Perspectives on burnout, trust, hope in medicine from the president of the AMA

American Medical Association President Jesse M. Ehrenfeld, MD, MPH (left), shakes hands with National Press Club President Eileen O’Reilly after Ehrenfeld's keynote address there on Oct. 25, 2023. This image was taken from the live webcast of the event.

American Medical Association (AMA) President Jesse M. Ehrenfeld, MD, MPH, was the keynote speaker at the National Press Club in Washington, D.C., on Oct. 25.

His presentation painted “a picture of our health care system in 2023, and it is not a happy or uplifting one,” with record physician burnout, shrinking Medicare reimbursement, administrative burdens, and a workforce exodus. Ehrenfeld also discussed AMA’s Recovery Plan for America’s Physicians.

Afterward, Ehrenfeld answered audience questions presented by National Press Club President Eileen O’Reilly, a science writer and managing editor for standards and training for news outlet Axios.

Here is a selection from the question-and-answer session. This transcript has been edited for length and clarity.

National Press Club: A medical graduate asks: State legislators I have talked with have said they are interested in granting provisional licenses for those who have been unmatched and can work under the supervision of board-certified doctors. What is your take on that?

Jesse M. Ehrenfeld, MD, MPH: The AMA has clear policy on this. We believe in the importance of having a graduate medical education in order to practice medicine. Those decisions are obviously left to the states in terms of what the licensure process looks like. But our approach is that we need to expand the GME (Graduate Medical Education) slots which unfortunately have not really budged in 25 years, because the dollars that support training positions are tied to Medicare funding. And since the 90s, basically it's been frozen. We had a little bit of a bump two years ago, another 1,000 spots. We need 14,000 spots, we need 20,000 spots, not just another 1,000 to solve this problem. That is the solution that we need, not some of these other options.

National Press Club: Is physician burnout unique to the U.S. medical system, and do you see it to the same extent in the U.S. or other countries with national health programs?

Ehrenfeld: I don't have data from other countries, but in my role as AMA president, I get to interact with my colleagues around the globe. And we work with the World Medical Association, brings together 115 nations, my counterparts and we actually get together in person twice a year to talk about policies. And what I do hear is that burnout is real in other nations all across the globe. And what I do hear is that other countries are having similar workforce issues. And you need to remember that 25% of practicing doctors in the U.S. came from other countries, so we benefit from what is happening in other systems in terms of their training systems and programs. We have to work together. Ultimately, it's a zero-sum game, but certainly those pressures do exist in other places.

National Press Club: I know journalists also face this issue as far as the diminishing trust in our institutions. How do you think we should fix that?

Ehrenfeld: It's a challenge. We certainly are, I think going to be dealing with the legacy of the pandemic, which is lasting, which is this crisis of misinformation. And unfortunately, it's leading people to make bad choices. We have not seen the kind of vaccination uptake that we'd like to see. I am getting my vaccine, my updated COVID Booster on Monday. Everybody else should too. It's really important, it's one of the best things that you can do along with seasonal flu and other things. But misinformation unfortunately continues to swirl around online. We have called on media companies to do their part. We need credible media outlets to do their part to lift up credible stories to help their readers understand what is evidence-based science, what is factual information, but it's something that's not going away anytime soon. I had the privilege of talking with Tony Fauci about a year and a half ago in a meeting and he suggested we just have to turn it up to 11 and make sure that we are not letting these other voices drown out what we know is science-based medicine.

National Press Club: How do you feel today's volatile political environment is contributing to physician burnout?

Ehrenfeld: So certainly, I think we live in a in a nation that is divided, but at the core, you know, people who join the profession, people who dedicate their lives to medicine, always put their patients first. And so you know, the great thing about the AMA, we bring together 190 state and specialty societies twice a year to have very vigorous, open debates about what we should do, and we have physicians from all over the country with various perspectives. The beautiful, I think very special part of our process, is that people bring their best arguments forward and they, you know, again, come at this from all sorts of angles. We vote, we set our policy, then we go out to dinner, and I wish that happened more here in Washington, D.C., where there is that sense of camaraderie and sense to put the mission first. I have a military background. I'm very much about trying to make sure that we execute the mission and putting mission above self. And I see that in our association, I see that in physicians. Unfortunately, we've got all this background noise that is making it more challenging.

National Press Club: Do you work with doctors in the military?

Ehrenfeld: I spent 10 years as a Navy physician, very proud of that, got to deploy overseas in 2014, 2015. I still have an adjunct appointment at the Uniformed Services University. And so certainly we have great representation within the AMA from the military physician community. All the services are represented by their respective Service Surgeon Generals or designee.

National Press Club: Are they dealing with different issues than the general physician population?

Ehrenfeld: They're very similar. And we actually had a really, I think seminal call right after I took office in June, with senior leadership within the military health system, about workforce challenges, burnout challenges and things like those. They have different issues, because the prior authorization challenges and the billing issues don't really exist to the same degree in the DoD (Department of Defense) system. But everybody is squeezed. There are lots of challenges that we see … find opportunities to partner on.

National Press Club: Pharma has been flooding the airwaves with ads blaming pharmacy benefit managers for the high price of drugs. Who in your opinion is to blame for the high price of medicines?

Ehrenfeld: So certainly, if we had more transparency around what PBM's are doing, we believe it would help us reduce overall costs. And so there is definitely a lot of finger-pointing going on. And one of the things that we do think would be helpful would be to have more competition in the marketplace. As you know, there's been a lot of consolidation. There are a handful of PBMs that really drive a lot of the market share and more transparency about what they're doing, how these rebate programs are working or not working, would certainly be helpful to patients and consumers.

National Press Club: In the past year, we've seen health care workers go on strike. Recently, Kaiser Permanente and a coalition of unions reached a deal to address staffing shortages and lagging wages after thousands of nurses, ER technicians and pharmacists went on strike. The speaks of a larger issue. Is our health care system broken?

Ehrenfeld: We have a health care system in crisis. And those pressures get manifested in all sorts of different ways, certainly labor actions is one of them. And we know that we can do better. We know that we can provide more resources, we can provide things that make it easier for people to practice medicine. I did not go to medical school to click buttons on my computer and not talk to my patients and yet increasingly, that's what people do. And it's frustrating for the average primary care doctor that spends less than half of their time actually in front of a patient talking to them, learning about them, trying to help them and their family, instead, doing all these things that are really administrative waste and don't add value to the system.

National Press Club: In 2022, the AMA found the highest percentages of burnout occurred among six specialties, emergency medicine, hospital medicine, family medicine, pediatrics, obstetrics and gynecology and internal medicine. Why do you think those are the ones facing the highest burnout?

Ehrenfeld: There's so much pressure on primary care right now, but I'm not surprised that our primary care specialties are on that list – pediatrics, OB/GYN, family medicine. So much pressure on folks at the front lines in the emergency departments because lingering issues with COVID and spikes and surges and all those kinds of things. But what happens when people don't have access to a primary care doctor? They go to the emergency department. And unfortunately, that pressure, that frustration, has all sorts of cascading impacts on those physicians and the things I think are very interrelated.

National Press Club: What brings you hope now, like what is a positive thing you see happening?

Ehrenfeld: Well, I'm the ever optimist, and it's good because I'm early still in my career and I got a lot of runway and a lot of years ahead of me seeing patients which excites me. But you know, on Monday, I'm going to get my COVID booster and put on my scrubs and I'm going to go take care of patients in the operating room. And when I walk into the hospital, which happens every time, I see my colleagues putting on their scrubs and their white coats, showing up for their patients, in spite of all of these enormous challenges, in spite of all of the obstacles and the frustrations and the wanting to bang your head against the wall, because you know, another insurance company has denied something that should be obviously approved. In spite of that, people show up and do the work. And I know that we continue to have people coming into the profession. Who do it for the right reasons, because they care about healing the nation and taking care of their patients. And I think as long as we continue to do that, regardless of what's ahead, we will have people who are there to take care of our patients.