Q&A: AMERICAN MEDICAL ASSOCIATION PRESIDENT JACK RESNECK, MD

But there are areas where we actually feel enthusiastic and see positive signs and momentum shifting. On Medicare payments, we’ve got a bill introduced. The news from the FDA advisory panels [on over-the-counter birth control pills] is a positive sign. We’ve got CMS dropping two rules on prior authorization that were transformative and the profession felt incredibly heard by the administration on what a burden this is for doctors and patients.

You recently wrote an op-ed about your fears that the legal challenge to FDA regulation of the abortion drug mifepristone could impact your members’ work more broadly. What specifically worries you?

The overall general assault on the doctor-patient relationship and the criminalization of health care has ended up being a rather large, unexpected piece of my presidency.

Jack Resneck was just days into his term as president of the American Medical Association when the Supreme Court overturned Roe v. Wade last summer.

The board-certified dermatologist suddenly found himself bombarded with questions from physicians who were struggling to navigate the national war over the right to terminate a pregnancy.

Pharmacists refused to fill prescriptions for patients suffering from everything from psoriasis to rheumatoid arthritis out of fear the medications could also be used for abortions. ER physicians pleaded for help squaring conflicting state and federal laws around abortions for patients facing obstetric emergencies. Doctors became both the plaintiffs and the targets of abortion-related lawsuits.

Resneck has also grappled over the past year with a workforce hollowed by pandemic burnout, the dilemma of whether and how to integrate AI into medicine, a wave of Covid disinformation and growing hostility to public health work.

As the mid-June end date to his one-year term as president approaches, he sat down with POLITICO to reflect on his tenure and share thoughts on how the field can adapt and rebuild after a brutal few years.

This conversation has been edited for length and clarity. What’stopofmindasyouneartheendofyourpresidency?

People love their jobs but there are a lot of things getting in the way of what drew them to medicine in the first place — whether it’s government interference in health care, whether it’s all the disinformation they’ve had to fight back against in the last few years, whether it’s all the administrative burdens and Medicare payment issue. Frankly, it’s a lot for physicians to deal with.

On the one hand, you have the reproductive health issue itself and mifepristone itself being a safe and effective drug that is absurdly being painted as something that it isn’t — and the implications both for medication abortions but also the management of miscarriages and all the threats and implications for public health.

And then what is getting less attention is the potential upending of the entire drug approval process that had been relatively stable for 85 years. I feel certain that if the entire Texas decision is not overturned, we could have [challenges to] contraception and vaccines and HIV drugs and cancer drugs and a whole line of other things following pretty quickly.

It’s a horrific thought, as a physician who is trying to practice medicine with things that we know work and are safe, to all of a sudden have individual judges with no medical or scientific training able to undo all of the expertise of the FDA.

Outside of the fight over the abortion pill, how else has the fall of Roe impacted your members?

In one category are the terrible impacts in restrictive states: people having to carry unwanted pregnancies, people with ectopics and miscarriages getting packed up in ambulances and sent across state lines or sent home until they get sicker, and doctors actually having to call attorneys to ask what to do next. But in the last few weeks, we also really started to see some of the downstream consequences that we predicted but are unfortunately coming to pass.

In Idaho, physicians are facing really hard decisions about having to abandon communities that they feel so connected to and so a part of because they just don’t feel like they can safely practice there anymore. Labor and delivery units in Idaho are closing and women are literally going to have to leave the state with any high risk pregnancies.

We’re also in that season of the year where medical students who have applied for residency get their match, and we’re seeing decreases of 10 percent or more [applications] in restrictive states — and that’s across the board, not just in OB. There’s been a major uptick in physician advocacy and activism. What does that mean for the AMA? Does it change the nature of the group?

People think of us in our advocacy role in terms of the congressional and judicial litigation pieces and our work with the administration and our collaboration with state medical associations and state houses. But they don’t always think of our leadership for medical education, and the huge role the AMA has played in funding and convening medical schools around the country to reform their curricula, or our large, growing and very dedicated Center for Health Equity or our group that thinks about innovation in healthcare, the future of AI and digital health and how’s that going to happen in ways that actually advance health and help patients instead of harming patients. We depend on the involvement of grassroots physicians in addition to national leaders and each and every one of those areas. To move forward, we need physicians to bring their background and their experience to running for local office, engaging with their school board when it’s thinking about public health policies in schools — all of those types of areas.

As you noted, doctors are working to change political debates,butthecountry’spoliticaldebatesarealsochanging the medical profession. What are you seeing on that front?

The politicization of science that we have all seen in the last few years has affected us.

What we have had to do in that changing environment is relentlessly focus on science and evidence. That is our hallmark and our calling card is we always have to come back to the best science and evidence and use that as the basis of our judgment.

So, we’re engaging on gender affirming care and trans issues because there is overwhelming evidence from the medical community and from science and well done studies about the impact on trans adolescents in particular and depression rates and suicide rates. We know what makes a difference and helps our patients, so we have an ethical and moral obligation to speak up on those things.

Areyouworriedthatphysiciansarelosingtheirconnection with a country that is seemingly less interested in evidence-based reasoning and more interested in politicized reasoning?

I think every physician, whether it’s from an organized medicine standpoint, or just working in their offices or hospitals every day and running into patients who have been influenced by sources of disinformation, is worried about the level of respect for science and evidence in the country. Whether it’s a politician doing it or whether it’s physicians actually being spreaders of disinformation, it’s been a wake up call. The public health community now realizes it has to fight back.

We can’t sit quietly and let these forces dominate the social media space or any other space. For example, we have to think about going all the way back to elementary and secondary education about science, and making sure we have a population that’s actually able to engage in these conversations — whether it’s about weather forecasts or the risks and benefits of any treatment or vaccine or preventative [care].

Was this month the right time to end the public health emergency?

This had to happen sometime. And it does feel like the country is in a different place.

Having an end date also meant there were some must-do things in order to protect patients, and a lot of those things have happened, including extensions for telehealth coverage for Medicare patients. But I think there are still ongoing concerns around patient access to testing, therapeutics, vaccines, etc. We need to make sure that patients who are insured continue to have access — preferably without co-pays or cuts to their deductibles — and we need good access for patients outside those coverage spaces. And then we still have a lot of questions and are doing a lot of work on [securing] ongoing federal funding for more vaccines and thinking about the next pandemic. We need public health departments actually funded and staffed and we need plans in place for future health emergencies — we continue to try to shine more light on that.

Amajorimpactofthepandemichasbeenphysiciansburning out and leaving the field. What needs to be done to prevent shortages from getting worse?

This is what keeps me up at night as AMA president.

But there are things we can do to make a difference. I think of the workforce as a pipeline with two openings. There’s the incoming on the front end, and we have been fighting for a long time for more funding for residency positions, because even if nobody leaves medicine, we don’t have enough doctors to take care of baby boomers as they age — across primary care, specialty care, you name it.

The challenge there is that Congress does not tend to do things with an eye towards 10 or 15 years away but rather with an eye towards next week. We have to convince them that this is where they should put investment, even though it’s not going to pay off for a while.

So we have to grow more doctors, but oh my goodness, in the meantime, while we’re trying to do that and trying to get Congress to support more funding, we’re lopping off people at the back end early because they’ve gotten burnt out.

That’s part of what drives a lot of our work around [prior authorization] and it’s why we have to have Medicare payment reform.

If you look back 10 years at the focus on physician wellness, you saw health systems and hospitals offering yoga classes continued on page 36

TheSFMMSsentthislettertolocalelectedleadersinMay. May 18, 2023

San Francisco Marin Medical Society (SFMMS)

Phone: (415) 561-0850

Re: Use of Walgreens Settlement Funds to Treat Opioid Addiction and Reduce Overdose in San Francisco

Dear Mayor London Breed, City Attorney Chiu, and San Francisco Board of Supervisors: The San Francisco Marin Medical Society (SFMMS), representing thousands of physicians in San Francisco and Marin Counties, deeply appreciates the leadership and dedication of the San Francisco City Attorney’s Office and the San Francisco Department of Public Health (SFDPH) in holding Walgreens accountable for exacerbating the epidemic of opioid addiction and overdoses in San Francisco. SFMMS remains concerned about the ongoing health crises for individuals without adequate support services for substance use disorders, and the $230 million settlement represents a significant opportunity to invest in care for some of the city’s most vulnerable populations.

SFMMS recommends that settlement funds be used to:

1. Fund SFDPH projects that most immediately advance services identified in its 2022 Overdose Prevention Plan,1 specifically: a. The establishment of at least two “Wellness Hubs.” b. Augmenting programs that improve appropriate access to medication-assisted treatment (MAT).

2. Increase workforce capacity by increasing the number of mental health/substance use care providers (through work/site commitments tied to loan repayment, hiring bonuses, scholarships, etc.) with prioritization of bilingual individuals. Specifically: a. Psychiatrists within SFPDH and those serving predominantly uninsured/Medi-Cal patients in San Francisco. b. School-based behavioral health care staff. c. Safety net primary care physicians, particularly those providing MAT.2 d. Physicians and/or nurse practitioners to staff Wellness Hubs for the provision of MAT.

3. Patient navigation staff dedicated to creating warm handoffs/transportation to better utilize increased treatment bed capacity for patients diverted from or stabilized and referred to those locations (e.g., DPH affiliated substance abuse expert(s) either located in or responsible for liaising with each local hospital to assist with referral to treatment).

4. Replicate the success of Marin County’s ‘OD Free Marin’ initiative by placing free naloxone vending machines in key locations across the county.

Background

In late 2022, SFDPH released its Overdose Prevention Plan, which articulated a comprehensive approach to the reduction of opioid overdoses in San Francisco. In this plan, DPH calls for the county to establish “Wellness Hubs” as “a cornerstone of the City’s efforts, which will provide overdose prevention services and resources, services to improve health, and linkages to treatment.” In January 2023, SFMMS wrote to San Francisco’s Board of Supervisors encouraging the timely funding of the Overdose Prevention Plan, including components of the plan related to the establishment of Wellness Hubs. The Wellness Hubs as originally proposed included overdose prevention sites, which are sometimes referred to as supervised consumption sites, which local, state, and national medical societies support. Even if Wellness Hubs are not permitted to provide supervised consumption services, they provide other vital resources for at-risk populations, including linkage to services and treatment elsewhere in the city, distribution of naloxone to the public and to at-risk individuals, and serve as visible public health infrastructure, improving public confidence in the county’s response to the substance use crisis.

Additionally, settlement funds should be used to increase San Francisco’s behavioral health workforce. Even before the health care workforce crisis created by COVID-19, the county and state faced a severe shortage of primary care and mental health providers. This issue has been particularly acute for teenagers, who have seen an exponential increase in depression and anxiety.3 SFMMS recognizes that these funds are time-limited, but there are several ways to incentivize, attract, and retain care providers where they are needed most through one-time signing bonuses, scholarships, and loan repayment tied to specific locations and populations. Data consistently shows a dire need for psychiatrists and primary care physicians to treat those currently affected by substance use disorders, as well as upstream behavioral health (particularly for youth) to prevent addiction before it starts. In addition, safety net clinics and Wellness Hub services should be supported in the hiring and retention of primary care providers4 for the provision of MAT on-site.

One of the most pressing issues facing this patient population, as well as the medical community, is the inappropriate and expensive use of emergency rooms to treat those suffering from addiction, behavioral health conditions, and lack of housing. The creation of treatment locations/beds, and a highly coordinated, hands-on patient navigations system and workforce is desperately needed to link patients to longer-term treatment, including patient transport options. For example, a DPH substance abuse expert could be funded to operate within or liaise with each local hospital to assist with referral to treatment.

Finally, San Francisco County should explore replicating the success of Marin County’s ‘OD Free Marin’ initiative.5 To increase access to naloxone, the lifesaving antidote to a fentanyl overdose, Marin County and OD Free Marin placed five free Narcan vending machines across the county. More than 4,000 kits have been distributed so far. Residents are also encouraged to take a Narcan video training, followed by the Narcan Proficiency Quiz.

We hope that the funds received by the city and county of San Francisco represent an opportunity to make tangible progress toward the goal of treating and preventing opioid addiction and overdose in San Francisco. Please do not hesitate to contact Conrad Amenta, Executive Director of SFMMS, at camenta@sfmms.org or (415) 706-3161, should you have questions about our recommendations or wish to receive more information from SFMMS physician leaders.

Sincerely,

Heyman Oo, MD, MPH

SFMMS President

1 https://sf.gov/sites/default/files/2022-09/SFDPH%20Overdose%20Plan%202022.pdf

2 https://www.acpjournals.org/doi/full/10.7326/M16-2149

3 https://www.cdc.gov/media/releases/2023/p0213-yrbs.html

4 https://www.chcf.org/publication/recovery-within-reach-medication-assisted-treatmentof-opioid-addiction-comes-to-primary-care/#related-links- and-downloads 5https://odfreemarin.org/