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American Medical Association Transgender Resolution

__________

 

(PDF)

AMERICAN MEDICAL ASSOCIATION HOUSE OF DELEGATES
Resolution: 122
(A-08)
Introduced by: Resident and Fellow Section, Massachusettes Medical Society, California
Medical Association, Medical Society of the State of New York
Subject: Removing Financial Barriers to Care for Transgender Patients
Referred to: Reference Committee A
1 Whereas, The American Medical Association opposes discrimination on the basis of
gender identity1
2 and
3
4 Whereas, Gender Identity Disorder (GID) is a serious medical condition recognized as
such in both the Diagnostic and Statistical Manual of Mental Disorders (4th 5 Ed., Text
Revision) (DSM-IV-TR) and the International Classification of Diseases (10th Revision),2
6
7 and is characterized in the DSM-IV-TR as a persistent discomfort with one’s assigned
8 sex and with one’s primary and secondary sex characteristics, which causes intense
emotional pain and suffering;3
9 and
10
11 Whereas, GID, if left untreated, can result in clinically significant psychological distress,
12 dysfunction, debilitating depression and, for some people without access to appropriate
medical care and treatment, suicidality and death;4
13 and
14
15 Whereas, The World Professional Association For Transgender Health, Inc. (“WPATH”)
16 is the leading international, interdisciplinary professional organization devoted to the
understanding and treatment of gender identity disorders,5
17 and has established
internationally accepted Standards of Care 6
18 for providing medical treatment for people
19 with GID, including mental health care, hormone therapy and sex reassignment surgery,
20 which are designed to promote the health and welfare of persons with GID and are
21 recognized within the medical community to be the standard of care for treating people
22 with GID; and
23
24 Whereas, An established body of medical research demonstrates the effectiveness and
25 medical necessity of mental health care, hormone therapy and sex reassignment
surgery as forms of therapeutic treatment for many people diagnosed with GID; 7 26 and
27
28 Whereas, Health experts in GID, including WPATH, have rejected the myth that such
29 treatments are “cosmetic” or “experimental” and have recognized that these treatments
can provide safe and effective treatment for a serious health condition;7
30 and
31
32 Whereas, Physicians treating persons with GID must be able to provide the correct
33 treatment necessary for a patient in order to achieve genuine and lasting comfort with
his or her gender, based on the person’s individual needs and medical history;8
34 and
35
36 Whereas, The AMA opposes limitations placed on patient care by third-party payers
when such care is based upon sound scientific evidence and sound medical opinion;
9, 10 37
38 andResolution: 122 (A-08)
Page 2
1 Whereas, Many health insurance plans categorically exclude coverage of mental health,
2 medical, and surgical treatments for GID, even though many of these same treatments,
3 such as psychotherapy, hormone therapy, breast augmentation and removal,
4 hysterectomy, oophorectomy, orchiectomy, and salpingectomy, are often covered for
5 other medical conditions; and
6
7 Whereas, The denial of these otherwise covered benefits for patients suffering from GID
8 represents discrimination based solely on a patient’s gender identity; and
9
10 Whereas, Delaying treatment for GID can cause and/or aggravate additional serious and
11 expensive health problems, such as stress-related physical illnesses, depression, and
12 substance abuse problems, which further endanger patients’ health and strain the health
13 care system; therefore be it
14
15 RESOLVED, That the AMA support public and private health insurance coverage for
16 treatment of gender identity disorder (Directive to Take Action); and be it further
17
18 RESOLVED, That the AMA oppose categorical exclusions of coverage for treatment of
19 gender identity disorder when prescribed by a physician (Directive to Take Action).
Fiscal Note: No significant fiscal impact.
References
1. AMA Policy H-65.983, H-65.992, and H-180.980
2. Diagnostic and Statistical Manual of Mental Disorders (4th ed.. Text revision)
(2000) (“DSM-IV-TR”), 576-82, American Psychiatric Association; International
Classification of Diseases (10th Revision) (“ICD-10”), F64, World Health
Organization. The ICD further defines transsexualism as “[a] desire to live and be
accepted as a member of the opposite sex, usually accompanied by a sense of
discomfort with, or inappropriateness of, one’s anatomic sex, and a wish to have
surgery and hormonal treatment to make one’s body as congruent as possible with
one’s preferred sex.” ICD-10, F64.0.
3. DSM-IV-TR, 575-79
4. Id. at 578-79.
5. World Professional Association for Transgender Health: http://www.wpath.org.
Formerly known as The Harry Benjamin International Gender Dysphoria
Association.
6. The Harry Benjamin International Gender Dysphoria Association’s Standards of
Care for Gender Identity Disorders, Sixth Version (February, 2001). Available at

http://wpath.org/Documents2/socv6.pdf.

7. Brown G R: A review of clinical approaches to gender dysphoria. J Clin Psychiatry.
51(2):57-64, 1990. Newfield E, Hart S, Dibble S, Kohler L. Female-to-male
transgender quality of life. Qual Life Res. 15(9):1447-57, 2006. Best L, and Stein K.
(1998) “Surgical gender reassignment for male to female transsexual people.”
Wessex Institute DEC report 88; Blanchard R, et al. “Gender dysphoria, gender
reorientation, and the clinical management of transsexualism.”J Consulting and
Clinical Psychology. 53(3):295-304. 1985; Cole C, et al. “Treatment of gender Resolution: 122 (A-08)
Page 3
dysphoria (transsexualism).” Texas Medicine. 90(5):68-72. 1994; Gordon E.
“Transsexual healing: Medicaid funding of sex reassignment surgery.” Archives of
Sexual Behavior. 20(1):61-74. 1991; Hunt D, and Hampton J. “Follow-up of 17
biologic male transsexuals after sex-reassignment surgery.” Am J Psychiatry.
137(4):432-428. 1980; Kockett G, and Fahrner E. “Transsexuals who have not
undergone surgery: A follow-up study.” Arch of Sexual Behav. 16(6):511-522. 1987;
Pfafflin F and Junge A. “Sex Reassignment. Thirty Years of International Follow-Up
Studies after Sex Reassignment Surgery: A Comprehensive Review, 1961-1991.”
IJT Electronic Books, available at http://www.symposion.com/ijt/pfaefflin/1000.htm;
Selvaggi G, et al. “Gender Identity Disorder: General Overview and Surgical
Treatment for Vaginoplasty in Male-to-Female Transsexuals.” Plast Reconstr Surg.
2005 Nov;116(6):135e-145e; Smith Y, et al. “Sex reassignment: outcomes and
predictors of treatment for adolescent and adult transsexuals.” Psychol Med. 2005
Jan; 35(1):89-99; Tangpricha V, et al. “Endocrinologic treatment of gender identity
disorders. ” Endocr Pract. 9(1):12-21. 2003; Tsoi W. “Follow-up study of
transsexuals after sex reassignment surgery.” Singapore Med J. 34:515-517. 1993;
van Kesteren P, et al. “Mortality and morbidity in transsexual subjects treated with
cross-sex hormones.” Clin Endocrinol (Oxf). 1997 Sep;47(3):337-42; World
Professionals Association for Transgender Health Standards of Care for the
Treatment of Gender Identity Disorders v.6 (2001).
8. The Harry Benjamin International Gender Dysphoria Association’s Standards of
Care for Gender Identity Disorders, at 18.
9. Id.
10. AMA Policy H-120.988
Relevant AMA policy
H-65.983 Nondiscrimination Policy
The AMA opposes the use of the practice of medicine to suppress political dissent
wherever it may occur. (Res. 127, A-83; Reaffirmed: CLRPD Rep. 1, I-93; Reaffirmed:
CEJA Rep. 2, A-05)
H-65.992 Continued Support of Human Rights and Freedom
Our AMA continues (1) to support the dignity of the individual, human rights and the
sanctity of human life, and (2) to oppose any discrimination based on an individual’s sex,
sexual orientation, race, religion, disability, ethnic origin, national origin or age and any
other such reprehensible policies. (Sub. Res. 107, A-85; Modified by CLRPD Rep. 2, I-
95; Reaffirmation A-00; Reaffirmation A-05)
H-180.980 Sexual Orientation as Health Insurance Criteria
The AMA opposes the denial of health insurance on the basis of sexual orientation.
(Res. 178, A-88; Reaffirmed: Sub. Res. 101, I-97)
H-120.988 Patient Access to Treatments Prescribed by Their Physicians
The AMA confirms its strong support for the autonomous clinical decision-making
authority of a physician and that a physician may lawfully use an FDA approved drug
product or medical device for an unlabeled indication when such use is based upon Resolution: 122 (A-08)
Page 4
sound scientific evidence and sound medical opinion; and affirms the position that, when
the prescription of a drug or use of a device represents safe and effective therapy, third
party payers, including Medicare, should consider the intervention as reasonable and
necessary medical care, irrespective of labeling, should fulfill their obligation to their
beneficiaries by covering such therapy, and be required to cover appropriate “off-label”
uses of drugs on their formulary. (Res. 30, A-88; Reaffirmed: BOT Rep. 53, A-94;
Reaffirmed and Modified by CSA Rep. 3, A-97; Reaffirmed and Modified by Res. 528, A-
99; Reaffirmed: CMS Rep. 8, A-02; Reaffirmed: CMS Rep. 6, A-03; Modified: Res. 517,
A-04) AMERICAN MEDICAL ASSOCIATION HOUSE OF DELEGATES
Resolution: 314
(A-08)
Introduced by: Resident and Fellow Section
Subject: Physician Scientist Benefit Equity
Referred to: Reference Committee C
1 Whereas, The importance of physician-scientists to modern medicine is well known as “Virtually
2 everything now used in clinical medicine can trace its roots to investigations performed in a
3 clinical or basic science department…;”¹ and
4
5 Whereas, The number of physician-scientists has been steadily declining and “There are nearly
6 25% fewer physician-scientists on medical school faculties today than two decades ago;”² and
7
8 Whereas, The reasons for the decline in the number of physician-scientists are numerous, they
9 are known to include “the heavy accumulation of debt through many years of research
10 training…” and “questions about earning a living from academic life:”² and
11
12 Whereas, A significant loss of benefits can occur when house staff work as physician-scientists
13 and receive salary support from research training grants, such as provided by the National
14 Institutes of Health (NIH) and other programs, including loss of health insurance, medical liability
15 insurance, life insurance, disability insurance, and retirement benefits; and
16
17 Whereas, This loss of benefits can present a disincentive to resident physicians pursuing a
18 research career and furthering medical knowledge to improve patient care; and
19
20 Whereas, This loss of benefits produces inequities between resident physicians serving in
21 research versus clinical roles within the same institution; therefore be it
22
23 RESOLVED, That our AMA support the concept that all resident and fellow physicians who
24 function in a role as physician scientists are provided with benefits packages comparable to
25 those provided to their peers in clinical residencies or fellowships, to include disability insurance,
26 life insurance, HIV indemnity, malpractice insurance including tail coverage, retirement benefits,
27 health, sick leave and wages commensurate with their education and experience, and if a given
28 benefit or salary is provided to some residents within a given program at the same postgraduate
29 level, then that benefit must be provided to all residents.
Fiscal Note: No significant fiscal impact
References
1. Neilson EG, Ausiello D, and Demer LL. J. Invest. Med. 1995, 43(6), 534-542
2. Neilson EG. J. Clin. Invest. 2003, 111(6),765-7. Resolution: 314 (A-08)
Page 2
Relevant AMA-RFS Policy
310.799R Benefit Packages for Resident Physicians
Resolved 1) that the AMA-RFS seek to assure that all institutions be required to provide their
resident physicians with disability insurance, life insurance, HIV indemnity, malpractice
insurance including tail coverage, retirement benefits, health, sick leave and wages
commensurate with their education and experience; and 2) if a given benefit or salary is
provided to some residents within a given program at the same postgraduate level, then that
benefit must be provided to all residents. However, this provision cannot be used to eliminate
the benefit in question. (RFS Substitute Resolution 13, I-92: Reaffirmed: RFS Report C, I-02)
310.992R Minimum Resident Benefits
Asked that the AMA-RFS continue to monitor the revision of the “General Requirements” of the
Essentials of Accredited Residencies in Graduate Medical Education for significant changes in
benefits language, and act on them as appropriate within current AMA-RFS actions and AMA
policies. (RFS Report I, I-89; Reaffirmed, RFS Report C, I-99)
Relevant AMA Policy
H-460.971 Support for Training of Biomedical Scientists and Health Care Researchers
Our AMA: (1) continues its strong support for the Medical Scientists Training Program’s stated
mission goals;
(2) supports taking immediate steps to enhance the continuation and adequate funding for
stipends in federal research training programs in the biomedical sciences and health care
research, including training of combined MD and PhD, biomedical PhD, and post-doctoral (post
MD and post PhD) research trainees;
(3) supports monitoring federal funding levels in this area and being prepared to provide
testimony in support of these and other programs to enhance the training of biomedical
scientists and health care research;
(4) supports a comprehensive strategy to increase the number of physician-scientists by: (a)
emphasizing the importance of biomedical research for the health of our population; (b)
supporting the need for career opportunities in biomedical research early during medical school
and in residency training; (c) advocating National Institutes of Health support for the career
development of physician-scientists; and (d) encouraging academic medical institutions to
develop faculty paths supportive of successful careers in medical research; and
(5) supports strategies for federal government-sponsored programs, including reduction of
education-acquired debt, to encourage training of physician-scientists for biomedical research.
(Res. 93, I-88; Reaffirmed: Sunset Report, I-98; Amended: Sub. Res. 302, I-99; Appended: Res.
515 and Reaffirmation A-00)
H-310.999 Guidelines for Housestaff Contracts or Agreements
The “Essentials of Approved Residencies, ” approved by the House of Delegates in 1970,
includes a section on relationships of housestaff and institutions. The following outline is
intended to promote additional guidance to all parties in establishing the conditions under which
house officers learn and provide services to patients.
Training programs have been central to the process of graduate medical education which has
produced a high level of medical competence in the United States. The American Medical Resolution: 314 (A-08)
Page 3
Association recognizes that the integrity of these programs is a primary objective in achieving
the best possible care of the patient. It is, therefore, incumbent upon members of the housestaff
and the institutions in which they are being trained to be aware of the parameters and
responsibilities applicable to their training programs. In the absence of such awareness,
unreasonable expectations may arise to threaten the harmony between hospital and housestaff
in the performance of their joint mission.
It should be emphasized that these guidelines are not intended as a fixed formula. Guidelines
that seek to cover public, voluntary and proprietary hospitals necessarily entail so many
variables from training institution to training institution that no single form of contract or
agreement would be universally applicable. This set of guidelines has, therefore, been
developed to cover the more significant substantive provisions of a housestaff contract or
agreement.
The subjects included in the Guidelines are not intended to be the only subjects important or
appropriate for a contract or agreement. Moreover, the definition of the respective
responsibilities, rights and obligations of the parties involved can assume various forms:
individual contracts or agreements, group contracts or agreements, or as a part of the rules of
government of the institution.
II. Proposed Terms and Conditions A. Parties to the Contract or Agreement (1) Contracts or
agreements may be formed between individuals or groups, and institutions. Such a group might
be a housestaff organization. (2) The two parties to an agreement or contract may be a single
institution or a group of institutions, and an individual member of the housestaff, an informal
group of the housestaff, or a formally constituted group or association of the housestaff, as
determined by the housestaff organization.
B. General Principles (1) Contracts or agreements are legal documents and must conform to the
laws, rules, and regulation to which the institutions are subject. Position, salary and all other
benefits should remain in effect insofar as possible without regard to rotational assignments
even when the member of the housestaff is away from the parent institution. Exceptions
required by law or regulations should be clearly delineated to the house officer at the time of the
appointment. Changes in the number of positions in each year of a training program should be
made so as not to affect adversely persons already in, or accepted in, that program. The
agreement should provide fair and equitable conditions of employment for all those performing
the duties of interns, residents and fellows. When a general contract or agreement is in effect
between an association and an institution, individual contracts or agreements should be
consistent. (2) Adequate prior notification of either party’s intent not to review the contract or
agreement should be required, and the date of such notification should be included in the
contract or agreement. (3) The institution and the individual members of the housestaff must
accept and recognize the right of the housestaff to determine the means by which the
housestaff may organize its affairs, and both parties should abide by that determination;
provided that the inherent right of a member of the housestaff to contract and negotiate freely
with the institution, individually or collectively, for terms and conditions of employment and
training should not be denied or infringed. No contract should require or prescribe that members
of the housestaff shall or shall not be members of an association or union.
C. Obligation of the Housestaff (1) Members of the housestaff agree to fulfill the educational
requirements of the graduate training programs, and accept the obligation to use their efforts to
provide safe, effective and compassionate patient care as assigned or required under the
circumstances as delineated in the ACGME “Essentials of Approved Residencies” and
previously approved standards of the AMA Council on Medical Education. (2) Members of the
housestaff should comply with the laws, regulations, and policies to which the institution is
subject. Resolution: 314 (A-08)
Page 4
D. Obligation of the Institution (1) The institution agrees to provide an educational program that
meets the standards of the ACGME “Essentials of Approved Residencies.” (2) The institution
agrees to maintain continuously its staff and its facilities in compliance with all of the standards
in the ACGME “Essentials of Approved Residencies.”
E. Salary for Housestaff (1) The salary to be paid and the frequency of payment should be
specified. The salary schedule should be published. The basis for increments and the time of
the increments should be specified. (2) In determining the salary level of a member of the
housestaff, prior educational experience should be considered, and a determination made as to
whether credit should be given. (3) The responsibilities of senior residents should be recognized
in salary differentials.
F. Hours of Work There should be recognition of the fact that long duty hours extending over an
unreasonably long period of time or onerous on-call schedules are not consistent with the
primary objective of education or the efficient delivery of optimal patient care. The institution
should commit itself to fair scheduling of duty time for all members of the housestaff, including
the provision of adequate off-duty hours.
G. Off-Duty Activities The contract or agreement should provide that a member of the housestaff
is free to use his off-duty hours as he sees fit, including engaging in outside employment if
permitted by the terms of the original contract or agreement, so long as such activity does not
interfere with his obligations to the institution or to the effectiveness of the educational program
to which he has been appointed.
H. Vacation and Leave The AMA encourages residency programs across the country to permit
and schedule off-duty time separate from personal vacation time to enable residents to attend
educational and/or organized medicine conferences. The amount of vacation, sick leave, and
educational leave to which each member of the housestaff is entitled should be specified.
Vacations should be expressed in terms of customary working days as defined by the institution.
If vacations may be taken only at certain times of the year, this restriction should be stated. Any
requirements for scheduling vacation time should also be stated. Provisions may also cover
leaves for maternity, paternity, bereavement, military duty, examinations and preparations
therefore, and educational conferences. Reimbursement for tuition and expenses incurred at
educational conferences should be considered. The agreement should set forth any progressive
increases in the amount of time allowed for vacation, sick leave, and educational leave.
Educational leave should not be deducted from vacation time.
I. Insurance Benefits Insurance benefits should be set forth with particularity and should be
tailored to the specific needs of the housestaff. Some of the more common insurance benefit
provisions are (1) hospitalization and basic medical coverage for the member of the housestaff,
spouse, and minor children; (2) major medical coverage for the member of the housestaff,
spouse, and minor children; and (3) group life insurance, and dismemberment and disability
insurance for the member of the housestaff only. It should also be specified whether the
institution will pay the full amount of premiums or only a portion of the premiums, the balance to
be paid by the member of the housestaff. Co-paid benefits should be established, separately
from other hospital employee benefits, as a means of maximizing benefits. In some instances,
free care for the housestaff and their families at the training institutions may be provided. In lieu
of insurance benefits, the contract or agreement may provide for fixed annual payments to a
housestaff association for each member of the housestaff so that the housestaff association
may determine and provide for insurance or other benefits for the housestaff.
J. Professional Liability Insurance The contract or agreement should specify the amount of
professional liability insurance that the institution will provide for each member of the housestaff
together with the limits of liability applicable to such coverage. It might also be appropriate to
provide in the contract or agreement that the housestaff and the institution will cooperate fully
with the insurance company in the handling of any professional liability claim. Resolution: 314 (A-08)
Page 5
K. Committee Participation Insofar as possible, the institution should agree to provide for
appropriate participation by the housestaff on the various committees within the institution. This
participation should be on committees concerning institutional, professional and administrative
matters including grievance and disciplinary proceedings. Members should have full voting
rights. Representatives of the housestaff should be selected by the members of the housestaff.
L. Grievance Procedures The contract or agreement should require and publish a grievance
procedure. A grievance procedure typically involves the following: (1) A definition of the term
“grievance” (e.g., any dispute or controversy about the interpretation or application of the
contract, any rule or regulation, or any policy or practice). (2) The timing, sequence, and end
point of the grievance procedure. (3) The right to legal or other representation. (4) The right of
an individual member of the housestaff or a housestaff association to initiate a grievance
procedure and the obligation of the housestaff to maintain patient care during the grievance
procedure. (5) A statement of the bases and procedures for the final decision on grievances
(end point), and agreement of both parties to abide by the decision. (6) Should costs arise in the
grievance procedure, a prior agreement as to how these costs will be apportioned between the
parties.
M. Disciplinary Hearings and Procedure With respect to disciplinary procedures, the provisions
of Article VIII – Hearing and Appellate Review Procedure of the JCAHO Guidelines for the
Formulation of Medical Staff Bylaws, Rules, and Regulations shall be applicable to the
housestaff in the same manner as they are to all other members of the medical staff with the
proviso that the Hearing and Appeals Committees shall contain appropriate representation of
the housestaff.
N. Description of the Educational Program The specific details of the operation of the
educational experience should be made available to each prospective candidate. These data
should include specific descriptions of training programs, including numbers of resident
positions at each level of training, copies of existing housestaff contracts or agreements,
approval status of programs to which candidate is applying, methods of evaluation, procedures
for grievances and disciplinary action, and commitments for further training.
O. Patient-Care Issues The quality of patient-care services and facilities may be specified in the
contract, and could include such matters as adequate equipment, bedspace, clinical staffing,
and clinical staff structuring.
P. Other Provisions The agreement should provide for adequate, comfortable, safe, and
sanitary facilities.
The foregoing provisions are not all-inclusive. Depending upon the institution’s size, resources,
location, and affiliations, if any, and also depending upon the relationship between the institution
and the housestaff association, other provisions may be included, such as: (1) Maintenance of
existing benefits and practices not otherwise expressly covered; (2) Housing, meals, laundry,
uniforms, living-out and telephone allowances; (3) Adequate office space, facilities, and
supporting services for housestaff affairs; (4) Housestaff association seminars and meetings.
(BOT Rep. H, I-74; Reaffirmed: CLRPD Rep. C, A-89; Appended: Res.323, I-97; Reaffirmation
A-00)
H-310.929 Principles for Graduate Medical Education
Our AMA urges the Accreditation Council for Graduate Medical Education to incorporate these
principles in the revised “Institutional Requirements” of the Essentials of Accredited Residencies
of Graduate Medical Education, if they are not already present.
(1) PURPOSE OF GRADUATE MEDICAL EDUCATION. There must be objectives for residency
education in each specialty that promote the development of the knowledge, skills, attitudes,
and behavior necessary to become a competent practitioner in a recognized medical specialty. Resolution: 314 (A-08)
Page 6
(2) RELATION OF ACCREDITATION TO THE PURPOSE OF RESIDENCY TRAINING.
Accreditation requirements should relate to the stated purpose of a residency program and to
the knowledge, skills, attitudes, and behaviors that a resident physician should have on
completing residency education.
(3) EDUATION IN THE BROAD FIELD OF MEDICINE. GME should provide a resident
physician with broad clinical experiences that address the general competencies and
professionalism expected of all physicians, adding depth as well as breadth to the competencies
introduced in medical school.
(4) SCHOLARLY ACTIVITIES FOR RESIDENTS. Graduate medical education should always
occur in a milieu that includes scholarship. Resident physicians should learn to appreciate the
importance of scholarly activities and should be knowledgeable about scientific method.
However, the accreditation requirements, the structure, and the content of graduate medical
education should be directed toward preparing physicians to practice in a medical specialty.
Individual educational opportunities beyond the residency program should be provided for
resident physicians who have an interest in, and show an aptitude for, academic and research
pursuits. The continued development of evidence-based medicine in the graduate medical
education curriculum reinforces the integrity of the scientific method in the everyday practice of
clinical medicine.
(5) FACULTY SCHOLARSHIP. All residency faculty members must engage in scholarly
activities and/or scientific inquiry. Suitable examples of this work must not be limited to basic
biomedical research. Faculty can comply with this principle through participation in scholarly
meetings, journal club, lectures, and similar academic pursuits.
(6) INSTITUTIONAL RESPONSIBILITY FOR PROGRAMS. Specialty-specific GME must
operate under a system of institutional governance responsible for the development and
implementation of policies regarding the following; the initial authorization of programs, the
appointment of program directors, compliance with the Essentials for Accredited Residencies in
Graduate Medical Education, the advancement of resident physicians, the disciplining of
resident physicians when this is appropriate, the maintenance of permanent records, and the
credentialing of resident physicians who successfully complete the program. If an institution
closes or has to reduce the size of a residency program, the institution must inform the residents
as soon as possible. Institutions must make every effort to allow residents already in the
program to complete their education in the affected program. When this is not possible,
institutions must assist residents to enroll in another program in which they can continue their
education. Programs must also make arrangements, when necessary, for the disposition of
program files so that future confirmation of the completion of residency education is possible.
Institutions should allow residents to form housestaff organizations, or similar organizations, to
address patient care and resident work environment concerns. Institutional committees should
include resident members.
(7) COMPENSATION OF RESIDENT PHYSICIANS. All residents should be compensated.
Residents should receive fringe benefits, including, but not limited to, health, disability, and
professional liability insurance and parental leave and should have access to other benefits
offered by the institution. Residents must be informed of employment policies and fringe
benefits, and their access to them. Restrictive covenants must not be required of residents or
applicants for residency education.
(8) LENGTH OF TRAINING. The usual duration of an accredited residency in a specialty should
be defined in the “Program Requirements.” The required minimum duration should be the same
for all programs in a specialty and should be sufficient to meet the stated objectives of residency
education for the specialty and to cover the course content specified in the Program
Requirements. The time required for an individual resident physician’s education might be Resolution: 314 (A-08)
Page 7
modified depending on the aptitude of the resident physician and the availability of required
clinical experiences.
(9) PROVISION OF FORMAL EDUCATIONAL EXPERIENCES. Graduate medical education
must include a formal educational component in addition to supervised clinical experience. This
component should assist resident physicians in acquiring the knowledge and skill base required
for practice in the specialty. The assignment of clinical responsibility to resident physicians must
permit time for study of the basic sciences and clinical pathophysiology related to the specialty.
(10) INNOVATION OF GRADUATE MEDICAL EDUCATION. The requirements for accreditation
of residency training should encourage educational innovation and continual improvement. New
topic areas such as continuous quality improvement (CQI), outcome management, informatics
and information systems, and population-based medicine should be included as appropriate to
the specialty.
(11) THE ENVIRONMENT OF GRADUATE MEDICAL EDUCATION. Sponsoring organizations
and other GME programs must create an environment that is conducive to learning. There must
be an appropriate balance between education and service. Resident physicians must be treated
as colleagues.
(12) SUPERVISION OF RESIDENT PHYSICIANS. Program directors must supervise the
clinical performance of resident physicians. The policies of the sponsoring institution, as
enforced by the program director, must ensure that the clinical activities of each resident
physician are supervised to a degree that reflects the ability of the resident physician. Integral to
resident supervision is the necessity for frequent evaluation of residents by faculty, with
discussion between faculty and resident. It is a cardinal principle that responsibility for the
treatment of each patient and the education of resident and fellow physicians lies with the
physician/faculty to whom the patient is assigned and who supervises all care rendered to the
patient by residents and fellows.
(13) EVALUATION OF RESIDENTS AND SPECIALTY BOARD CERTIFICATION. Residency
program directors and faculty are responsible for evaluating and documenting the continuing
development and competency of residents, as well as the readiness of residents to enter
independent clinical practice upon completion of training. Program directors should also
document any deficiency or concern that could interfere with the practice of medicine and which
requires remediation, treatment, or removal from training. Inherent within the concept of
specialty board certification is the necessity for the residency program to attest and affirm to the
competence of the residents completing their training program and being recommended to the
specialty board as candidates for examination. This attestation of competency should be
accepted by specialty boards as fulfilling the educational and training requirements allowing
candidates to sit for the certifying examination of each member board of the ABMS.
(14) GRADUATE MEDICAL EDUCATION IN THE AMBULATORY SETTING. Graduate medical
education programs must provide educational experiences to residents in the broadest possible
range of educational sites, so that residents are trained in the same types of sites in which they
may practice after completing GME. It should include experiences in a variety of ambulatory
settings, in addition to the traditional inpatient experience. The amount and types of ambulatory
training is a function of the given specialty.
(15) VERIFICATION OF RESIDENT PHYSICIAN EXPERIENCE. The program director must
document a resident physician’s specific experiences and demonstrated knowledge, skills,
attitudes, and behavior, and a record must be maintained within the institution. (CME Rep. 9, A-
99)
H-295.942 Providing Dental and Vision Insurance to Medical Students and Resident
Physicians Resolution: 314 (A-08)
Page 8
The AMA urges (1) all medical schools to pay for or offer affordable policy options and,
assuming the rates are appropriate, require enrollment in disability insurance plans by all
medical students; (2) all residency programs to pay for or offer affordable policy options for
disability insurance, and strongly encourage the enrollment of all residents in such plans;
(3) medical schools and residency training programs to pay for or offer comprehensive and
affordable health insurance coverage, including but not limited to medical, dental, and vision
care, to medical students and residents which provides no less than the minimum benefits
currently recommended by the AMA for employer-provided health insurance and to require
enrollment in such insurance; (4) carriers offering disability insurance to: (a) offer a range of
disability policies for medical students and residents that provide sufficient monthly disability
benefits to defray any educational loan repayments, other living expenses, and an amount
sufficient to continue payment for health insurance providing the minimum benefits
recommended by the AMA for employer-provided health insurance; and (b) include in all such
policies a rollover provision allowing continuation of student disability coverage into the
residency period without medical underwriting. (5) Our AMA: (a) actively encourages medical
schools, residency programs, and fellowship programs to provide access to portable group
health and disability insurance, including human immunodeficiency virus positive indemnity
insurance, for all medical students and resident and fellow physicians; (b) will work with the
ACGME and the LCME, and other interested state medical societies or specialty organizations,
to develop strategies and policies to ensure access to the provision of portable health and
disability insurance coverage, including human immunodeficiency virus positive indemnity
insurance, for all medical students, resident and fellow physicians; and (c) will prepare
informational material designed to inform medical students and residents concerning the need
for both disability and health insurance and describing the available coverage and
characteristics of such insurance. (BOT Rep. W, I-91; Reaffirmed: BOT Rep. 1, I-934;
Appended: Res. 311, I-98; Modified: Res. 306, A-04) AMERICAN MEDICAL ASSOCIATION HOUSE OF DELEGATES
Resolution: 315
(A-08)
Introduced by: Resident and Fellow Section
Subject: Evaluation of Increasing Resident Review Committee (RRC) Requirements
Referred to: Reference Committee C
1 Whereas, The creation of the Outcome Project and the development of the six core
2 competencies from the Accreditation Council for Graduate Medical Education has lead to a
3 novel and valuable shift in the focus of graduate medical education toward competency-based
4 learning; and
5
6 Whereas, The shift in focus to competency-based learning has created a need for new
7 assessment tools, structured curricula, and extensive documentation of resident performance
8 data in an attempt to quantify a largely qualitative experience; and
9
10 Whereas, Excessive documentation requirements could detract from time available for
11 residents and fellows to learn directly from patients during clinical encounters and less time for
12 staff to teach residents, therefore be it
13
14 RESOLVED, That the AMA study residency/fellowship documentation requirements for
15 program accreditation and the impact of these documentation requirements on program
16 directors and residents with recommendations for improvement.
Fiscal Note: Estimated cost of $38,602 to visit between 10 to 20 GME sponsoring institutions
and analyze work effort involved by a representative sample of program directors and
Designated Institutional Officers to respond to ACGME accreditation requirements.
Relevant AMA Policy
H-315.982 CMS Documentation Guidelines for Teaching Physicians
The AMA will work with the CMS to: (1) reduce the redundant and burdensome documentation
for teaching physicians; (2) accept documentation by the physician team under the supervision
of a teaching physician if it collectively meets all CMS documentation requirements: and (3)
accept a statement of the teaching physician’s level of participation in patient care as sufficient
or adequate documentation. (Res. 861, A-98)
D-300.995 Reducing Burdens of CME Accreditation and Documentation
Our AMA will work with the Accreditation Council for Continuing Medical Education to simplify
the requirements for documentation and administration of accredited CME programs. (Res. 304,
I-01) AMERICAN MEDICAL ASSOCIATION HOUSE OF DELEGATES
Resolution: 316
(A-08)
Introduced by: Resident and Fellow Section
Subject: Loss of Status Following Family Medical Leave Act (FMLA) Qualified Leave
During Residency Training
Referred to: Reference Committee C
1 Whereas, Current AMA policy (H-420.967) states “Physicians should be able to return to their
2 practices or training programs after taking maternity leave without the loss of status”; and
3
4 Whereas, The Family Medical Leave Act (FMLA) guarantees that eligible employees be given “a
5 minimum of twelve weeks of unpaid leave per year” for certain medical and family reasons
6 (including pregnancy/childbirth) and be restored “to the same or an equivalent position” upon
their return to work1
7 ; and
8
9 Whereas, Certain residency training programs require residents taking family medical leave
10 (including maternity leave) for periods protected under the FMLA (up to 12 weeks) to repeat the
entire year, citing this requirement as necessary to maintain board eligibility2
11 ; and
12
13 Whereas, Specialty board policies regarding board eligibility do not seem to explicitly require a
14 resident taking family medical leave to repeat the entire year (rather than simply extend training)
in the event of a resident taking a period of leave protected under the FMLA3, 4 15 ; and
16
17 Whereas, Residents who must repeat an entire year of training as a direct result of taking an
18 FMLA-protected maternity leave suffer a “loss of status”, as well as lost potential income, as a
19 result of taking maternity leave; and
20
21 Whereas, Perpetuation of policies that result in this kind of “loss of status” due to residents
22 taking maternity leave lowers morale for many residents and may discourage women from
entering the specialty of their choice 5, 6 23 ; and
24
25 Whereas, Residency programs imposing such a requirement as a result of actual or falsely
26 construed specialty board policy may unknowingly be committing a tort against those residents
27 who suffered a “loss of status” and those who did not take desired leave as a result of the threat
28 of “loss of status”; and
29
30 Whereas, The policies of the specialty boards regarding family medical leave and board
31 eligibility requirements are extremely variable between specialties and confusing to residents
32 and faculty alike; therefore be it
33
34 RESOLVED, That our AMA oppose requiring residents to repeat a year of training when
35 returning to work following a leave that qualifies under the federal Family Medical Leave Act
36 (New HOD Policy); and be it further
37 Resolution: 316 (A-08)
Page 2
1 RESOLVED, That our AMA urge the American Board of Medical Specialties and its member
2 boards to be in compliance with the Family Medical Leave Act and to retract any policies that do
3 not comply (Directive to Take Action).
Fiscal Note: Less than $1000
References
1. U.S. Department of Labor: Compliance Assistance – Family and Medical Leave Act.

http://www.dol.gov/esa/whd/fmla/

2. Jagsi R, Tarbell, NJ, and DF Weinstein. Supplement to “Becoming a Doctor, Starting a
Family — Leaves of Absence from Graduate Medical Education.” New England Journal of
Medicine, 2007; 357(19): 1889-1891.
3. American Board of Orthopedic Surgery, Inc. 2008 Rules and Procedures for Residency
Education. https://www.abos.org/documents/2008RP.doc
4. Rose, SH, Burkle CM, Elliott BA, et al. “The Impact of Parental Leave on Extending Training
and Entering the Board Certification Examination Process.” Mayo Clinic Proceedings. 2006;
81(11):1449-53.
5. Jagsi R, Tarbell, NJ, and DF Weinstein. “Becoming a Doctor, Starting a Family — Leaves of
Absence from Graduate Medical Education.” New England Journal of Medicine, 2007;
357(19): 1889-1891.
Relevant AMA Policy:
H-420.967 Maternity Leave Policies
Over the past decade, the medical community has made significant progress in responding to
the unique needs of women medical students and physicians, including the issue of maternity
leave. The continuation and enhancement of these efforts should be encouraged. Therefore,
(1) The AMA urges medical schools, residency training programs, medical specialty boards, the
Accreditation Council for Graduate Medical Education, and medical group practices to
incorporate and/or encourage development of written maternity leave policies as part of the
physician’s standard benefit agreement.
(2) AMA policy regarding recommended components of maternity leave policies for physicians,
as specified in Policy 420.987 is expanded to include physicians in practice, reading as follows:
(a) Residency program directors and group practice administrators should review federal law
concerning maternity leave for guidance in developing policies to assure that pregnant
physicians are allowed the same sick leave or disability benefits as those physicians who are ill
or disabled; (b) Staffing levels and scheduling are encouraged to be flexible enough to allow for
coverage without creating intolerable increases in other physicians’ work loads, particularly in
residency programs; and (c) Physicians should be able to return to their practices or training
programs after taking maternity leave without the loss of status.
(3) Our AMA encourages residency programs, specialty boards, and medical group practices to
incorporate into their maternity leave policies a six-week minimum leave allowance, with the
understanding that no woman should be required to take a minimum leave. (BOT Rep. HH, I-90;
Modified: Sunset Report, I-00)
H-420.961 Education — Policies for Maternity, Family and Medical Necessity Leave for
Residents and Employed Physicians
AMA adopts as policy the following guidelines for, and encourage the implementation of,
Maternity and Family Leave for Residency Programs and Employed Medical Staffs: (1) The
AMA urges medical schools, residency training programs, medical specialty boards, and the Resolution: 316 (A-08)
Page 3
Accreditation Council for Graduate Medical Education to incorporate and/or encourage
development of written leave policies, including parental leave, family leave, and medical leave;
(2) Residency program directors should review federal and state law for guidance in developing
policies for parental, family, and medical leave; (3) Physicians who are unable to work because
of pregnancy, childbirth, and other related medical conditions should be entitled to such leave
and other benefits on the same basis as other physicians who are temporarily unable to work for
other medical reasons; (4) Residency programs should develop written policies on parental
leave, family leave, and medical leave for physicians. Such written policies should include the
following elements: (a) leave policy for birth or adoption; (b) duration of leave allowed before
and after delivery; (c) category of leave credited (e.g., sick, vacation, parental, unpaid leave,
short term disability); (d) whether leave is paid or unpaid; (e) whether provision is made for
continuation of insurance benefits during leave and who pays for premiums; (f) whether sick
leave and vacation time may be accrued from year to year or used in advance; (g) extended
leave for resident physicians with extraordinary and long-term personal or family medical
tragedies for periods of up to one year, without loss of previously accepted residency positions,
for devastating conditions such as terminal illness, permanent disability, or complications of
pregnancy that threaten maternal or fetal life; (h) how time can be made up in order for a
resident physician to be considered board eligible; (i) what period of leave would result in a
resident physician being required to complete an extra or delayed year of training; (j) whether
time spent in making up a leave will be paid; and (k) whether schedule accommodations are
allowed, such as reduced hours, no night call, modified rotation schedules, and permanent parttime scheduling; (5) Staffing levels and scheduling are encouraged to be flexible enough to
allow for coverage without creating intolerable increases in the workloads of other physicians,
particularly those in residency programs; (6) Physicians should be able to return to their
practices or training programs after taking parental leave, family leave, or medical leave without
the loss of status; and (7) Residency program directors must assist residents in identifying their
specific requirements (for example, the number of months to be made up); because of leave for
eligibility for board certification. Residency program directors must notify residents on leave if
they are in danger of falling below minimal requirements for board eligibility. Program directors
must give these residents a complete list of requirements to be completed in order to retain
board eligibility. (CME Rep. 6, A-98; Reaffirmation I-03)
H-420.979 AMA Statement on Family and Medical Leave
Our AMA supports policies that provide employees with reasonable job security and continued
availability of health plan benefits in the event leave by an employee becomes necessary due to
documented medical conditions. Such policies should provide for reasonable periods of paid or
unpaid: (1) medical leave for the employee, including pregnancy; (2) maternity leave for the
employee-mother; (3) leave if medically appropriate to care for a member of the employee’s
immediate family, i.e., a spouse or children; and (4) leave for adoption or for foster care leading
to adoption. Such periods of leave may differ with respect to each of the foregoing
classifications, and may vary with reasonable categories of employers. Such policies should
encourage voluntary programs by employers and may provide for appropriate legislation (with or
without financial assistance from government). Any legislative proposals will be reviewed
through the Association’s normal legislative process for appropriateness, taking into
consideration all elements therein, including classifications of employees and employers,
reasons for the leave, periods of leave recognized (whether paid or unpaid), obligations on
return from leave, and other factors involved in order to achieve reasonable objectives
recognizing the legitimate needs of employees and employers. (BOT Rep. A, A-88; Reaffirmed:
Sunset Report, I-98) Resolution: 316 (A-08)
Page 4
H-420.987 Maternity Leave for Residents
The AMA believes that: (1) Residency program directors should review federal law concerning
maternity leave and note that for policies to be in compliance, pregnant residents must be
allowed the same sick leave or disability benefits as other residents who are ill or disabled. (2)
The duration of disability leave should be determined by the pregnant resident’s physicians,
based on the individual’s condition and needs. (3) All residency programs should develop a
written policy on maternity and paternity leave for residents that addresses: (a) duration of leave
allowed before and after delivery; (b) category of leave credited; (c) whether leave is paid or
unpaid; (d) whether provision is made for continuation of insurance benefits during leave, and
who pays the premium; (e) whether sick leave and vacation time may be accrued from year to
year or used in advance; (f) how much time must be made up in order to be considered board
eligible; (g) whether make-up time will be paid; (h) whether schedule accommodations are
allowed; (i) leave policy for adoption; and (j) leave policy for paternity. (4) Resident numbers and
scheduling are encouraged to be flexible enough to allow for coverage without creating
intolerable increases in other residents’ work loads. (5) Residents should be able to return to
their training program after disability leave without loss of training status. (BOT Rep. Z, A-84;
Reaffirmed by CLRPD Rep. 3 – I-94; Reaffirmed and Modified: CME Rep. 2, A-04)
H-420.996 Maternity Leave for Housestaff
Our AMA encourages flexibility in residency training programs, incorporating maternity leave
and alternative schedules for pregnant housestaff. (Sub. Res. 89, I-79; Reaffirmed: CLRPD
Rep. B, I-89; Reaffirmed: Sunset Report, A-00)
D-310.970 Improving Parental Leave Policies for Residents
Our AMA will study and encourage the Accreditation Council for Graduate Medical Education’s
participation in such study of (1) the feasibility of considering guaranteed paid maternity leave
for residents of no less than six weeks duration, with the possibility of unpaid maternity leave of
an additional six weeks; (2) written leave policies for residents for paternity and adoption; and
(3) the effect of such maternity, paternity, and adoption leave policies on residency programs,
with report back to the House of Delegates at the 2008 Annual Meeting. (Res. 303, A-07) AMERICAN MEDICAL ASSOCIATION HOUSE OF DELEGATES
Resolution: 317
(A-08)
Introduced by: Resident and Fellow Section
Subject: Telemedicine and Medical Licensure
Referred to: Reference Committee C
1 Whereas, The advancement of telemedicine will allow patients both in the United States of
2 America and worldwide to obtain excellence in healthcare; and
3
4 Whereas, Telemedicine promotes increased access to healthcare by eliminating travel
5 expenses, aiding those with impediments to mobility, and connecting patients directly with the
6 most highly trained physicians in the world; and
7
8 Whereas, Physicians who wish to obtain a U.S. state medical license must first successfully
9 pass all three Steps of the United States Medical Licensing Examination, an examination
10 sponsored by the National Board of Medical Examiners, not a state board medical examination;
11 and
12
13 Whereas, Physicians wishing to be board certified in the U.S. must successfully pass their
14 respective specialty board examination(s), usually a national board examination for each
15 specialty, not a state specific specialty board exam; and
16
17 Whereas, Physicians nationwide should, to the best of their ability, practice medicine according
18 to evidence-based medicine, regardless of where the physician was trained, the state in which
19 the physician treats patients, or the state in which the patient is a permanent resident; and
20
21 Whereas, Currently each state has its own medical license which must be successfully applied
22 for and maintained if a physician wishes to treat patients in that state (with limited consultative
23 exceptions), and the application for and acquisition of a state medical license is typically a long
24 process; and
25
26 Whereas, For physicians engaging in repetitive telemedicine activities, the maintenance of
27 multiple active medical licenses is economically prohibitive as annual or semi-annual renewal
28 fees accrue; and
29
30 Whereas, Physicians with a valid state license who practice in a Veterans Health Administration
31 (VHA) Hospital are permitted to work in VHA hospitals beyond the state in which they are
32 licensed, without being required to hold multiple licenses; and
33
34 Whereas, Our patients should be free to seek healthcare they deem most appropriate and the
35 AMA should lead the charge for constant medical innovation by supporting increased access to
36 excellent medical care; therefore be it
37
38 RESOLVED, That the AMA study how guidelines regulating medical licenses are affected by
39 telemedicine and medical technological innovations that allow for physicians to practice outside
40 their states of licensure (Directive to Take Action).Resolution: 317 (A-08)
Page 1
Fiscal Note: Estimated cost of $135,128 to develop instrument and conduct survey and follow up.
Relevant AMA Policy:
H-160.937 The Promotion of Quality Telemedicine
(1) The AMA adopts the following principles for the supervision of nonphysician providers and
technicians when telemedicine is used: (a) The physician is responsible for, and retains the
authority for, the safety and quality of services provided to patients by nonphysician providers
through telemedicine. (b) Physician supervision (e.g. regarding protocols, conferencing, and
medical record review) is required when nonphysician providers or technicians deliver services
via telemedicine in all settings and circumstances. (c) Physicians should visit the sites where
patients receive services from nonphysician providers or technicians through telemedicine, and
must be knowledgeable regarding the competence and qualifications of the nonphysician
providers utilized. (d) The supervising physician should have the capability to immediately
contact nonphysician providers or technicians delivering, as well as patients receiving, services
via telemedicine in any setting. (e) Nonphysician providers who deliver services via telemedicine
should do so according to the applicable nonphysician practice acts in the state where the
patient receives such services. (f) The extent of supervision provided by the physician should
conform to the applicable medical practice act in the state where the patient receives services.
(g) Mechanisms for the regular reporting, recording, and supervision of patient care delivered
through telemedicine must be arranged and maintained between the supervising physician,
nonphysician providers, and technicians. (h) The physician is responsible for providing and
updating patient care protocols for all levels of telemedicine involving nonphysician providers or
technicians.
(2) The AMA urges those who design or utilize telemedicine systems to make prudent and
reasonable use of those technologies necessary to apply current or future confidentiality and
privacy principles and requirements to telemedicine interactions.
(3) The AMA emphasizes to physicians their responsibility to ensure that their legal and ethical
requirements with respect to patient confidentiality and data integrity are not compromised by
the use of any particular telemedicine modality. (4) The AMA advocates that continuing medical
education conducted using telemedicine adhere to the standards of the AMA’s Physician
Recognition Award and the Essentials and Standards of the Accreditation Council for
Continuing Medical Education. (CME/CMS Rep., I-96; Reaffirmed: CMS Rep. 8, A-06)
H-480.974The Evolving Impact of Telemedicine
Our AMA: (1) will evaluate relevant federal legislation related to telemedicine;
(2) urges CMS and other concerned entities involved in telemedicine to fund demonstration
projects to evaluate the effect of care delivered by physicians using telemedicine-related
technology on costs, quality, and the physician-patient relationship;
(3) urges medical specialty societies involved in telemedicine to develop appropriate practice
parameters to address the various applications of telemedicine and to guide quality assessment
and liability issues related to telemedicine; (Reaffirmed by CME/CMS Rep. A-96)
(4) encourages the CPT Editorial Board to develop CPT codes or modifiers for telemedical
services;
(5) will work with CMS and other payers to develop and test, through these demonstration
projects, appropriate reimbursement mechanisms;
(6) will develop a means of providing appropriate continuing medical education credit,
acceptable toward the Physician’s Recognition Award, for educational consultations using
telemedicine; and Resolution: 317 (A-08)
Page 2
(7) will work with the Federation of State Medical Boards and the state and territorial licensing
boards to develop licensure guidelines for telemedicine practiced across state boundaries.
(CMS/CME Rep., A-94; Reaffirmation A-01)
H-480.969 The Promotion of Quality Telemedicine
(1) It is the policy of the AMA that medical boards of states and territories should require a full
and unrestricted license in that state for the practice of telemedicine, unless there are other
appropriate state-based licensing methods, with no differentiation by specialty, for physicians
who wish to practice telemedicine in that state or territory. This license category should adhere
to the following principles: (a) application to situations where there is a telemedical transmission
of individual patient data from the patient’s state that results in either (i) provision of a written or
otherwise documented medical opinion used for diagnosis or treatment or (ii) rendering of
treatment to a patient within the board’s state; (b) exemption from such a licensure requirement
for traditional informal physician-to-physician consultations (“curbside consultations”) that are
provided without expectation of compensation; (c) exemption from such a licensure requirement
for telemedicine practiced across state lines in the event of an emergent or urgent
circumstance, the definition of which for the purposes of telemedicine should show substantial
deference to the judgment of the attending and consulting physicians as well as to the views of
the patient; and (d) application requirements that are non-burdensome, issued in an expeditious
manner, have fees no higher than necessary to cover the reasonable costs of administering this
process, and that utilize principles of reciprocity with the licensure requirements of the state in
which the physician in question practices. (2) The AMA urges the FSMB and individual states to
recognize that a physician practicing certain forms of telemedicine (e.g., teleradiology) must
sometimes perform necessary functions in the licensing state (e.g., interaction with patients,
technologists, and other physicians) and that the interstate telemedicine approach adopted must
accommodate these essential quality-related functions. (3) The AMA urges national medical
specialty societies to develop and implement practice parameters for telemedicine in
conformance with: Policy 410.973 (which identifies practice parameters as “educational tools”);
Policy 410.987 (which identifies practice parameters as “strategies for patient management that
are designed to assist physicians in clinical decision making,” and states that a practice
parameter developed by a particular specialty or specialties should not preclude the
performance of the procedures or treatments addressed in that practice parameter by
physicians who are not formally credentialed in that specialty or specialties); and Policy 410.996
(which states that physician groups representing all appropriate specialties and practice settings
should be involved in developing practice parameters, particularly those which cross lines of
disciplines or specialties). (CME/CMS Rep., A-96; Amended: CME Rep. 7, A-99)
H-480.961 Teleconsultations and Medicare Reimbursement
Our AMA demands that CMS reimburse telemedicine services in a fashion similar to traditional
payments for all other forms of consultation, which involves paying the various providers for
their individual claims, and not by various “fee splitting” or “fee sharing” reimbursement
schemes. (Res. 144, A-93; Reaffirmed: CMS Rep. 10, A-03; Reaffirmation A-07)
H-480.968 Telemedicine
AMA: (1) encourages all national specialty societies to work with their state societies to develop
comprehensive practice standards and guidelines to address both the clinical and technological
aspects of telemedicine; (2) will assist the national specialty societies in their efforts to develop
these guidelines and standards; and urges national private accreditation organizations (e.g.,
URAC and JCAHO) to require that medical care organizations which establish ongoing
arrangements for medical care delivery from remote sites require practitioners at those sites to Resolution: 317 (A-08)
Page 3
meet no less stringent credentialing standards and participate in quality review procedures that
are at least equivalent to those at the site of care delivery. (Res. 117, I-96; Reaffirmed: CSAPH
Rep. 3, A-06)
H-480.984 Technology Assessment in Medicine
(1) The AMA believes that technology assessment programs and coverage determinations
should be based upon the following principles in order to assure sound clinical practice and
equitable public policy: (a) The primary objective of health care technology assessment should
be the development of accurate and complete information for physicians on safety,
effectiveness, and clinical indications in order to enhance the appropriate utilization of health
care technology. (b) The development of information on safety, effectiveness, and indications
for use should be based upon a rigorous scientific methodology. (c) The primary responsibility
for the conduct of technology assessment should rest with the medical profession, with
participation from both the research and practice communities. Participation in such assessment
by all appropriate medical specialties is important, particularly when use of the technology
crosses specialties. (d) The pluralistic approach to technology assessment in both the public
and private sectors should be strongly encouraged and continued. (e) The results of technology
assessment must be communicated in an accurate and timely manner throughout the research
and practice communities; specialty societies and other health care professional organizations
should intensify efforts to disseminate such information. (f) Health care technologies should be
re-evaluated on a continuing basis after their introduction, particularly if they are expensive or
have the potential to cause serious harm if applied inappropriately. (g) Obsolete technologies
should be identified and their further use should be discouraged. (h) Cost-effectiveness is an
important consideration in technology assessment, but it should remain subordinate to
considerations of safety and effectiveness. (i) Decisions as to the cost-effectiveness of
technology can best be made by the physician on an individual patient basis, taking into
consideration the needs of the individual and the results of cost-effectiveness analyses.
Therefore, cost-effectiveness should not be used by payers to preclude or limit the availability of
a safe and effective technology by either refusal to reimburse or by the provision of more limited
reimbursement for such technology. (j) Payer determinations regarding coverage for health care
technologies must be made with the involvement of the medical community and the public. Such
determinations should be timely and responsive to the evolving information on safety and
effectiveness. (k) Payer coverage policies for investigational technologies should be flexible and
reviewed frequently so as to assure that the needs of individual patients are met. (l) Payers
should integrate the concept of risk/benefit analysis into their decision-making and adapt their
coverage policy accordingly. In serious and life-threatening illnesses, payers must recognize
that patient and physician may agree upon a particular therapy, notwithstanding a lesser degree
of certitude about that therapy’s safety and effectiveness, if no other alternative therapies are
available.
(2) The AMA should continue its efforts to educate the public about the contributions of
innovations in health care technology to the health and well-being of all people and the
prevention of disease.
(3) The AMA should emphasize access to effective technologies (and reimbursement for such
technologies) which may be more appropriate for a subset of patients, even though other
technologies may be more effective for the majority of patients for a given clinical condition, in
order to protect physician judgment and patient preference in selection of therapy.
(4) When safety, effectiveness and availability have been established, cost should be a
substantial determining factor in the choice of technology. (Joint CMS/CSA Rep., I-90;
Reaffirmed: In Lieu of Res. 711, I-93; Amended: CSA Rep. 8, A-03) Resolution: 317 (A-08)
Page 4
H-275.955 Physician Licensure Legislation
Our AMA (1) reaffirms its policies opposing discrimination against physicians on the basis of
being a graduate of a foreign medical school and supports state and territory responsibility for
admitting physicians to practice; and (2) reaffirms earlier policy urging licensing jurisdictions to
adopt laws and rules facilitating the movement of physicians between states, to move toward
uniformity in requirements for the endorsement of licenses to practice medicine, and to base
endorsement of medical licenses on an assessment of competence rather than on passing a
written examination of cognitive knowledge. (CME Rep. B, A-90; Reaffirmation A-00)
H-275.962 Proposed Single Examination for Licensure
Our AMA: (1) endorses the concept of a single examination for medical licensure; (2) urges the
NBME and the FSMB to place responsibility for developing Steps I and II of the new single
examination for licensure with the faculty of U.S. medical schools working through the NBME;
(3) continues its vigorous support of the LCME and its accreditation of medical schools and
supports monitoring the impact of a single examination on the effectiveness of the LCME; (4)
urges the NBME and the FSMB to establish a high standard for passing the examination, (5)
strongly recommends and supports actively pursuing efforts to assure that the standard for
passing be criterion-based; that is, that passing the examination indicate a degree of knowledge
acceptable for practicing medicine; and (6) urges that appointing graduates of LCME accredited
medical schools to accredited residency training not be dependent on their passing Steps I and
II or the single examination for licensure. (CME Rep. B, I-89; Reaffirmed: Sunset Report, A-00)
H-275.967 Licensure by Endorsement
The AMA opposes national legislation which would mandate licensing reciprocity by all state
licensing authorities. (Res. 42, A-88; Reaffirmed: Sunset Report, I-98)
H-275.978 Medical Licensure
The AMA: (1) urges directors of accredited residency training programs to certify the clinical
competence of graduates of foreign medical schools after completion of the first year of
residency training; however, program directors must not provide certification until they are
satisfied that the resident is clinically competent; (2) encourages licensing boards to require a
certificate of competence for full and unrestricted licensure; (3) urges licensing boards to review
the details of application for initial licensure to assure that procedures are not unnecessarily
cumbersome and that inappropriate information is not required. Accurate identification of
documents and applicants is critical. It is recommended that boards continue to work
cooperatively with the Federation of State Medical Boards to these ends; (4) will continue to
provide information to licensing boards and other health organizations in an effort to prevent the
use of fraudulent credentials for entry to medical practice; (5) urges those licensing boards that
have not done so to develop regulations permitting the issuance of special purpose licenses. It
is recommended that these regulations permit special purpose licensure with the minimum of
educational requirements consistent with protecting the health, safety and welfare of the public;
(6) urges licensing boards, specialty boards, hospitals and their medical staffs, and other
organizations that evaluate physician competence to inquire only into conditions which impair a
physician’s current ability to practice medicine. (BOT Rep. I-93-13; CME Rep. 10 – I-94); (7)
urges licensing boards to maintain strict confidentiality of reported information; (8) urges that the
evaluation of information collected by licensing boards be undertaken only by persons
experienced in medical licensure and competent to make judgments about physician
competence. It is recommended that decisions concerning medical competence and discipline
be made with the participation of physician members of the board; (9) recommends that if
confidential information is improperly released by a licensing board about a physician, the board Resolution: 317 (A-08)
Page 5
take appropriate and immediate steps to correct any adverse consequences to the physician;
(10) urges all physicians to participate in continuing medical education as a professional
obligation; (11) urges licensing boards not to require mandatory reporting of continuing medical
education as part of the process of reregistering the license to practice medicine; (12) opposes
the use of written cognitive examinations of medical knowledge at the time of reregistration
except when there is reason to believe that a physician’s knowledge of medicine is deficient;
(13) supports working with the Federation of State Medical Boards to develop mechanisms to
evaluate the competence of physicians who do not have hospital privileges and who are not
subject to peer review; (14) believes that licensing laws should relate only to requirements for
admission to the practice of medicine and to assuring the continuing competence of physicians,
and opposes efforts to achieve a variety of socioeconomic objectives through medical licensure
regulation; (15) urges licensing jurisdictions to pass laws and adopt regulations facilitating the
movement of licensed physicians between licensing jurisdictions; licensing jurisdictions should
limit physician movement only for reasons related to protecting the health, safety and welfare of
the public; (16) encourages the Federation of State Medical Boards and the individual medical
licensing boards to continue to pursue the development of uniformity in the acceptance of
examination scores on the Federation Licensing Examination and in other requirements for
endorsement of medical licenses; (17) urges licensing boards not to place time limits on the
acceptability of National Board certification or on scores on the United State Medical Licensing
Examination for endorsement of licenses; (18) urges licensing boards to base endorsement on
an assessment of physician competence and not on passing a written examination of cognitive
ability, except in those instances when information collected by a licensing board indicates need
for such an examination; (19) urges licensing boards to accept an initial license provided by
another board to a graduate of a US medical school as proof of completion of acceptable
medical education; (20) urges that documentation of graduation from a foreign medical school
be maintained by boards providing an initial license, and that the documentation be provided on
request to other licensing boards for review in connection with an application for licensure by
endorsement; and (21) urges licensing boards to consider the completion of specialty training
and evidence of competent and honorable practice of medicine in reviewing applications for
licensure by endorsement. (CME Rep. A, A-87; Modified: Sunset Report, I-97; Reaffirmation A-
04)
H-275.993 Examinations for Medical Licensure
Our AMA affirms its recommendation that medical school faculties continue to exercise the
responsibilities inherent in their positions for the evaluation of students and residents,
respectively. (CME Rep. B, I-81; Reaffirmed: CLRPD Rep. F, I-91; Modified: Sunset Report, I-
01) AMERICAN MEDICAL ASSOCIATION HOUSE OF DELEGATES
Resolution: 318
(A-08)
Introduced by: Resident and Fellow Section
Subject: Protecting Patients and Residents by Reducing Extended Work Shifts
Referred to: Reference Committee C
1 Whereas, Five years have passed since both the American Medical Association (AMA) and the
2 American Council on Graduate Medical Education (ACGME) adopted specific duty hour
restrictions to protect residents, fellows, and patientsi,ii 3 ; and
4
5 Whereas, The current duty hour restrictions continue to allow residents and fellows to work for
6 up to 30 continuous hours with no dedicated time for sleep; and
7
8 Whereas, A growing body of literature published mostly in the past five years has shown that
9 decreasing or eliminating extended work shifts (defined as shifts greater than 16 hours) may
improve both resident quality of life and patient safetyiii,iv,v,vi,vii,viii,ix,x,xi,xii 10 ; and
11
12 Whereas, This same body of literature also suggests that decreasing or eliminating extended
13 shifts does not compromise resident education, even for residents in surgical
programsxiii,xiv,xv,xvi,xvii,xviii,xix,xx,xxi,xxii,xxiii 14 ; and
15
16 Whereas, Despite the accumulated evidence, it would be premature to create a new mandate
17 eliminating extended work shifts for residents and fellows at a time when many residency
18 programs are still struggling to comply with the current duty hour restrictions; and
19
20 Whereas, Residency programs can instead be encouraged to voluntarily reduce or eliminate
21 extended work shifts in order to improve resident quality of life and patient safety, allowing
22 individual programs to move towards this goal at their own pace; and
23
24 Whereas, Decreasing or eliminating extended work shifts will require new team-based
25 approaches to patient care as well as improvements in the way physicians communicate patient
26 information to each other at the time of shift-change; therefore be it
27
28 RESOLVED, That our AMA reaffirm support of the current ACGME duty hour restrictions, and
29 be it further
30
31 RESOLVED, That our AMA encourage the voluntary reduction or elimination of extended work
32 shifts (>16 hours) for residents and fellows by academic medical centers and teaching hospitals
33 while opposing a new ACGME mandate at this time, and be it further
34
35 RESOLVED, That our AMA continue to evaluate outcomes-based research on the impact of
36 reductions in extended work shifts on (1) Patient Safety, (2) Resident Education, (3) Resident
37 Safety, (4) Resident Quality of Life and (5) Professionalism in Transfer of Care, and be it further
38 Resolution: 318 (A-08)
Page 2
1 RESOLVED, That our AMA develop specific prioritized research questions/objectives to further
2 evaluate issues related to resident duty-hour reforms, such as best practices for signing out
3 patients and organizing patient care teams.
ii H-310.927
ii ACGME Duty Hours, 2007. Accessed at http://www.acgme.org/acWebsite/dutyHours/dh_Lang703.pdf on March
21, 2008.
iii Lockley, S.W., et al., Effect of reducing interns’ weekly work hours on sleep and attentional failures.[see
comment]. New England Journal of Medicine, 2004. 351(18): p. 1829-37.
iv Gottlieb, D.J., et al., Effects of a night float system on housestaff neuropsychologic function.[see comment].
Journal of General Internal Medicine, 1993. 8(3): p. 146-8.
v
Goldstein, M.J., et al., A 360 degrees evaluation of a night-float system for general surgery: a response to
mandated work-hours reduction. Current Surgery, 2004. 61(5): p. 445-51.
vi Hutter, M.M., et al., The impact of the 80-hour resident workweek on surgical residents and attending surgeons.
Annals of Surgery, 2006. 243(6): p. 864-71; discussion 871-5.
vii Afessa, B., et al., Introduction of a 14-hour work shift model for housestaff in the medical ICU.[see comment].
Chest, 2005. 128(6): p. 3910-5.
viii Landrigan, C.P., et al., Effect of reducing interns’ work hours on serious medical errors in intensive care
units.[see comment]. New England Journal of Medicine, 2004. 351(18): p. 1838-48.
ix de Virgilio, C., et al., The 80-hour resident workweek does not adversely affect patient outcomes or resident
education. Current Surgery, 2006. 63(6): p. 435-9; discussion 440.
x
Malangoni, M.A., et al., Life after 80 hours: the impact of resident work hours mandates on trauma and emergency
experience and work effort for senior residents and faculty. Journal of Trauma-Injury Infection & Critical Care,
2005. 58(4): p. 758-61; discussion 761-2.
xi Mann, F.A. and P.L. Danz, The night stalker effect: quality improvements with a dedicated night-call rotation.
Investigative Radiology, 1993. 28(1): p. 92-6.
xii Gottlieb, D.J., et al., Effect of a change in house staff work schedule on resource utilization and patient care. Arch
Intern Med, 1991. 151(10): p. 2065-70.
xiii Barden, C.B., et al., Effects of limited work hours on surgical training.[see comment]. Journal of the American
College of Surgeons, 2002. 195(4): p. 531-8.
xiv Cockerham, W.T., et al., Resident work hours: can we meet the ACGME requirements? American Surgeon, 2004.
70(8): p. 687-90.
xv Jarman, B.T., et al., The 80-hour work week: will we have less-experienced graduating surgeons? Current
Surgery, 2004. 61(6): p. 612-5.
xvi Afessa, B., et al., Introduction of a 14-hour work shift model for housestaff in the medical ICU.[see comment].
Chest, 2005. 128(6): p. 3910-5.
xvii Goldstein, M.J., et al., A 360 degrees evaluation of a night-float system for general surgery: a response to
mandated work-hours reduction. Current Surgery, 2004. 61(5): p. 445-51.
xviii Welling, R.E., et al., Work hours compliance in a community hospital. Current Surgery, 2004. 61(2): p. 241-3.
xix McElearney, S.T., et al., Effect of the 80-hour work week on cases performed by general surgery residents.
American Surgeon, 2005. 71(7): p. 552-5; discussion 555-6.
xx de Virgilio, C., et al., The 80-hour resident workweek does not adversely affect patient outcomes or resident
education. Current Surgery, 2006. 63(6): p. 435-9; discussion 440.
xxi Ferguson, C.M., et al., Effect of work-hour reforms on operative case volume of surgical residents. Current
Surgery, 2005. 62(5): p. 535-8.
xxii Hutter, M.M., et al., The impact of the 80-hour resident workweek on surgical residents and attending surgeons.
Annals of Surgery, 2006. 243(6): p. 864-71; discussion 871-5.
xxiii Malangoni, M.A., et al., Life after 80 hours: the impact of resident work hours mandates on trauma and
emergency experience and work effort for senior residents and faculty. Journal of Trauma-Injury Infection &
Critical Care, 2005. 58(4): p. 758-61; discussion 761-2. AMERICAN MEDICAL ASSOCIATION HOUSE OF DELEGATES
Resolution: 426
(A-08)
Introduced by: Resident and Fellow Section
Subject: Pediatric Suspected Intentional Trauma
Referred to: Reference Committee D
1 Whereas, More than 6,000,000 children were reported as maltreated and 899,000 were
confirmed victims by child protective services in 2005,1 2 and
3
4 Whereas, 62.8 percent of victims experienced neglect, 16.6 percent were physically abused, 9.3
5 percent were sexually abused, 7.1 percent were psychologically maltreated, and 2.0 percent
were medically neglected,1 6 and
7
Whereas, 1460 children died in 2005 from child abuse,1 8 and
9
10 Whereas, Recent studies demonstrate that only 50-60% of abuse related deaths are reported
making child abuse deaths as the least reported form of fatal maltreatment,2 11 and
12
13 Whereas, Children who experience maltreatment are at increased risk for adverse health effects
14 and behaviors as adults—including smoking, alcoholism, drug abuse, eating disorders, severe
obesity, depression, suicide, sexual promiscuity, and certain chronic diseases,3,4 15 and
16
17 Whereas, Maltreatment during infancy or early childhood can cause important regions of the
18 brain to form improperly, leading to physical, mental, and emotional problems such as sleep
disturbances, panic disorder, and attention-deficit/hyperactivity disorder,5 19 and
20
21 Whereas, 25% to 30% of infant victims of shaken baby syndrome die from their injuries, and
22 nonfatal consequences of shaken baby syndrome include varying degrees of visual impairment
(e.g., blindness), motor impairment (e.g. cerebral palsy) and cognitive impairments,6 23 and
24
25 Whereas, Victims of child maltreatment who were physically assaulted by caregivers are twice
as likely to commit physical assault as adults, 7 26 and
27
28 Whereas, The direct costs (judicial, law enforcement, and health system responses to child
29 maltreatment) are estimated at $24 billion each year. The indirect costs (long-term economic
consequences of child maltreatment) exceed an estimated $69 billion annually, 8 30 and
31
32 Whereas, More than 53% of physicians do not report child abuse when they state they have a
suspicion for abuse, 9 33 and
34
35 Whereas, Researchers found that 31% of traumatic head injuries were not recognized by the
physicians who first evaluated these victims, 10 36 and
37 Resolution: 426 (A-08)
Page 2
1 Whereas, Physicians serve on the front lines of detecting and diagnosing child abuse and yet
2 less than 57% of physicians who are mandated reporters receive any training regarding child
abuse reporting; therefore be it,11 3
4
5 RESOLVED, That our AMA support comprehensive reporting and investigation of all cases of
6 reasonably suspected child abuse and neglect using an inclusive and interdisciplinary method in
7 accordance with state and federal laws; and be it further
8
9 RESOLVED, That our AMA support the creation of a national standardized pediatric intentional
10 trauma curriculum for medical students and residents.
Fiscal Note: Staff cost estimated at less than $500 to implement.
References
1. Department of Health and Human Services (DHHS) (US), Administration on Children, Youth,
and Families (ACF). Child maltreatment 2005. Washington (DC): Government Printing Office;
2007. http://www.acf.hhs.gov/programs/cb/pubs/cm05/index.htm.
2. Crume, T., DiGuiseppi, C., Byers, T., Sirotnak, A., & Garrett, C. Underascertainment of child
maltreatment fatalities by death certificates, Pediatrics 110 2 1990-1998.
3. Felitti V, Anda R, Nordenberg D, Williamson D, Spitz A, Edwards V, et al. Relationship of
childhood abuse and household dysfunction to many of the leading causes of death in adults.
American Journal of Preventive Medicine 14(4): 245–58; 1998.
4. Runyan D, Wattam C, Ikeda R, Hassan F, Ramiro L. Child abuse and neglect by parents and
caregivers. In: Krug E, Dahlberg LL, Mercy JA, Zwi AB, Lozano R, editors. World Report on
Violence and Health. Geneva, Switzerland: World Health Organization: 59-86; 2002.
5. Department of Health and Human Services (DHHS) (US), Administration on Children, Youth,
and Families (ACF). In focus: understanding the effects of maltreatment on early brain
development. Washington (DC): Government Printing Office; 2001.
6. National Center on Shaken Baby Syndrome: www.dontshake.com.
7. Tjaden P, Thoennes N. Full report of the prevalence, incidence, and consequences of
violence against women: findings from the National Violence Against Women Survey.
Washington (DC): National Institute of Justice; 2000.
8. Fromm S. Total estimated cost of child abuse and neglect in the United States—statistical
evidence. Chicago (IL): Prevent Child Abuse America (PCAA); 2001.
9. Delaronde S, et al, Opinions Among Mandated Reporters Toward Child Maltreatment
Reporting Policies, Child Abuse and Neglect Jul 24(7): 901-10; 2000.
10. Herman-Giddens, M., Brown, G., Verbiest, S., Carlson, P., Hooten, E., Howell, E., & Butts,
J. Underascertainment of child abuse mortality in the United States. Journal of the American
Medical Association (282) 5. 463-467 1999. Resolution: 426 (A-08)
Page 3
11. Vieth V, Unto the Third Generation: A Call to End Child Abuse in the United States Within
120 Years, Journal of Aggression, Maltreatment and Trauma (5) 2006.
Relevant AMA Policy
H-515.989 Evidence of Standards for Child Sexual Abuse
The AMA continues to support the standardization of evidence in child sexual abuse cases and
urges that examination and treatment of child abuse victims be done by a physician. (Res. 78, I-
87; Reaffirmed: Sunset Report, I-97)
H-60-990 Child Pornography
The AMA (1) supports reassembling an interdisciplinary panel of experts periodically to continue
to address shared concerns and information relevant to the issue of child pornography; (2)
encourages and promotes awareness of child pornography issues among physicians; (3)
through physicians, encourages parents to use the educational textbook entitled, Sex Talk for a
Safe Child; (4) promotes physician awareness of the need for follow-up psychiatric treatment for
all victims of child pornography; (5) encourages research on child abuse (including risk factors,
psychological and behavioral impact, and treatment efficacy) and dissemination of the findings;
(6) wherever possible, encourages international cooperation among medical societies to be alert
to and intervene in child pornography activities; and (7) cooperates with other national
organizations and federal and local agencies in addressing the problem of child pornography.
(BOT Rep. Z, A-88; Reaffirmed: Sunset Report, I-98)
H-60.961 HHS to Require the States to Repeal the Religious Exemption in the Child
Abuse and Neglect Prevention Statutes
The AMA will petition the Secretary of HHS to remove the religious exemption in child abuse
and neglect cases from the Code of Federal Regulations and to exercise administrative
authority to urge state officials to repeal existing child abuse and neglect religious exemption
provisions in state statutes, thereby restoring equal protection under the law for all children.
(Sub. Res. 219, A-93; Reaffirmed by BOT Rep. 24, A-97)
H-75.991 Requirements or Incentives by Government for the Use of Long-Acting
Contraceptives
(1) Involuntary use of long-acting contraceptives because of child abuse raises serious
questions about a person’s fundamental right to refuse medical treatment, to be free of cruel
and unusual punishment, and to procreate. The state’s compelling interest in protecting children
from abuse may be served by less intrusive means than imposing contraception on parents who
have committed child abuse. The needs of children may be better met by providing close
supervision of the parents, appropriate treatment and social services, and foster placement care
when necessary. There is not sufficient evidence to demonstrate that long-acting contraceptives
are an effective social response to the problem of child abuse. Before long-acting
contraceptives could be considered as a response to individual cases of child abuse, the issue
would need to be addressed by society broadly. Society must be careful about taking shortcuts
to save resources when constitutional rights are involved. (2) Serious questions are raised by
plea bargains, or negotiations with child welfare authorities, that result in the use of long-acting
contraceptives. Such agreements are made in inherently coercive environments that lack
procedural safeguards. In addition, cultural and other biases may influence decisions by the
state to seek the use of a long-acting contraceptive. (3) If welfare or other government benefits
were based on the use of long-acting contraceptive agents, individuals would be required to
assume a potentially serious health risk before receiving their benefits. Government benefits
should not be made contingent on the acceptance of a health risk. (4) Individuals should not be
denied access to effective contraception because of their indigence. Use of long-acting Resolution: 426 (A-08)
Page 4
contraceptives should be covered by Medicaid and other health insurance programs, both public
and private. (5) Long-acting contraceptives may be medically contraindicated. Assessing the
health risks of long-acting contraceptives is substantially outside the purview of courts and
legislatures. (BOT Rep. EE, I-91; Reaffirmed: Sunset Report, I-01; Reaffirmation A-04)
H-60.992 Missing and Exploited Children
To enhance physician involvement with issues related to missing and exploited children, the
AMA supports the following statements and activities: (1) Child abductions and runaway
behaviors are harmful and emotionally upsetting, divisive, and chaos-producing to victims and
their families. Any disappearance of a child constitutes a family crisis with both victims and
families at high risk for developing physical and emotional problems. Any child who is the object
of a custody dispute is vulnerable to parental snatching, running away and/or being abused. (2)
Medical interventions, including family therapy, should occur immediately after a child is
reported missing; if the child returns home or is found dead, physicians and other health care
professionals should continue to monitor the victim patient and/or the patient’s family. (3)
Children abducted by family members or strangers should be considered victims of child abuse
and such occurrences should be designated as reportable instances of child abuse under state
statutes. (4) Prevention efforts should focus on reducing family stress, combatting alcoholism
and drug abuse, dealing with poor marital relationships including divorce mediation and
counseling, and providing supportive services for families at risk. (5) All shelter services that are
presently available to runaways and homeless youths should contain a high quality health care
component. Comprehensive standards of health care should be developed for the national
network of runaway centers. Physicians should be consultants to and work with governing
boards of these agencies. (6) Children’s medical records should be intelligible and include a
complete medical history, distinguishing physical characteristics and detailed information, as
outlined in the Child Identification Form developed by the AMA. The AMA encourages
physicians to utilize this form in their practice settings. Pediatricians and family physicians
should encourage parents to arrange for the speedy transfer of the child’s previous medical
records and physicians should respond promptly to such requests. The parent’s refusal to
comply with this request should warrant further questioning of the parents or a report of a
possible missing child. (7) At prevention, diagnostic and treatment levels, physicians should
attempt to identify troubled children and their families early and ensure that appropriate
treatment takes place or that referrals are made to the other medical specialists or community
resources. (8) The primary care physician, medical examiner and dentist are key members of
the missing child identification team, and should be knowledgeable about the steps to be taken
(completing the NCIC forms) immediately after a child is reported missing. (9) Physicians should
actively promote the practice of obtaining clear and readable fingerprints and footprints as a
technically useful way to document these unique physical characteristics of children. (10) State
medical societies should consider establishing committees on child abuse and neglect, with the
topic of missing and exploited children included in the charge of responsibilities. (11) The AMA
supports continued research on abducted children (both parent and stranger abductions),
runaways, homeless youth and their families, and how physicians can help them. (12) All levels
of medical education should emphasize the diagnosis, comprehensive treatment and prevention
of problems associated with families that suffer from stress and that may be related to problems
of alcoholism, drug abuse, domestic violence and marital dysfunction. Educational programs
should address the reactions of physicians to these complex and frustrating social problems.
(13) The AMA supports cooperating with the American Academy of Pediatrics, the American
Psychiatric Association, the American College of Obstetricians and Gynecologists, and the
College of American Pathologists in developing and disseminating information about the health
care needs of missing children and effective prevention strategies. (14) The AMA supports
cooperating with the American Bar Association, the American Psychiatric Association, law
enforcement agencies and the National Center for Missing and Exploited Children in Resolution: 426 (A-08)
Page 5
considering the problem of identifying and tracking perpetrators of child abductions. (BOT Rep.
O, A-86; Reaffirmed: Sunset Report, I-96; Reaffirmed and Modified: CSAPH Rep. 3, A-06)
H-245.984 Treatment Decisions for Seriously Ill Newborns
Physicians should play an active role in advocating for changes in the Child Abuse Prevention
Act as well as state laws that require physicians to violate the ethical guidelines stated in E-
2.215 (Treatment Decisions for Seriously Ill Newborns). (CEJA Rep. I, A-92; Modified and
Reaffirmed: CEJA Rep. 1, A-03)
H-515.988 Repeal of Religious Exemptions in Child Abuse and medical Practice statutes
Our AMA (1) reaffirms existing policy supporting repeal of the religious exemption from state
child abuse statutes; (2) recognizes that constitutional barriers may exist with regard to
elimination of the religious exemption from state medical practice acts; and (3) encourages state
medical associations that are aware of problems with respect to spiritual healing practitioners in
their areas to investigate such situations and pursue all solutions, including legislation where
appropriate, to address such matters. (BOT Rep. H, A-90; Reaffirmed: Sunset Report, I-00)
H-515.983 Physicians and Family Violence
Ethical Considerations: (1) The medical profession must demonstrate a greater commitment to
ending family violence and helping its victims. Physicians must play an active role in advocating
increased services for victims and abusers. Protective services for abused children and elders
need to be better funded and staffed, and follow-up services should be expanded. Shelters and
safe homes for battered women and their children must be expanded and better funded.
Mechanisms to coordinate the range of services, such as legal aid, employment services,
welfare assistance, day care, and counseling, should be established in every community.
Mandatory arrest of abusers and greater enforcement of protection orders are important law
enforcement reforms that should be expanded to more communities. There should be more
research into the effectiveness of rehabilitation and prevention programs for abusers.
(2) Informed consent for interventions should be obtained from competent victims of abuse. For
minors who are not deemed mature enough to give informed consent, consent for emergency
interventions need not be obtained from their parents. Physicians can obtain authorization for
further interventions from a court order or a court-appointed guardian. (3) Physicians should
inform parents of a child-abuse diagnosis and they should inform an elderly patient’s
representative when the patient clearly does not possess the capacity to make health care
decisions. The safety of the child or elderly person must be ensured prior to disclosing the
diagnosis when the parents or caretakers are potentially responsible for the abuse. For
competent adult victims physicians must not disclose an abuse diagnosis to caregivers,
spouses, or any other third party without the consent of the patient. (CEJA Rep. B, I-91;
Reaffirmed: CSA Rep. 7, I-00; Modified and Reaffirmed: CEJA Rep. 1, A-03)
H-525.980 Expansion of AMA Policy on Female Genital Mutilation
The AMA (1) condemns the practice of female genital mutilation (FGM); (2) considers FGM a
form of child abuse; (3) supports legislation to eliminate the performance of female genital
mutilation in the United States and to protect young girls and women at risk of undergoing the
procedure; and (4) supports that physicians who are requested to perform female genital
mutilation on a patient provide culturally sensitive counseling to educate the patient and her
family members about the negative health consequences of the procedure, and discourage
them from having the procedure performed. Where possible, physicians should refer the patient
to social support groups that can help them cope with changing societal mores. (CSA Rep. 5, I-
94; Res. 513, A-96; Reaffirmed: CSAPH Rep. 3, A-06)
D-60.982 Long Term Effects of Early Abuse/Neglect on Brain Development Resolution: 426 (A-08)
Page 6
Our AMA will: (1) work with national organizations, e.g., American Academy of Pediatrics,
American Academy of Child and Adolescent Psychiatry, American College of Obstetricians and
Gynecologists, and others involved with early brain research, child abuse and neglect and
public education to make educational materials available to hospital infant and pediatric
personnel, physicians, parents, other child care providers and educators and the public at large;
(2) urge state and local medical societies to work with their legislators to put in place
educational, and where appropriate, support programs for those involved with infants and young
children, i.e., parents, students in junior and senior high school, child care providers, and early
childhood educators; and (3) work with the federal government and pertinent agencies to make
this issue–prevention of early abuse and brain damage with its devastating long term effects for
individuals and society–a priority of our nation. (BOT Action in response to referred for decision
Res. 526, A-02)
D-515-993 Support for Legislative Action and Improved Research on the Health
Response to Violence and Abuse
Our AMA, in conjunction with other members of the Federation and the National Advisory
Council on Violence and Abuse will: (1) identify and actively support state and federal legislative
proposals designed to increase scientific knowledge, promote public and professional
awareness, enhance recognition and ensure access to appropriate medical services for patients
who have experienced violence and/or abuse; (2) actively support legislation and congressional
authorizations designed to increase the nation’s health care infrastructure addressing violence
and abuse including proposals like the Health CARES (Child Abuse Research, Education and
Services) Network; (3) actively support expanded funding for research on the primary
prevention of violence and abuse, the cost of violence and abuse to the health care system, and
the efficacy of interventions and methods utilized in the identification and treatment of victims of
violence and abuse; (4) actively study the best practices in diagnosis and management of family
violence (including an analysis of studies not reviewed in the recent US Preventive Services
Task Force Recommendations on Screening for Family Violence) and present a report that
identifies future research and practice recommendations; and (5) invite a Federation-wide task
force to review and promote the best practices in the identification, management and prevention
of family violence. (Res. 438, A-04) AMERICAN MEDICAL ASSOCIATION HOUSE OF DELEGATES
Resolution: 612
(A-08)
Introduced by: Resident and Fellow Section
Subject: Accuracy of Internet Physician Profiles
Referred to: Reference Committee A
1 Whereas, Various internet sites such as WebMD, VIMO and HealthGrades provide physician
2 provider information such as education/training, practice type, location, board certification
status, and disciplinary actions 1 3 ; and
4
5 Whereas, Information provided in internet physician profiles is often obtained from third party
6 sources and may contain erroneous information such as inaccurate listing of specialty or
practice location, and these sites do not claim accuracy of the provided information 2, 3, 4 7 ; and
8
9 Whereas, Physicians are not always notified that their provider information is being posted or
10 provided open access to their full information profile, and may even be required to pay to see
11 their full profile, and there is no mechanism for oversight of the physician profile information; and
12
13 Whereas, Patients are increasingly using the internet to review the credentials of their
physicians 5
14 , and may receive misinformation from these internet sites, therefore be it
15
16 RESOLVED, That the AMA investigate the publication of physician information on internet
17 websites; and be it further
18
19 RESOLVED, That the AMA investigate potential solutions to erroneous physician information
20 contained on Internet websites with report back at I-08.
Fiscal Note: Implement accordingly at estimated staff cost of $4,752.
References
1. WebMD Find a Doctor page: http://www.webmd.com/healthcare_services/default.htm; VIMO Search
for a Doctor page: http://www.vimo.com/doctor/; HealthGrades http://www.healthgrades.com/.
2. WebMD Legal disclaimer: “WebMD, its licensors, and its suppliers make no representations or
warranties about the following: The accuracy, reliability, completeness, currentness, or timeliness of
the Content, software, text, graphics, links, or communications provided on or through the use of the
WebMD Site or WebMD” Accessed March 2, 2008 from http://www.webmd.com/policies/about-termsand-conditions-of-use#part4.
3. VIMO legal disclaimer: “Vimo gathers data from a variety of different sources, public and private.
While we strive to provide the most accurate, up-to-date information possible, we can’t guarantee that
our listings are completely without error” accessed March 2, 2008 from

http://www.vimo.com/html/copyright.php.

4. HealthGrades legal disclaimer “HealthGrades obtains its information from sources it believes to be
reliable. However, because of the possibility of human and mechanical error as well as other factors,
HealthGrades makes no representations or warranties, express or implied, as to the accuracy or Resolution: 612 (A-08)
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timeliness of its information, and cannot be responsible or liable for any errors or omissions in its
information or the results obtained from the use of such information.” Accessed March 2, 2008 from

http://www.healthgrades.com/consumer/index.cfm?fuseaction=modnw&modtype=content&modact=le

gal_disclaimer&tv_eng=home&tv=home.
5. Kaiser Family Foundation Online Health Information Poised to Become Important Resource For
Seniors, But Not There Yet (January 12, 2005). Accessed March 2, 2008 from

http://www.kff.org/entmedia/entmedia011205nr.cfm.

Relevant AMA Policy
H-406.996 Use and Release of Physician-Specific Health Care Data
(1) Our AMA advocates that third party payers, government entities and others that use and
release physician-specific health care data adhere to the following principles: (a) Physicians
under review and relevant physician organizations shall be provided with an adequate
opportunity to review and respond to proposed physician-specific health care data
interpretations and disclosures prior to their publication or release. (b) Effective safeguards to
protect against the dissemination of inconsistent, incomplete, invalid, inaccurate or subjective
physician-specific health care data shall be established. (c) Reliable administrative, technical,
and physical safeguards to prevent the unauthorized use or disclosure of physician-specific
health care data shall be developed. (d) Such safeguards shall treat all underlying physician-
specific health care data and all analyses, proceedings, records, and minutes from quality
review activities on physician-specific health care data as confidential, and provide that none of
these documents shall be subject to discovery, or admitted into evidence in any judicial or
administrative proceeding. (2) Our AMA supports release of severity-adjusted physician-specific
health care data from carefully selected pilot projects where the data may be deemed accurate,
reliable, and meaningful to physicians, consumers, and purchaser; (3) Our AMA urges that any
published physician-specific health care data be limited to appropriate data concerning the
quality of health care, access to health care, and the cost of health care; (4) Our AMA opposes
the publication of physician-specific health care data collected outside of carefully selected pilot
studies or where the data are not deemed accurate, reliable, or meaningful; (5) Our AMA urges
that a copy of the information in any such profile be forwarded to the subject physician, and that
the physician be given the right to review and certify adequacy of the information prior to any
profile being distributed, including being placed on the Internet; and (6) Our AMA urges that the
costs associated with creation of any such profiling system should not be paid for by physicians
licensure fees. (BOT Rep. Q, I-92; BOT Rep. W, A-92; Reaffirmed: Res. 719, A-93; CMS Rep.
10, A-96; Appended: Res. 316, I-97; Reaffirmation A-01; Reaffirmation A-02; Reaffirmation A-
05; Reaffirmed in lieu of Res. 724, A-05)
E-5.027 Use of Health-Related Online Sites
As Internet prevalence and access rapidly increases, individuals turn to the Internet to find
health-related information quickly and efficiently. Online users can access innumerable
informational or interactive online sites, many of which are maintained by physicians or rely on
their services. Physician involvement should be guided by the following considerations: (1)
Physicians responsible for the health-related content of an online site should ensure that the
information is accurate, timely, reliable, and scientifically sound, and includes appropriate
scientific references. (2) The provision of diagnostic or therapeutic services through interactive
online sites, including advice to online users with whom the physician does not have a preexisting relationship or the use of decision-support programs that generate personalized
information directly transmitted to users, should be consistent with general and specialtyspecific standards. General standards include truthfulness, protection of privacy, principles of
informed consent, and disclosures such as limitations inherent in the technology. (3) When
participating in interactive online sites that offer email communication, physicians should follow Resolution: 612 (A-08)
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guidelines established in Opinion 5.026, “The Use of Electronic Mail.” (4) Physicians who
establish or are involved in health-related online sites must minimize conflicts of interest and
commercial biases. This can be achieved through safeguards for disclosure and honesty in
funding and advertising. It also requires that physicians not place commercial interests ahead of
patient health; therefore, physicians must not use health-related online sites to promote
unnecessary services, refer patients to entities in which they have ownership interests, or sell
products outside of established ethical guidelines. (See Opinions 2.19, “Unnecessary Services;”
8.032, “Conflicts of Interest: Health Facility Ownership by a Physician;” 8.062, “Sale of NonHealth-Related Goods from Physicians’ Offices;” and 8.063, “Sale of Health-Related Products
from Physicians’ Offices”). Promotional claims on online sites must conform to Opinion 5.02,
“Advertising and Publicity.” (5) Physicians who establish or are involved in health-related online
sites that use patient-specific information must provide high-level security protections, as well as
privacy and confidentiality safeguards. (I, II, IV, V, VI) Issued December 2003 based on the
report “Use of Health-Related Online Sites,” adopted June 2003, (AJOB 2003; 3(3)).
H-478.999 An International Code of Ethics for Internet Health Sites
Our AMA supports of a universal code of ethics for Internet health sites. (Res. 615, A-00)
H-375.969 Physician Access to Performance Profile Data
AMA policy is that every physician should be given a copy of his/her practice performance
profile information at least annually by each organization retaining such physician information.
(Res. 827, A-98)

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