Should the AMA right-size its House of Representatives?

Is the American Medical Association (AMA) House of Delegates too big for its own good? That’s one of the questions outgoing AMA CEO James Madara, MD, presented during his speech Friday in Orlando, Florida on the opening night of the midterm meeting of delegates.

“At my first appearance in this house in 2011 there were just over 500 delegates; today there are more than 700,” said Madara, who will leave the AMA in June 2025 when his current contract expires. He cited several factors that contributed to the increase, “one of which is the decision to balance representation between state and specialized societies. But another factor that accounts for almost 40% of this increase in house size is due to membership growth and our current board. Membership immediately results in an increase in the number of delegates.”

“Now a house of substantial size presents both opportunities and challenges – opportunities to add even more diverse opinions, experiences and contributions,” he continued. “On the other side of the coin, large consultative bodies can be cumbersome and inefficient.”

“General conclusions suggest that as representative bodies become larger, they tend to spend more money, and the quality of democracy generally declines,” Madara said. “But what is too small or too big? … While there is no universally accepted rule for judging optimal size, there are guideposts.”

One such guideline is the cube root law, which “specifies that the optimal number of seats in the legislature relates to the cube root of the population represented,” Madara said. “Since there are approximately 1 million physicians in the US, the cube root would suggest a house of only 1,000 with only 100 representatives. Now 100 seems far too small for our house, because almost 200 associations are represented, for example. But while One Hundred Delegates may not make sense, does seven times that number deserve any consideration?”

“Perhaps another signpost is the simple fact that the AMA House of Representatives is now significantly larger than a joint session of Congress representing 330 million Americans,” he added. “The bottom line is that if we plan for continued growth and membership but don’t consider the downstream effects on the size of this home, we may ultimately run into a functionality problem.”

The other question for delegates to consider is how best to represent employed physicians, Madara continued. “When I started in 2011, about 42% of physicians were employed, and now that number is above 50%,” he said. “In the 1980s, 76% of physicians had their own practice. By 2022, that number had dropped to 44%.”

“Now I feel like there will always be a critical segment of physicians in private, independent practice – perhaps smaller, but this population will need to be supported, and the need for support will be greater than ever before,” he says . said. “But with a growing number of physicians working in groups, we need to pay equal attention to those voices and those needs.”

Just as the AMA changed its representation in the 20th century to reflect the increase in the number of specialists, “in this century we also need to hire the groups of physicians,” Madara said, adding that this represents a change in the balance in the representation may entail.

“For example, when groups of working physicians become members, they are largely divided into representation in existing state or specialty associations,” he said. “Yet physicians who are employed and in groups also have their own specific needs. A step towards recognizing this fact has already been taken with the creation of the integrated medical practices section, which provides a route to submit resolutions and thus influence policy. Is this level of representation enough of a voice for what is now more than 50% of physicians?”

These questions cannot be answered by the AMA’s management team, he concluded. “I simply emphasize these questions and feel obliged to do so, as these are likely fundamental challenges for our future.”