House calls: activism is all in a day's work.

John MacKeigan, MD, rises before dawn to catch the 6 a.m. flight from Grand Rapids, Mich., to Washington, D.C., a midweek pilgrimage he makes five times each year. He dons soft sole shoes for what he knows will be an intense 10-hour day of pavement pounding to offices of U.S. senators and representatives.

The 62 year-old, colorectal surgeon is vice president of medical affairs for Michigan Medical, P.C., a 200-physician, multispecialty practice. He is also a consummate political activist who believes it is his unpaid duty to make medicine's viewpoint known at the highest levels of government.

"The world is run by legislative fiats and mandates," MacKeigan says. If he and others did not do this work, he says, "there would be chaos--inappropriate decisions would be made."

By 8 a.m., he arrives at Reagan National Airport and makes a beeline for a hotel to meet his delegation. MacKeigan is debriefed with talking points about Medicare payment rollbacks that threaten to cut off access to health care for seniors.

Like a precise military operation, two teams of five, a driven mix of doctors and Michigan State Medical Society legislative committee members, fan out to appointed destinations. If they get a lucky break, the teams will bend the ears of congressman from their home district instead of being shuffled off to staffers.

More than 40 years ago, before Medicare, Medicaid, managed care, Stark, and a crush of medical liability claims, physicians practiced unencumbered by intrusion of government or business. Few medical organizations had a lobbying presence in the capital then. Some relied on the American Medical Association or other groups to do their bidding; some had public affairs directors who did the job, and some hired on an as-needed basis "paid persuaders," D.C.-based lobbyists.

After Watergate, the number of subcommittees increased and so did government complexity. At the same time, instead of patients paying doctors, hospitals and pharmacies paid third parties. With the shift to insurance and government intervention in payment and health care delivery, physicians today can't order a lab test or X-Ray without consideration of a law, rule, regulation or liability.

"Medicine has evolved from a ma and pa country setting to a large industry with oversight comparable with other large service industries such as banking," says Leo Furcht, MD, 60, a Minneapolis pathologist who spends one day a week in Washington lobbying for stem cell research and other federal grant dollars for the Federation of American Societies for Experimental Biology, an 85,000 member biomedical research advocacy group.

Washington is the decision-making capital of the country where a vote in Congress, a presidential directive or a new regulation can positively or adversely affect the house of medicine. For self-preservation, scarcely a single medical society can afford to forgo a presence in the capital to protect their turfs from encroachment and advance issues that will serve them. Now and then, they throw in issues of public health and welfare.

"Someone needs to be in D.C. to put the message together, to deliver it in a focused, consistent way every chance they get," says former Minnesota Congressman, Gerry Sikorski, JD, now a Washington lobbyist with Holland & Knight, a top lobby law firm on K Street, the lobbyists' main boulevard.

Gaining access

Defensive and offensive positions are pursued by either the society's internal lobbying machine, via political action committees (PACs) that dole out campaign contributions to medicine-friendly candidates, and/or by hiring a savvy K Street "contract" firm expert at navigating the government behemoth.

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Collectively, 188 health professional groups spent $53.2 million lobbying lawmakers in 2005, according to The Center for Responsive Politics, Washington, D.C., a nonpartisan research group that tracks money in U.S. politics. The American Medical Association disbursed the lion's share, $19.2 million. The American Society for Clinical Laboratory Science anted up the smallest amount, $15,000, to make lawmakers aware of the shortage of technicians due to low reimbursement of laboratory services.

Funding does not include extensive grassroots efforts such as generating letters and telephone calls from back home, advertising, the work of issue-focused 527s--independent, tax-exempt political groups regulated by the IRS that sometimes monopolize the airwaves--or the $39 million-plus health professionals contributed to federal political campaigns and national parties.

But despite substantial financial muscle; despite well-placed physician leaders--former Senator Bill Frist (R-Tenn.) and Democratic National Committee Chairman Howard Dean, MD (D-Vt.), and despite the fact that practicing doctors who lobby curry considerable respect among politicians, Congress has been unable to deliver on issues that affect most of the family of medicine, such as simplest of medical liability reform, a $250,000 cap on noneconomic damages.

Medicare cuts are expected to ravage practices starting January 1, and managed care companies continue to dictate the terms of relationships between physicians and patients. All of these issues have topped the AMA's advocacy agenda for years and will continue in 2007.

Why aren't doctor's successful? Certainly there are countervailing forces like a strong defense from moneyed trial lawyers and insurers. "Then it becomes whose tsunami is more powerful than the other," Furcht says.

And sometimes it just takes time. "It's a process not designed by the founders to be quick and clean. There are hundreds of task forces, committees--it's a hippo doing a pirouette," says former Congressman Sikorski.

D.C. insiders also point to several of medicine's failings. For one, doctors don't spend enough time developing political relationships. "They don't appear as the holy spirit at all times at all places, wherever there are politicians--in their congressman's home district office, at town meetings, cook offs, country fairs, even dunk tanks, " Sikorski says. "The world belongs to those who show up. Doctors haven't shown up."

MacKeigan may be unusual in that he believes involvement is essential. Just as science requires education, young doctors must consider political participation part of their profession, he says. "Physician activism is no longer a choice," former AMA board chair, Duane Cady, MD, implored in an April editorial in American Medical News.

Further, "Medical schools may need to broaden their curriculums to include an emphasis on the bigger picture of policy and government when training the next generation of physicians if they hope to have physicians shaping the direction of health care in the United States," wrote authors of a Johns Hopkins study on physicians in Congress appearing in the Journal of the American Medical Association in 2004.

There are efforts being made.

* Supported by seed money from the Washington, D.C.-based public interest watchdog group, Public Citizen, a handful of medical schools, such as Albert Einstein College of Medicine, Bronx, N.Y., offer electives in political advocacy.

* To combat low morale, 27 percent of respondents to a recent survey published by The Physician Executive said they lobbied local, state or federal government(s) for health care changes.

* And in another study published in November 2006 by JAMA, about two-thirds of physicians surveyed reported being actively involved in activities such as community participation, political involvement and collective advocacy.

In all, physicians may be starting to understand no matter how frenetic their schedules, they must get involved.

"We are so busy, we can hardly spare the time to enter the debate but we feel we have no choice but to go to Washington and have our voices heard," says William Wickemeyer, MD, 57, CEO of Iowa Heart Institute, a private, 58-physician Des Moines group practice of cardiologists, cardiac and vascular surgeons. "The stakes are too high to ignore. If you don't pay attention, you could run yourself out of business."

Roughly half of Iowa's Heart's 130,000 annual visits are from Medicare recipients. If Medicare cuts occur, the practice predicts a loss of 20 percent of its income. "We could get to the point where we have to refuse Medicare patients," Wickemeyer says. "We'd have to cut many of our physicians and staff which would be a disaster. Iowa is vastly underserved in cardiology already. It's potentially devastating,"

The cardiologist donates to candidates and occasionally meets with local politicians. He participated in a November "fly in" to assist the Cardiology Advocacy Alliance, a 4,000-member lobbying group to which Iowa Heart has contributed "tens of thousands" of dollars. CAA donations are voluntary but strongly encouraged. Iowa Heart has 100 percent physician participation.

Though the group "recruits like crazy," says Wickemeyer, it cannot afford to pay cardiologists well because the state's Medicare reimbursement is among the country's lowest. Seven openings have remained vacant and two physicians left recently to practice in other states where salaries are better. "If Medicare cuts go through, it would make it impossible to attract cardiologists to our state," he adds.

Creating coalitions

Another physician failing is that when doctors have an issue, they don't form enough coalitions. "They have to learn to work with other non-doctor, Mother Theresa/Joan of Ark type groups," Sikorski says. Doctors must present their issues as the concerns of the majority--family groups, patients, business groups, veterans groups and more.

Creating alliances was the key to winning a major fight to expand federal funding for embryonic stem cell research, a bill passed in both houses was vetoed by President George Bush in July.

Furcht's FASEB group formed alliances with dozens of like-minded associations, like Juvenile Diabetes and Christopher Reeve Foundations, that brought hundreds of patients in wheelchairs to Washington, a commanding display. Celebrities, such as Mary Tyler Moore and Michael J. Fox, representing non-profit groups, also made appearances.

"Forming allegiances with other groups has a very powerful effect," Furcht says. "It's absolutely critical. There is power in numbers and constituencies,"

Alliance building is complicated. Doctors could be allied with trial lawyers on the ability of patients to sue their HMOs, or mortal enemies on tort reform. Typically friendly medical groups are bedfellows for tort reform but also butt heads. For example, cardiologists support specialty hospitals as efficient but the American Hospital Association is against them for siphoning off expensive procedures from community hospitals.

A final failing, MacKeigan says, is the growth of specialization and specialty societies that has splintered allegiances and advocacy. The AMA was once the unchallenged spokesman of professional medicine in Washington. Today a mere 250,000 of 800,000 patient care doctors are members.

"Physicians are not speaking with one voice as they might have in the 1960s--we're too segmented," MacKeigan says. "As a result, the AMA drops membership and collectively our voice is split. If you have only $1,000 or less to spend on memberships, once you pay your county, state and specialty society fees, there's nothing left for the AMA."

In all, winning over Washington requires a consistent, persistent, multi-pronged approach. Here are several recommendations for how physicians can succeed in political debates. Some require as little as an hour each week making phone calls. Others, like running for office, demand substantial sacrifices.

Become a candidate

While lobbying and other measures are beneficial, holding elective office gives doctors a seat at the table. "A greater presence of physicians in Congress, with their specialized training and perspective on health care, can potentially have a significant impact on health policy, especially with physicians reaching positions of Congressional leadership," wrote authors of the JAMA report.

How does the electorate feel about doctors as political candidates? Voters consider them honest, trustworthy, responsive and caring with a sense of community and a genuine concern for other people's well being, according to Moore Information Inc. and Peter D. Hart Research that conducted focus groups and asked the question for the AMA in 2003. However, physicians were perceived limited in scope and would have to prove competence in areas such as national security and the economy.

From 1960-2004, only 25 physicians served in Congress or just 1.1 percent, vs. 979 or 44.6 percent lawyers, the largest member occupation, wrote JAMA authors "Few physicians walk the corridors of power in Washington, D.C., where major decisions are made," according to the report.

A majority of the 25 physicians, 60 percent, were Republican, and all but two served in the House. The average length of congressional service for doctors was nine years. Today there are 11 physicians serving in Congress, and 225 lawyers, a 1:20 ratio.

Doctors support the GOP on such issues as medical malpractice reform but transfer allegiance to Democrats when it comes to patients' rights legislation and expanding Medicare payments.

With the recent power shift in Congress, doctors can expect more favorable treatment for expanding federal funding for graduate medical education, but the subject of tort reform will likely not even come up, says Washington lawyer-lobbyist, Michael Gaba, who leads a team of half dozen that handles the American College of Chest Physicians, federal advocacy.

Why are more lawyers than doctors in Congress? Researchers postulate that physicians are trained to focus on patient care, not policy. Lawyers are trained in law and have traditionally assumed roles in public service.

To help level the playing field, the AMA's Cady suggests doctors run for office, a position not wholly supported. "I'm very protective of the investment we have in physicians," says AMA president, William Plested, MD. "We can't lose them from taking care of patients. I hate to think that we (doctors) are so poorly represented that we have to stop our practices and become legislators in order to be heard."

At least two medical associations offer schools that teach physicians how to become candidates or work behind the scenes running campaigns: The AMA and the American Academy of Pediatrics. Some attendees, such as Congressman Tom Price, MD, (R-Ga.) an orthopod, go on from the schools to win federal offices.

While the AMA foots the bills for its programs, AAP requires a fee. Spouses are encouraged to attend because running for office is deemed a team effort. Candidates are often political action committee executives recruited from state medical societies.

"We ask them to send us their best folks," relates an AMA employee. Some students give up the prospect when they find out how difficult it is or that they have to forfeit their practices.

Interest appears to be growing, though. From 2004 to 2006, physicians annually attending the AMA candidate workshop increased from 18 to 30; and from 13 to 22 in the campaign school.

Become a lobbyist

Lobbyists are a pervasive force in Washington responsible for the daily workings of government and politics. They shape every piece of legislation. And the benefits cannot be understated.

According to a report by Jeffrey Birnbaum, journalist and author of several books on lobbying and politics, one D.C. lobbyist group tabulated that for every $1 million its clients spent on its services, it delivered an average of $100 million in federal government benefits.

There are 16,000 registered lobbyists, who by legal definition devote more than 20 percent of their time to the vocation, according to the American League of Lobbyists, Alexandria, Va. However, there could be double that number because some physician lobbyists and others are unaware of the rules and remain unregistered, says league president, Paul Miller.

Contrary to what physicians may think, lawmakers want to hear from them. "Every member of Congress I ever worked with is in the business because they want to change the structure," says Sikorski, who served for 10 years. "They are ready to pounce on anyone who has information about the issues."

Sikorski says doctors must understand they have authority that no one else does to speak as insiders about medical issues. "I appreciated when doctors took time out to visit me. I was flattered. I don't know what's happening in the trenches of medicine. They do. If I wanted to be effective, I had to hear from them."

Physicians don't have to go to Washington to express their views. The most effective way to communicate is to meet legislators in their districts when they are home, says Leonard Rubenstein, JD, executive director, Physicians for Human Rights, a D.C. foundation-supported group that lobbies to end torture, health disparities, AIDS in Africa and more.

When contacting legislators, physician/lobbyists need to develop a crisp, clear message that articulates their position, according to political experts. Speak in bullet points, accentuating three or four major ones. Leave behind reading material. The congressman probably won't read it but the staff may.

In addition, from time to time, doctors should represent public health issues, like tobacco control and violence prevention, that have nothing to do with bread and butter matters. Surveys of congressional legislative assistants found physician lobbyists were effective on Capitol Hill but too often addressed issues of self-interest, according to a study published in 2000 in the Archives of Internal Medicine.

David Tayloe, MD, a Goldsboro, N.C., pediatrician who practices in a group of seven doctors, agrees. He is a member of the board of the American Academy of Pediatrics and makes several annual trips to Washington on behalf of the organization to lobby for car seats, keeping guns out of the hands of children, bicycle helmets, SIDS education and child abuse prevention.

So when Tayloe has an area of self-interest, he receives near instant entree to politicians. "We push a lot of issues that have no effect on physician pocketbooks, so when we talk about low Medicaid fees, they listen," Tayloe says.

Tayloe is also effective in helping to kill what he considers detrimental legislation. When a group of small businesses pushed for federal legislation to allow bare bones affordable health plans that eliminated vaccines and check ups for children, Tayloe went on the offensive. AAP enlisted the help of Johns Hopkins epidemiologists, American Cancer Society, American Diabetes Association and other groups to convince legislators that lack of preventive health services was bad for children. The measure failed in May.

Participate in a campaign

Volunteering to assist in a campaign is a great tactic to know a candidate and his or her staff on an intimate level. "The best way to get anywhere is to get to know your congressman on a first-name basis," MacKeigan says.

If the candidate is elected, you have a personal relationship. Doctors then become resources when the lawmaker needs to understand a complex medical issue. "Support candidates on the lowest level because they eventually move to higher posts," suggests Plested.

Hosting a fundraiser in your home on behalf of the candidate helps establish you as a key player in the politics of your area. It fosters a closer association with the candidate and since the candidate is a guest in your home, he or she will remember your involvement.

Contribute to a PAC

The easiest form of involvement in politics is a personal donation to a candidate via PAC money--"legal bribery" as author Birnbaum refers to it--which gives direct to candidates, or makes indirect contributions to national parties, so called, "soft money."

"Any contribution supports access to legislators and advances the interests of medicine," MacKeigan says.

A sad reality is that candidates who spend the most win elections, according to the Center for Responsive Politics 2006 election analysis. For example, of 398 of 428 decided House races, top spenders won 98 percent of the time.

The average cost of winning a 2006 House race was $966,000 and $7.8 million for a Senate seat. Some spend a lot more, like Senator Hillary Rodham Clinton (D-N.Y.) who depleted at least $35.9 million to keep her seat, compared to her opponent, Republican John Spencer who spent at least $4.8 million.

It isn't hard to figure out which candidates are medicine friendly. The AMA grants Dr. Nathan Davis awards to those who support its views. In 2006, recipients included Senator Jon Kyl and Rep. J. Dennis Hastert, proponents of tort reform. State medical associations typically dispense names of statewide candidates who support medical issues.

Hire an expert lobbying firm

Medical groups too small to have their own brick and mortar presence in Washington sometimes hire lobby firms. Even large medical groups with lobbying machines hire them for their expertise. So powerful are these firms, they are sometimes referred to as the 5th estate, behind the three branches of government and the media.

In a 2003 Fortune article entitled, "The Persuaders," political insider Birnbaum relates how the firms can act as advocates or executioners of legislation by planting boosters in the audiences of key congressmens' town hall meetings to create the appearance of broad-based support for an issue. They can initiate ad campaigns praising supportive lawmakers or create negative ads for congressmen who don't toe the line.

For the most part, the firms maintain a balance between republicans and democrats so they can get things done and prosper no matter who is in charge.

Crisis is their stock in trade. Hired guns charge from $20,000 per month to the sky is the limit if they have to drop everything to take care of a pressing problem, Sikorski says. Among the firms used by the AMA and AHA are: McManus Group, Timmons & Co., Bockorny Petrizzo Inc., and Quinn, Gillespie & Associates.

To find a lobbyist, try www.lobbysearch.com or www.alldc.org. Washington Representatives is considered the best directory, but their Web site is subscription-only, www.lobbyists.info

Mobilize patients

Unlike attorneys, doctors see large number of patients daily, a tremendous advantage.

"We need to get physicians to tell patients what's going on. Not in exam rooms, but in waiting rooms. Put folders on tables or signs. When patients bring up the issues, suggest they talk to their legislators," says AMA president Plested.

Encourage patients to sign up with AMA Grassroots Outreach, www.patientsactionnetwork.org, which has a 1.4 million membership. Patients receive action alert emails instructing them when their help is needed, such as with Medicare and medical liability reform. Prepared letters are sent with their approval to their congressmen. "When we need their help, we've generated a lot of activity," Plested says.

Maureen Glabman is a Miami-based health care reporter and recipient of the 2000 Reuters Fellowship in Medical Journalism at Columbia University's Graduate School of Journalism.

For More Information

AMA Guide to Communicating With Members of Congress www.amaassn.org/ama/pub/category/16473.html

Related Column: Ethical Aspects

The Power of Professionalism: Should It Be Used As A Political Weapon?

By Richard E. Thompson, MD

See Page 59

RELATED ARTICLE: Physicians in Congress

Of 535 Congressmen/women, 10 are physicians; and 225 are attorneys

1. Arkansas, Rep. Vic Snyder, MD, Democrat, Family Medicine

2. Florida, Rep. David Weldon, MD, Republican, Internal Medicine

3. Georgia, Rep. Tom Price, MD, Republican, Orthopaedic Surgery

4. Georgia, Rep. Phil Gingrey, MD, Republican, OB/GYN

5. Louisiana, Rep. Charles Boustany, MD, Republican, Cardiovascular Surgery NEW?

6. Oklahoma, Senate, Tom Coburn, MD, Republican, Family Practice OB/GYN

7. Texas, Rep. Ron Paul, MD, Republican, OB/GYN

8. Texas, Rep. Michael Burgess, MD, Republican, OB/GYN

9. Washington, Rep. Jim McDermott, MD, Democrat, Psychiatry

10. Wisconsin, Steve Kagen, MD, Democrat, Internal Medicine

* Virgin Islands Delegate--Donna Christian-Christensen, MD, Democrat, Family Practice

RELATED ARTICLE: 2007 Advocacy Schools

Here's a partial list of the advocacy schools scheduled for 2007

AMPAC (American Medical Association PAC) Campaign School, April 18-22, 2007, in Arlington, Virg., 202-789-7465. Limited to 35 enrollees. Geared to physicians interested in working behind the scenes, becoming involved in the political process by helping other MDs and medicine-friendly candidates get elected to office. Simulates a campaign for the US House of Representatives, with demographics, voting statistics and candidate biographies. Participants break into teams, engage in strategy exercises, vote targeting, advertising, public speaking and insider tactics. No charge. Spouses encouraged.

AMPAC (American Medical Association PAC) Candidate Workshop, February 16-18, 2007, in Arlington, Virg., 202-789-7465. Limited to 20 enrollees. Aimed at physicians and friends of medicine seriously considering a run for public office. Political veterans offer expert advice about politics and the sacrifices necessary to mount an effective campaign. Focuses on how and when to make the decision to run, how to become an effective public speaker, the importance of a disciplined campaign plan and message, and secrets of effective fundraising.

AMPAC (American Medical Association PAC) Regional Campaign Seminar, 202-789-7465. One day session hosted by state medical societies. Combines elements of AMPAC Campaign School and Candidate Workshops. Participants learn fundamentals of campaigns such as developing a strategy, building a campaign message, fundraising techniques, strengths and weaknesses of types of paid media.

American Academy of Pediatrics Legislative Conference, June 3-5, Washington, D.C., $550, 202-347-8600. Limited to 100. Doctors learn to be political advocates on state and federal levels. They also learn how government works, build coalitions, work with the media and mediate. On the last day, registrants go to the Capitol to meet with members of Congress and/or their staffs. Eligible for CME.

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