Mid-summer brings in a new executive team for Los Angeles, Orange and San Bernardino counties. In July, three major medical associations--the Los Angeles County Medical Association, the Orange County Medical Association and the San Bernardino County Medical Society--rang in new presidents and other executive members. While all three support many of the same policies and actions as their predecessors, they all bring in their own special interests, causes and fresh ideas. Here's where--and how--you can expect them to lead their members in the coming year.

Howard Krauss, MD
President, Los Angeles County Medical Association

Remember "Network"? Peter Finch won a posthumous Oscar for the 1976 movie in large part for an stunning, unforgettable scene in which he exhorts his viewers to rise up and say--all together now--"I'm as mad as hell and I'm not going to take this anymore." That's exactly what Howard R. Krauss, MD, the ophthalmologist who just became the 137th president of the Los Angeles County Medical Association, wants physicians to do.

Listen to this: "I'll admit that surviving an upbringing in a city housing project in the Bronx has contributed to a significant reservoir of paranoia and cynicism that's easy for me to tap into, and I hope I'm wrong, but I know that it's time for physicians to come together to take back the practice of medicine from the politicians, the press, the regulators, the administrators, the reviewers and, worst of all in the lineup, from the for-profit health plans. It's not about our income. I haven't taken a raise in ten years. It's about our ability to be respected as the best authority for evaluating and directing the management of our patients' care."

Specifically, says Dr. Krauss, a 25-year veteran of LACMA, organized medicine must drive a return to the primacy of the physician-patient relationship. "A physician shouldn't have to employ someone to obtain authorizations for treatment or spend 15 minutes on the telephone tracking down a health plan nurse to obtain authorization for a MRI for a patient with headaches and papilledema," he says. "Our system abuses patients and doctors."

One especially damaging result of the bizarre economic pressures in the healthcare system is a medical profession that has circled its wagons--rifles aimed inward. "We've allowed ourselves to be divided against ourselves," he says. "While the for-profit health plans and their CEOs have enjoyed ever-more-sumptuous meals, we physicians have been set to fighting under the table, at their feet, over which one of us is entitled to the biggest crumb!"

The situation is dire, he adds. Solo and small-group practice doctors fight with group docs. "Cognitive doctors" demand an ever-increasing share of an ever-shrinking pie. Radiologists continue to support changes in law and regulation to inhibit ownership or utilization of imaging devices by non-radiologists. And plastic surgeons continue to advocate that only those certified by the American Board of Plastic Surgery are the best-qualified to perform any procedure construed to be cosmetic or plastic.

And things are going to get waaaaaay worse before they get better if physicians don't get, well, as mad as hell. "If we physicians don't claim the high ground, to which we are inherently entitled, of individually and collectively being the prime authority in the care of our patients; if we don't work together to fight for the best interests of our patients, we will become extinct," he says. The American healthcare system is close, he warns, to "a monolithic, universal takeover by for-profit health plans that will be more concerned about executive compensation and 'shareholder value' than about facilitating the provision of high-quality, necessary medical care."

He's already part of the counterattack, and LACMA will continue to play a leadership role in the struggle, he says. Already, LACMA has forged a close relationship with Los Angeles City Attorney Rocky Delgadillo in his lawsuit against Anthem's individual policy recissions, helping the cause by urging doctors to report data through the Association to boost the lawsuit's chance of success. "As best as I can tell, most of the problems now and going forward are because of this huge conglomeration of merged, giant for-profit health plans that don't seem to have a primary interest in the well-being of the individual patient," Dr. Krauss says. "I'm delighted to see that there are still some brave people in local and state government who are willing to help us challenge them."

Indeed, Dr. Krauss is quite clear about how he wants to use the power of his presidency: "to raise physician and patient consciousness and to unite physicians and patients in the common vision of recovering and protecting the primacy of the physician-patient relationship in any and all modes of medical practice." The odds, he concedes, are overwhelming. "Medical leadership isn't rocket science and it isn't brain surgery--it's much harder," says Dr. Krauss who, in fact, has degrees in Electrical Engineering and Aeronautics and Astronautics, has professionally designed missiles, spacecraft and satellites and is a co-founder of the UCLA Skull Base Surgery and Orbitocranial Tumor Programs.

But Dr. Krauss says the key to success lies in the math and the message. "The more physicians who raise their voices in concert," he says, "the greater the impact of the message will be. And that message must be uniform and must not be about us, but about the welfare and well-being of our patients."

The problem is the internecine fistfight among physicians themselves is taking up too much energy. "We can prevail if physicians quit moaning, whining and bickering among themselves," he says, "and come together under the umbrellas of LACMA and the California Medical Association to work together for the good of our patients and for the common good of all physicians." As LACMA president, he intends to make that as easy for physicians to do as possible. He plans to bring more LACMA activities to local districts, where physicians will have more opportunities to be heard and to participate in political advocacy through local interactions with public officials. He intends to recruit greater participation by hospital and university medical staff physicians and will strive to demonstrate value to all physicians in all modes of practice.

That's Dr. Krauss' main message to doctors all over Southern California, in fact. It's a pretty simple message, and it's one you've heard before. But it bears repeating. And you can bet Dr. Krauss is going to repeat it a lot in the next year. "My message to any physician who has read this far," he says, "is this: 'Pick up your phone or go online. Join, rejoin or renew your membership in your county medical association and CMA. Make a generous contribution to LACPAC and CALPAC. And volunteer to be personally involved-now!'"

James J. Strebig, MD, FACP
President, Orange County Medical Association

Being a doctor is something worth fighting for, says James J. Strebig, MD, FACP, an internal medicine specialist in private practice in Irvine. And as the new president of the Orange County Medical Association, he wants your help in the struggle. "I believe that the medical profession is the most noble of professions," Dr. Strebig says. "But it's been under attack by many external forces for many years." And organized medicine, he feels strongly, is the best way to marshal opposition to those forces and, in the process, to strengthen the physician-patient relationship and improve the clinical quality of the services one side of that important relationship provides to the other.

"Organized," of course, means more than one person is involved. And when it comes to improving physicians' practices, more is always better. That's why Dr. Strebig plans to place a special focus on increasing OCMA membership during his tenure as president. "OCMA is a member service organization," he says. "My focus as president will be to increase membership, as well as to improve and expand services to our members." Specifically, he adds, he'd like to build membership in part through collaborations with large medical groups and other physician organizations. He also notes that doctors' clout in the political arena would increase exponentially if more physicians added their voices to the chorus. "The more physicians we can say we represent, the greater the impact we can have," he says. "And that would be to the betterment of all doctors and patients."

And while programs and projects that benefit the whole medical profession are an important element of any medical association's activities, Dr. Strebig wants to make OCMA membership more meaningful to members' day-to-day practices, and he'd like to see fewer non-members benefiting from the products and services that membership--and the fees that go with it--offer. "I want to try to address the 'free-ridership' issue of non-members by establishing written policies and differential costs and benefits," he says. "We have several thousand physicians in Orange County, but we don't have all of them as members."

That's true in every county, of course, but Dr. Strebig plans to take that particular bull by the horns as president in the OC. "We do a lot of lobbying on behalf of all physicians," he explains. "Members benefit from that lobbying, and so do non-members. I don't know that we can, or should, lobby just for doctors who are members, but there are other services we provide where we need to be asking whether the recipient is a member--and if not, ask that recipient to explain why we should continue to provide the service." Already, he says, he and his incoming team are working with OCMA's executive director, the person who runs the association administratively day to day, about "ways to identify areas where we can distinguish between providing services to members and to non-members," he says. "As a member service organization, we should be serving our members."

Here's one concrete way he wants to do that: "I would like to develop mechanisms to encourage physician members to preferentially refer patients to other physician members, and mechanisms to encourage patients to preferentially select physicians who are physician members." The plan, he elaborates, is to mimic the physician directories published by large independent practice associations for the very same purpose--letting them know who, among their available referral options, are also members of the organization. "I want to push for a directory of OCMA physicians specifically at each large hospital in the county, such as Hoag or St. Joseph's [hospitals]," he says. "Doctors' referring patterns tend to be through one hospital. So I'd pick one of those institutions and have a directory printed up with all OCMA members listed by specialty, and then distribute the directories to the physicians and patients in that institution's local community."

Accompanying that directory would be a letter encouraging doctors to use it as their referral source book--and encouraging patients to see those doctors. The California Dental Association has had success doing something very similar, Dr. Strebig points out, even running advertisements asking, "Is your dentist a member of the CDA?" He adds: "There are things we can do to make the organization more visible and more public. If we have even higher visibility in the media, then perhaps we can increase our stature among patients in the community, as well. Then you can send out the message asking patients to ask if doctors are members of the OCMA."

His is not a recent enthusiasm for organized medicine; indeed, Dr. Strebig joined OCMA in 1994, as soon as he moved to the area. "I became active in organized medicine my first year out of residency training," he says. "My early involvement was with the Young Physician Section of the California Medical Association. I was chair of the YPS in 1997 and 1998." It's no surprise, then, that he offers this encouragement to his fellow physicians: "Never give up trying to recruit non-member colleagues to join us in organized medicine to help carry out our mission to fight for doctors, patients and the medical profession."

Guillermo Valenzuela, MD, MBA
San Bernardino County Medical Society

Advocacy is a critical mission for physician organizations; nobody's denying that. But Guillermo Valenzuela, MD, MBA, the just-installed president of the San Bernardino County Medical Society, wants to make it his mission to also help doctors remember why they became doctors in the first place. "We have to fight the fights, but we also deserve to go home with the feeling that today we did something good," he says. "Pointing to everything that's wrong with what we do is not going to change anything. We should spend more time emphasizing what we do well, which is taking good care of our patients."

Of course, that includes protecting them from insurance companies and sometimes the government--in the form of Medicare and Medi-Cal cuts--he adds. "But instead of thinking about nothing but pay-for-performance programs and insurance company reimbursement," he emphasizes, "let's remember the joy of being a doctor--and try to have fun again doing what we do."

One of his focuses during his term as president, he says, will be programs to spark in young children that love of being a doctor, with the hope that it will encourage them, as well, to take better care of themselves along the way. His involvement with young people saw its genesis a few years ago in a news report that housing a prisoner costs more than a year at Harvard University. Stunned, he says, he decided he'd be the one to do something about it. He chose a nearby high school with a particularly low graduation rate and offered $500 and a cap and gown to every 9th grade student who completed all 12 years.

As his involvement in the program grew, he realized that intervention in the students' mid-teens was helping, but faced a likely insurmountable obstacle to real effectiveness: the previous 14 or 15 years of the kids' lives, when they didn't have a program available to boost their chances of graduation. So Dr. Valenzuela wants to capture students' imaginations about medicine when they're even younger.

"I picked four elementary schools with 700 students total and sponsored an essay competition--'What I Want to Be When I Grow Up'--in which the winning student in each grade gets a laptop," he reports. "If we educate children, they'll be more interested in learning, and maybe we'll help discover some bright students who will pursue medicine later on." The society, he adds, already supports elementary school programs, so his emphasis will be a natural fit. "I'll try to get involved as much as I can with early grades programs," he says.

It's his inclination to get involved that led Dr. Valenzuela to SBCMS about a decade ago. "I feel that it's my duty to participate in the things that I care about," he says, "and I care about the changes taking place in medicine." The more he got involved in the organization, the more involved he wanted to get, moving up through the ranks.

Here's part of the reason: "I've learned over the years to be very tolerant when people have an opinion that's different from mine," he says. "When I was younger, I saw things more in black and white terms, with very little gray. But as I've participated in the [medical] society, I've found there are more points of view than my own--and that some of them are even better than mine. I've learned to truly listen to people and to try to understand what they're trying to say." A natural consensus-builder, he says he's known for seeking a lot of advice and for trying, when possible, to reach consensus on contentious issues.

That means that if you're looking for fireworks from San Bernardino in the next year, you're likely to be disappointed. Dr. Valenzuela doesn't plan to issue any dramatic new directions in policy, to rattle any establishment cages nor to break ranks with other physicians on any critical matters. The society under his leadership will support California Medical Association positions as far as political advocacy, he says, and will focus much of its outreach efforts on San Bernardino County's youngest residents.

The MBA after his name, he adds, makes the economic issues bedeviling the healthcare system clearer to him--but that often only adds to his frustration. Understanding how the economy works is often as terrifying as it is empowering. "At least I understand the economic forces that are moving healthcare. That makes me often wonder, however, if some of the economic issues are really--or should really be--social issues."

Indeed, he says, "I'm becoming more and more convinced that, short of socialized medicine, at some point society is going to have to decide that healthcare is a social responsibility. It's useful to have an MBA, but it's also necessary to take a step back and wonder how fixing the economic side of healthcare is really going to solve the bigger problem by actually improving outcomes. In the face of that uncertainty, the right thing to do is to get involved."