Seat at the Table

IN THIS ISSUE: Hackett Award | President Dan Winstead | Seat at the Table | CLP 2021 | Posters | Award Winners | A&E Abstracts

The Academy’s strategic objectives include developing relationships with leading organizations in Medicine and Psychiatry, one of which is the AMA. Here we delve into the role of L. Lee Tynes, MD, PhD, FACLP, at the American Medical Association (AMA), founded in 1847, and now with more than 240,000 physician and medical student members.

L. Lee Tynes, MD, PhD, FACLP
L. Lee Tynes, MD, PhD, FACLP

A Seat at the Table

Tell us about an AMA Specialty and Service Society (SSS) meeting where you represent ACLP.
The SSS is the largest caucus in the AMA and meets twice annually in conjunction with the Interim and Annual Meetings of the AMA House of Delegates (HOD). There are 155 member organizations comprising mostly national medical specialties, but also professional interest medical associations, and military service groups. The SSS serves as a type of special interest caucus representing medical specialists (as opposed to state medical societies and other entities in the HOD). It is also the gateway for becoming a voting member of the HOD. An association must first be represented in the SSS for three years before it is eligible to seek admission to the HOD. An eight-person Governing Council (including the SSS chair and chair-elect among others) oversees the SSS alongside the Credentials, Rules, Long-range Planning, and Nominating Committees.   

The SSS typically meets once before the HOD to conduct business and review resolutions deemed of high importance or impact by the Governing Council. Typically, there are about 180 delegates present; a quorum is one-third of member organizations. A majority vote (when  related to speaking in the HOD) is three-fifths of members present. While SSS members may certainly author resolutions that are then submitted for consideration in the HOD, the SSS does not itself produce policy decisions for the AMA.

I also attend the Section Council on Psychiatry which tends to be more active during the HOD process than the SSS. It’s one of 29 HOD section councils representing specific medical specialties and comprises psychiatrists from the APA, AAPL, AACAP, and AAGP. ACLP will become an official member once we obtain a seat in the HOD. We meet on several occasions before and during the HOD proceedings to review the slate of resolutions and reports that will be discussed—to ensure that Psychiatry, particularly our member organizations, has its voice heard both in Reference Committees and in discussion from the floor during HOD business meetings. The APA has a strong presence in the Section Council by virtue of the number of delegates they seat in the HOD. APA staff are instrumental in organizing the work of the Section Council.

The Psychiatry Caucus tends to meet the night before the HOD business meetings. It consists of Psychiatry delegates across the HOD, no matter who they are representing (e.g., state medical societies, national organizations, military, etc.). It is a fair bit more informal and allows for a discussion of prominent issues facing Psychiatry, as well as plenty of networking! I’m told the latter is much better in person, and I’m anxious not to have to meet in two dimensions anymore!

Finally, a quick overview of the HOD itself is probably in order. Meetings are chaired by the Speaker of the House with assistance from the Vice-Speaker. This year the Speaker is Bruce Scott, MD, an ear-nose-and-throat surgeon from Kentucky. A majority of the voting members of the HOD constitutes a quorum. The HOD includes well over 600 voting delegates (and a corresponding number of alternate delegates) from more than 170 medical societies. Some organizations are also allowed to officially observe the proceedings of the HOD, although they are not able to vote (including me, until ACLP earns an official seat). This results in around 800 people attending the business meetings over a span of five days, including the Reference Committee meetings (yes, we’ve had Zoom meetings with 800 people signed on!). Delegates represent organizations such as state or territorial medical associations, national medical specialty organizations, professional interest medical associations, the federal services, and the AMA’s member sections.

Does ACLP delegate to you input towards HOD policy decisions through these channels without referring back to the Academy?
The ACLP delegates to me the responsibility of proffering input into these discussions, consistent with ACLP’s mission and strategic plan.

ACLP (and presumably all other SSS member organisations) are periodically then invited to co-sign, within a deadline, AMA statements on policy decisions. ACLP’s Board has commented that this typically happens at very short notice. What is the timescale?
Actually, these requests are not about signing off on AMA policy, but typically involve signing on to a letter to Congress in support of, or opposing, a bill (or to another federal agency such as the VA regarding proposed rules or policy.) We also receive requests to support AMA resolutions created by members of the Section Council (which require unanimous support by the member organizations) in order to send them forth to the HOD. That said, there do not appear to be any hard-and-fast rules about turn-around time, but the typical deadline is about a week. If we want our voice heard and considered, we need to respond within that timeframe.

What happens if a minority of organizations disagree? What happens if a majority disagree?
As mentioned already, some of the actions involve a decision to sign on to a letter (or not). Others, however, like the proposed resolutions presented to the HOD on behalf of the Section Council, require unanimous support, and so might not go forth without our vote. One caveat to this last point is that we are not yet official members of the Section Council, so technically we can’t veto a proposal, but the Council has included us in these issues at this stage in anticipation that we will be members in two years. 

How does the AMA disseminate its policy decisions to practitioners? Does the AMA have statutory influences leading to legislative programs—and is this their preferred route?
PolicyFinder on the AMA  website is the principal mechanism through which the AMA distributes information on its policy positions and can be accessed by any interested individual. For recent policy developments, one can find proceedings from the recent HOD on the AMA Policy page. The AMA also promotes policies as the situation dictates by: communications; representation on standard-setting and accreditation bodies; participating in the legislative process at national and state levels; litigation; advocacy campaigns at national, state, and private sector levels; and advocacy to regulatory bodies.

Could you talk us briefly through the SSS opposition to the Department of Veterans Affairs’ Interim Final Rule (IFR), Authority of VA Professionals to Practice Health Care, with which ACLP concurred?
Opposition to the VA IFR was a ‘sign-on letter.’ The letter was sent to our leadership by the AMA Director of Federation Relations, noting that: “The IFR establishes the VA’s authority to allow virtually all non-physician providers, as defined in the U.S. Code (38 U.S.C. 7401(1) or (3)), to practice without the clinical supervision of a physician. In doing so, the IFR pre-empts state license, registration, certification, supervision or other requirements.“ 

The letter emphasized the difference in training between physicians and non-physician health care providers, the importance of respecting the process at the state level in establishing and enforcing scope of practice laws, and emphasized mental health as one of the areas of significant service provided by the VA system.

As is typical, we had about a week to poll the ACLP Board on whether to sign on. The Board agreed to do so and we became one of about 100 specialty and state medical organizations to do so (we are the second name on the signatory list, behind only the AMA itself).

To date, since your appointment, there have been no SSS decisions specifically related to C-L Psychiatry practice. Although, as you become embedded in the process, you would expect to present C-L Psychiatry-related issues?
Absolutely! Many issues of importance to C-L psychiatrists will also be important to our non-C-L Psychiatry counterparts, but when we identify an issue of focal importance to C-L Psychiatry, I envision us (with me as a point-person) taking the lead on crafting and promoting a resolution to address it which would ultimately be heard in the HOD.

Could such issues derive not just from the ACLP Board but from individual ACLP members/SIGs/committees/forums?
I don’t think we’ve yet created a formal pathway for processing a topic, concern, or resolution proposal from our membership. My expectation is that the ACLP Board will initially be the source for any such action, perhaps serving as a filter and conduit for proposals from membership. Depending upon the volume, there may ultimately be a need to create a more formal process.

The ACLP Board, in considering how to respond swiftly to SSS sign-up requests, has indicated reliance on the Executive Committee to check whether proposed policy aligns with ACLP’s strategic objectives, as well as APA legislative priorities, before Board endorsement. The Board has agreed that, after satisfying ACLP strategic objectives, ACLP will endeavor to align with APA legislative priorities when evaluating future requests. You’d welcome that approach?
Indeed. The APA has a number of delegates in the SSS—not counting those, like me, who represent other organizations, but are also APA members. So, yes, they are well represented. I think the approach you outline makes the most sense. I think most of the membership would agree that partnering and aligning with APA priorities (outside of areas that may conflict with ACLP priorities) generally serves us well in terms of solidarity, strength in numbers, and reciprocal relationships.


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