SFMMS Interview: Jack Resneck, MD AMA President-Elect

JACK RESNECK, MD, AMA President-Elect

Steve Heilig, MPH

Next year, dermatologist Jack Resneck, MD will become the first AMA president from San Francisco since the 1960s. He is a graduate of UCSF and practices there, where he is vice-chair of his department, and has been President of the California Society for Dermatology and Dermatologic Surgery, board chair of the AMA and chair of their Council on Legislation as well. He has an appointment in UCSF’s Philip R. Lee Institute for Health Policy Studies, and here shares some of his background and interests, how his clinical practice informs his advocacy work, and how the AMA is addressing its “reputational lag” in the modern era. – Steve Heilig, MPH

Congratulations on becoming the AMA president elect – the first from San Francisco in decades and the first ever from UCSF.

Thanks! It’s exciting to be in this role as a Californian and UCSF physician, and also the first dermatologist in about a hundred years. To start, where are you from?

I grew up in Shreveport, Louisiana. My father is a physician who did his residency training at UCSF, so we had a three-year detour to the Bay Area when I was a little kid. Subsequently, we returned to Louisiana where I lived until leaving for college at Brown University. I came to UCSF for medical school after a brief time working in DC, and I stayed here for internship, residency, fellowship, and then joined the faculty. Do you recall first making your decision to go into medicine?

I don’t remember a particular moment; growing up in a medical family and watching my dad love his career as a physician working in a small practice clearly had an impact. As a kid, you often think you want to do something different from your parents, but I fortunately recognized at some point that medicine was pretty cool. I was a policy major as an undergraduate and then spent a little time working in Washington, DC. I loved working on big issues that could affect lots of patients and physicians, but I realized I was missing that special one-on-one connection of the patient/physician relationship. I feel like I’ve been incredibly lucky to end up with a career that lets me serve both as a physician taking care of individual patients—and also working at the policy level in organized medicine to make it easier for all of us to care for our patients. How did you choose your specialty? That was a last-minute choice. I had already filled out my applications for residencies in internal medicine. But a lastminute dermatology rotation in fourth year convinced me to follow the family footsteps and return to dermatology. What was your first exposure to, or awareness of, the AMA?

As a medical student, I wasn’t yet very aware of everything the AMA does for physicians and our patients. I suspect I held many assumptions based on “reputational lag” from several decades ago. When I was a resident at UCSF, I was chosen by my specialty society to be part of the AMA Resident and Fellows Section, with very little knowledge of what to expect. Once I arrived, I kind of fell in love with the whole process. Many physicians aren’t aware that AMA policy is set by a large House of Delegates, with physicians representing state medical associations, national specialty societies, federal health services, and others. The policymaking process is incredibly democratic. It begins with resolutions that originate from physicians, and the ensuing testimony and debates are science and evidence-based.

I quickly realized as a resident witnessing this process that policy was being set by people who cared and showed up to do the work. So I kept showing up and building relationships with colleagues, including the fantastic delegation from the California Medical Association. I kept witnessing the difference that individual physicians could make bringing great policy ideas, and the impact that AMA could ultimately have carrying out those policies. The process can actually be quite nimble—I remember one meeting where a group of medical students brought a resolution to ask AMA to help their colleagues under DACA program protections facing a risk of deportation, and almost immediately, the AMA was engaged nationally on the issue. It’s not uncommon to see small groups of people show up and convince colleagues of issues they care about and watch a large and fortunately influential organization make a positive difference.

You’ve worked and published a fair bit yourself on health policy issues; what have been some of your own interests?

I’ve long been very interested in improving access to care, and it’s great to be so involved with the AMA in an era where that has been a big priority. Some of my recent work has related to telemedicine, digital health, and augmented intelligence—both the tremendous upsides when implemented well, and the risks if done poorly. I’ve pushed for expanded coverage so patients can use virtual tools to connect with their physicians, especially in the wake of the pandemic, but I’ve also studied the poor quality of care from some of the corporate, direct-to-consumer internet telehealth sites.

I’ve also published illustrating the enormous burden of prior authorization on physicians and patients—prior auth has grown so far beyond its original intent of focusing on new, high-cost tests and treatments. Instead, many of us now find ourselves even having to fight with insurers over generic medications, or refills when a patient is already stable on a therapy. I’ve also worked on the problems with the current quality and cost measurement and reporting systems. While we all firmly believe in quality improvement, the measurement ecosystem right now isn’t focused on a narrow set of goals that matter to physicians and patients, and has become too burdensome.

I’ve been very interested in learnings from healthcare delivery during the COVID-19 pandemic. We’ve witnessed serious health inequities that have long existed but were laid bare for all to see by the pandemic as communities experienced different risks, different outcomes, and varying access to vaccines and care. I’m proud that AMA has created a Center for Health Equity with ambitious plans to dismantle structural racism in healthcare and embed equity and racial justice throughout the organization. I’m also passionate about medical education, and the AMA has been investing for several years in reimagining physician training and lifelong learning. This has included grants to several California medical schools that are part of a consortium we convene regularly to share new ideas and best practices. There continues to be a big shift of physicians into large systems instead of solo or smaller groups. What can the AMA do to help physicians stay in control of such decisions that impact patient care?

We want to preserve the viability of all practice venues as options for physicians. We have to continue to fight the burdens that get in the way of what brought us all to this profession – caring for our patients. And some of those burdens fall particularly hard on smaller, independent practices that haven’t received the resources they need to invest in electronic health records, quality reporting, and many other accumulating requirements. We undertook some survey work a few years back and basically learned that for every one hour of patient care, physicians are saddled with about two hours of administrative work on computers or phones. That has to change—we have to get physicians back spending time doing what they love and what they are best at. The flat payments from Medicare and other insurers have been part of the problem. Another thing the COVID pandemic has unmasked is the incredible financial fragility of many small practices. The AMA worked with Congress to secure billions in funding for private practices, but sadly, we know many may not survive the pandemic.

I mentioned prior auth earlier. This is incredibly frustrating for me and for most of my colleagues around the country. We still can’t see in our EHR systems which prescriptions are on formulary or seamlessly file a prior auth request electronically. My patients and I continue to be frustrated every time a prescription for a generic topical cream that has been around since the 1960s gets rejected, or a refill triggers a new PA requirement after a patient has found an effective treatment and is doing well. And part of the lengthy appeal process often involves debating the merits of a treatment on the phone with someone who isn’t a physician and has never heard of the disease we are treating. Physicians want to be good stewards of resources, but this maddening process has to change, and the AMA is fighting for that change at the national and state levels. You mentioned a “reputational lag” with respect to the AMA. We’ve seen the AMA attacked from both the left and right, going back to the Medicare debate in the 1960s and the ACA a decade ago. I think the most common perception locally is that the AMA has been too representative in policy, with respect to diversity and women in the profession, and issues like those. How do you see the AMA’s evolution on such issues?

Obviously, we have members with a wide diversity of political and other perspectives. As a large advocacy organization, we strive for nonpartisan approaches when possible to solve the most urgent pain points that patients and physicians feel. It’s our job to work with anybody who will sit down with us to make medicine better and improve public health. That being said, times have changed and certainly our policies have evolved. The House of Delegates meetings are clearly evidence of that, and I think that most physicians from our area would be pretty excited to see what the AMA has done, and is doing, to advance clinical practice and address inequities in the system. We fought efforts to tear the ACA down as it was clear that would limit access for so many patients. We’re keeping science at the forefront in the midst of the pandemic, speaking out on social determinants of health, and treating gun violence as a public health crisis. Many physicians aren’t aware of our litigation center, and the dozens of court cases we’re involved with at any given time. We sued the FDA, for example, for failing to follow their own policies to remove menthol from cigarettes, long used by the tobacco industry to particularly target Black youth, with devastating results.

We were one of the leading voices in the courts when the federal government tried to change the Title X program to gag physician speech, restricting doctors from even counseling patients about all their reproductive health options. I already mentioned our efforts to preserve DACA protections, and we have been involved in litigation to protect LGBTQ patients, and particularly our trans community, from abhorrent discrimination. So, there’s a lot going on, and our struggle always is to communicate to the profession everything we are doing.

There has been some heated debate at the AMA about racism and inequality in healthcare, and even a dust-up at JAMA. How is AMA now confronting these divisive issues?

I’m incredibly proud of the work that our Center for Health Equity is doing. Of course, we’re not surprised that our plan to advance health equity and racial justice across our work at the AMA has been controversial to some. But it’s based on policy our House of Delegates has adopted over the past few years, and also it’s rooted in science and evidence about the impact of inequities in medicine and society and what we can do and need to do to address them—improving the health of individuals and communities, and building alliances with historically marginalized physicians and other stakeholders. We need to push upstream to address social determinants of health and the root causes of these inequities, and to ensure that future innovations (such as AI) are implemented in ways that reduce rather than exacerbate health inequities. We have a huge problem with drug abuse and addiction, worsened during the pandemic. How is AMA addressing that now? I was impressed and maybe surprised to see the AMA endorse at least the trial of safe injections sites, ahead of even the CMA on this.

Yes, substance abuse disorders have clearly been an ongoing “second pandemic.” Certainly, we are a source of education for physicians around the country, with prescribing patterns changing for the better. We have pushed insurers and the government to provide coverage for evidence-based pain management alternatives, and to increase broader access to medication assisted treatment for substance use disorders. We have called for better access to SUD treatment in prisons and jails, and for expanded harm-reduction policies such as naloxone access and needle and syringe-exchange programs. Unfortunately, we’ve seen big increases in the use of fentanyl and other synthetic opiates around the country, magnified during this pandemic, and we need to look harder at these issues and work collaboratively at the state level to address them.

Healthcare costs remain a huge issue, including pharma and other contributors – how is the AMA addressing the problem? I have testified in front of Congress on the serious issue of drug pricing. Of course we physicians are excited about new treatments that help our patients, and we expect that they will be more costly at first—but when we see such medications continue to double or quadruple in price many years after their introduction, that impacts our patients’ ability to access those drugs. And we’ve seen even generics that used to be affordable, skyrocket in price. This requires a multi-pronged approach.

As physicians we witness this problem every day when working with a patient to consider treatment options. We want to be responsible stewards of resources, but the supply chain has so little transparency between the manufacturers, the PBMs, and the insurers, that it’s very difficult to know the cost of anything we are prescribing. Patients are always surprised that my EHR doesn’t tell me what’s on their formulary, what the prices are, or what the patient’s share of cost will be. Instead, the patient gets a big surprise upon arriving at the pharmacy, learning they need a prior authorization, or that the drug isn’t on their formulary and will cost a tremendous amount. This is a market failure and there is a lack of competition. We need supply chain pricing transparency, accurate real-time pharmacy benefit data at the point of care, legislation to combat anti-competitive behavior and price gouging, and more biosimilars. Our public health system has long been noted to be chronically underfunded and disjointed, and the pandemic has highlighted that. How is AMA working with that, and are you working with the American Public Health Association and others on preparedness, prevention, and other public health needs?

Yes, we have been working with colleagues in public health on a number of shared goals. We have to push our work upstream to address social determinants and other drivers of public health, such as housing insecurity, food insecurity, transportation insecurity, and other barriers that impact individuals and communities. Years of underinvestment have left us, in some cases, with an overburdened public health workforce that was challenged to confront a pandemic of this scale. And we have seen public health officials become the target of misunderstanding, political attacks, and even threats of violence that are completely unacceptable. We consistently bring science and evidence to issues that are too often politicized. Physicians are playing important roles online and in social media to be credible sources for information rooted in science and evidence.

When do you actually take office as AMA president?

I will be inaugurated in June, 2022. It’s a three-year cycle from president-elect to president and then immediate past-president. What happens to your own clinical practice during this time?

Well, it’s obviously got to shrink a bit, but it’s also very important to me to continue to see patients. When I am testifying before Congress or in other venues about the challenges we physicians and our patients are facing, being able to speak from personal experience about an interaction I had with a patient or an argument with a health insurer makes me more effective as an advocate. And I think it also keeps me grounded in the joys and challenges of being a physician, the obstacles and burdens we face every day. But mainly I really love providing care and want it to continue being a big part of my life.

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