08/20/2013 08:11 am ET Updated Oct 20, 2013

Why Medical Organization Politics Matter, Even When It's Hard to Tell the Revolutionaries from the Counter-Revolutionaries

Social media allows for interesting exchanges, but one of the more quirky ones I've encountered recently occurred in the comments section of the online drawing game Draw Something. I sometimes ignore my gamely duties for extended periods, and after a recent return, a draw-mate asked where I'd been. When I sent along my drawing of an anteater or something for her to identify, I noted in the comments section that I've been busy with efforts to help many of my PA colleagues nudge my professional organization back on track after some recent semi-Stalinist divergences by organization leadership. After she easily identified the anteater and sent along her drawing of a stagecoach for me to identify, she included this in the comment section: "good luck with the revolution!"

Social media allows us to do many things, but this seemed pretty amazing: communicating with an old friend who I have seen maybe twice in the last 25 years, and most recently at least a decade ago; creating fun and (at least in my case) childish drawings for each other to guess; sending along the occasional comment with the drawing; and having the he comment almost knock me out of my chair with its richness and provocation of my organizational pondering.

My organization is the American Academy of Physician Assistants (AAPA). You probably know about Physician Assistants (PAs) know that we are kin to nurse practitioners, that we practice medicine in concert with MDs, that we've been around for about 50 years as a profession, and that we exist to fill the gaps in service to often underserved populations. I've been a PA (Physician Assistant) since 2000, and in my ongoing life-role as an "affiliator" (previously known as "joiner"), I've been involved in lower-level AAPA volunteer leadership since around 2002. I know that many colleagues, maybe most, find the notion of professional organizational politics to be B-O-R-I-N-G. It was the same for me in junior high and high school, when I was always interested in student council and sometimes obscure modes of student leadership. As a student at a western university long, long ago, I won election to what was called the Incidental Fee Committee. It's hard to imagine a more somnolence-inducing title for a committee than that, and some of my friends at that time thought I was pretty lame for caring about something called the Incidental Fee Committee. While they were smoking pot, taking LSD, streaking, and doing nude yoga, I was running for some unheard-off student office.

But what I think they missed, and what somehow, by nook or by crook, I saw, was that this group controlled over a million dollars of money paid by students as part of their tuition and fees, and that the IFC could make very key decisions about student funding, and about which student groups would receive potentially thousands of dollars in funding. It was a powerful position with far-reaching power to impact student's lives, and even to impact the local community via the community-based actions of some of the student groups asking for funding.

With the AAPA, my volunteer leadership has been an exciting and challenging experience. I'll never forget the thrill of learning of my selection to the AAPA Committee on Diversity in 2003, and of being part of a large organization with tens of thousands of members, multi-million dollar budgets, and a high-profile national role in addressing the needs of an every diversifying profession. Goll-ly I thought, what a great organization!

Fast-forward to 2007. The last five years of the academy have been marked by enormous organizational challenges and accompanying change. A long time CEO left in 2007, to be replaced by a new CEO with a strong vision, the will to activate a very sharp guillotine, and a strong belief in the book "From Good to Great." In that book, the author proposes a scenario whereby organizations should see themselves as a bus, and then leadership should try to be sure to get the right people on, or off, the bus. And during this era, people were flying off the bus at a dizzying rate. Many of those unfortunate bus-exiters were staff who were beloved and well-known to thousands of PA members. And suddenly, they were gone. And of course, any member who dared ask "should we really be jettisoning all of this institutional memory?" were reminded that "change is difficult."

His stay ended abruptly in 2011, with some mysterious twists and skepticism-inducing press releases, with the Board of Directors noting that our fearless bus-driver was leaving yesterday, without any notice mind you, to explore other opportunities.

It must be said that he did leave in his wake some new and progressive visioning, but also an organizational staff who would twitch if you mentioned his name, and a new strategic plan and volunteer structure described as "bold" and "visionary." Members who asked too many questions (like me) had already been cast as "protectors of the status quo," and "change resisters." With the CEO's bizarre and rapid departure, the Board of Directors circled the wagons (or perhaps we should say circled the buses), and were quick to draw lines in the sand between them and members who begged to differ with decision-making of the board. Sometimes it sounded very similar to the "you are with us, or you are against us," a framework all too well-known during this turbulent period in America.

It was a strange time, and was most distressing because it moved the energy of this large association away from focusing on ways to improve the care of the public by enhancing the utilization of PAs, instead focusing on how to stop the bleeding provoked by a wacky CEO and his loyal band of Board of Directors. But PAs know better than anyone that time is the great healer, and cooler heads seemed to prevail, with the Board of Directors leadership appearing to be on track to work hard in reaching out to membership, lower-level membership leaders including committee chairs and members, and elected members of the AAPA House of Delegates, an group of over 200 members with representation from state and other constituent groups. The past bus-emptier had led some efforts that had alienated many in the House of Delegates, including bringing in a new legal team who had suddenly asserted that the equal partnership between the Board and House of Delegates was illegal, and that the House must yield almost all of its decision-making power. This was not received with great humor by the House, and further strained the Board's relationship with the House and membership in general. But shared governance seemed to be remerging, and waters were growing a little calmer.

Fast-forward again to February 2013, when an elected President of the AAPA greeted a group of volunteers gathered in Virginia at the now opulent national headquarters of the AAPA with the news that the Board of Directors had decided to unilaterally terminate the long-standing membership committee structure: "Thank you all so much for taking time out of your busy medical practices to serve on committees, for coming all the way to Virginia for the weekend to do your important work, and by the way, you're all fired."

A new CEO had been in place for a year, and like any good CEO of the AAPA, they had their pet book. (What is the deal, by the way, with CEOs and their biblical fascination with these books?) So the new CEO, like the old CEO, had been hired by a board apparently still very much wanting to make the AAPA Board of Directors a book club, and they quickly embraced by the new CEOs book Race for Relevance. This is a book written by and for professional association managers, and the authors do not hold members of membership organizations in high esteem. This seems odd, that a group of people who often make hundreds of thousands of dollars per year as CEOs of membership organizations like the AAPA and whose salaries are paid by members of these organizations would appear so disdainful of those who fund their leather chairs and hefty price tags.

One of the lame parts of the Race for Relevance "hey members, you guys suck!" deal is that of course it's never really said to members, just to those who will lead the members. It's not so much "hey members, you guys suck!" as it is "hey leaders, your members suck, but don't tell them you think that!" These cynical, bite-the-hand-that feeds-you assertions never appear anywhere that members can really see or hear them, in the glossy newsmagazines that are mailed to all the tens of thousands of members, the "look what your association is doing for you!" eblasts, etc.

Here are just a few gems from Race for Relevance related to the "committee problem" of membership associations:
On paper, committees look great. They capture talent from the membership, focus this valuable resource on important association activities, and make a significant contribution in advancing the association's mission and objectives. Committee participation has several byproducts: It can engage members in a meaningful way, give members a networking opportunity, and provide the association with a pool of potential future leaders. But let's face it, that's not how most committees work. If an association has a couple of active and productive committees, it is fortunate.

Or, try this one on for size:
We believe that the majority of committees do not produce, do not capitalize on the volunteer resource at their disposal, do not result in a positive experience for the member, and in fact, drive off more members than they cultivate. And in many instances, the volunteers who survive are not always the best and the brightest. Though not always, they sometimes are groupies and wannabes who like to travel, hang with the big dogs, hobnob with peers, and feed their egos.

Or, maybe this one:
Identify the individuals who will stand in the way. As with board downsizing, list the involved volunteers who are likely to oppose the change. The most likely are long-time chairpersons. Upcoming volunteers with an eye on a chair position are another. Make a list, understand their argument for the status quo, and be prepared to respond.

Make a list. Really? This what our professional associations, funded by our membership dues, need to be doing, making lists of dissident members who need to be neutralized?

Maybe I've been on the wrong committees to see this kind of laggardly behavior on the part groupies and wannabes wanting only to get free trips. The committees I have served on in the AAPA have been loaded with inspiring, driven Physician Assistants hell-bent on improving our association, and on building a medical system where PAs help provide superior care to all patients. Loaded with people who made service to the profession and the patients we serve a high priority. Loaded with positive and engaged members who wanted to help the AAPA make a difference. And then to hear that really we're just elitists after free trips (as if it's really fun staying in hotels, yahoo!) just trying to hob nob with the "big dogs" is a bit much. Let's just say it all seems a little nervy.

In the AAPA governance structure, the CEO plays a very key role in the workings of the Board of Directors. The CEO is hired by the Board, and consequently it's a cozy relationship from the beginning, one that each partner (CEO and Board of Directors) is highly incentivized to make work.

It should be said that when they're not describing membership volunteers on committees as muggers and thieves, the authors of Race for Relevance do express some insight about the challenges facing membership organization, and the need to modernize and be forward-thinking. But at its core, the book is cynical, anti-membership, and seductive with its self-described "radical agenda." It just seems so odd, for a book describing how to save membership organizations. The message seems to be "get the annoying members out of the way, and let the CEO and BOD run the show. Let the experts do their job." It describes the benefit of increasing power at the top, of replacing members as chairs of committees and putting staff in charge, of smaller boards, and increases power by the CEO.

It also reads with great confidence, as the authors dismiss members in membership organization as though there is strong evidence that such a model will save struggling membership associations, who all face the challenges if decreasing membership, increased competition for membership attention and dollars, and a rapidly changing health care landscape.

In fact, there is no such evidence. The book is based on nothing but notions, and what little data there is indicates that the solutions proposed in Race for Relevance guarantee very little other than more powerful CEOs, more able to call the shots without annoying members trying to insert themselves in the major decisions.

The February AAPA "no more committees, because we're nimble and responding to a fast-changing health care landscape!" floored many members, particularly ones who had been part of past processes intended to make sure that the BOD would work hard to collaborate with the AAPA House of Delegates in considering structural decisions. The decision by the BOD also blind-sided many powerful constituencies in the organization. One group, including several former elected presidents of the AAPA and some current committee members (including me) went to the BOD and asked them to slow down, do what they said they would in the past, and to wait until the annual House of Delegates meeting in May to make such a significant decision. But the BOD declined, noting all the while that change is difficult, those who would cling to the status quo must adapt. And become more nimble.
Fast forward one more time (that's it, I promise, no more fast forwarding) to May 2013, where the meeting of the House of Delegates was almost completely dominated by an upset House of Delegates, with many asking why the Board of Directors would bulldoze such a major decision without honoring its past commitments. The Board rallied around a defensive posture consisting mostly of "we didn't do anything wrong!" and "change is difficult! We must move forward! We must be nimble! We cannot embrace the status quo!" And in the end, the House would have little of it (full disclosure: I am member of the House of Delegates), and called for a bevy of task forces between the House and Board members to reconsider the changes, and look at enhancing the relationship between the HOD and BOD.

So that's where we are. Task Forces have been appointed, with all of the task forces chaired of course by Board of Directors members. Board members continue to describe the past committee structure as "elitist," those of us who are concerned about these issues as "change resisters", and as "embracers of the status quo."

In the end, who really are the revolutionaries here? Is it the leadership of the academy including the Board of Directors and new CEO who have grabbed the mantle of leadership, thrown down the Race for Relevance book as a gauntlet, and said "you are with us, or you are a terrorist"? Of are the revolutionaries people like me, who worry that the democratic and membership-driven traditions of the nearly fifty year old academy are being ravaged by a zealous and talking-point prone Board of Directors and CEO?

Whoever the revolutionaries really are will be left to others to decide, But if it comes down to a battle of talking points, let's line them up and let history decide. Let's go talking-point to talking-point, head to head.

In this corner, the AAPA Board's talking points:
1. Change is difficult!
2. Those who oppose us are embracers of the status quo.
3. Getting rid of cumbersome old stupid committees will make us nimble!
4. Staff are best suited to lead our work!
5. We're transparent!

And in that corner, the insurgent AAPA member talking points:
1. Stop speaking in talking points.
2. Listen. Reflect.
3. Remember the democratic traditions of our organization.
4. Members should be in charge of their own organization.
5. You can't push your own perspective and hear someone else's at the same time.
6. Saying "we're transparent!" over and over again does not make it so.
7. "Nimble" is a word that should be banned.
8. Stop speaking in talking points.

The next few months will reveal where the current version of the AAPA is headed, but wherever that is, it's become clear that membership is not likely to leave it to the Board of Directors, elected by less than 10% of the over 30,000 AAPA members, to unilaterally determine what's best for the academy, and for the patients that the academy serves. And that is something that, for PAs and our patients, is worth celebrating.