boros sisters, Nicolette and Victoria, who got me involved in Cleveland years ago. Of course, then I kept using those skills. I believe in the concept of “10,000 hours to mastery,” where you have to have a certain core amount of ability but the difference between an exceptional performance and just excellent or really good performance comes with lots and lots of practice. I owe a lot to the AMA and ACEP and my involvement in professional societies because the people who I have met have been exceptional mentors and friends over the years and have been supportive.
KK: I’ve seen you do it successfully many times, and as much as I’d like to say that it is a learned skill, it can be refined, it is really part of your DNA. Note to the Toastmasters: it’s time to expand your membership to 14 years and older.
SS: When the Boros sisters came to my eighth grade, I said to them at the end, “This is fun. I wish I could do more.”
They said, “Well, you can. We’re going to have a District 10 conference, and the international president is coming as a guest to give us an award to recognize us. Why don’t you come along to tell us your story about what you learned?” Well, I sat at the head table and was talking with the international president, Helen Blanchard. I said, “Gosh, I wish I could do more,” and she said, “It’s funny you should say that. When I joined, the bylaws said that you had to be a man and women were not allowed, but the application didn’t have an area where you had to write your gender, so the club said, ‘We’d be happy to have you—just put your first initial.’” She signed up as H. Blanchard, and she was a woman in an organization that said you have to be a man.
She told me, “You know what? If it worked for me, our application doesn’t include a field for your date of birth. I don’t see why, if the chapter wants you, you don’t just sign up because it doesn’t ask you how old you are.” So when you talk about somebody who’s able to have an inspirational impact on someone who now uses those skills every day, you never know when you’re going to have a positive impact. I bet that woman would have been shocked to hear that I still know her name and tell that story.
KK: Well, she made quite a difference with that one piece of advice for you. It’s amazing. So in recap, you’re the first emergency physician to be the head of the AMA, you’re the second-youngest president of the AMA, and I will say now after hearing your story, you are the first rule breaker to be the president of the AMA.
SS: Don’t get me in trouble, but yeah.
- IHS Inc. The complexities of physician supply and demand: projections from 2013 to 2025. Association of American Medical Colleges. March 2015.