Introduction to “Recontextualizing Physician Associations: Revisiting Context, Scope, Methodology”

Physician associations, in particular the American Medical Association (AMA), were long seen as a dominant force in health policy, using their symbolic power, access to politicians, financial resources, and collective strength to shape policy in their interest.1 However, with the rise of other policy actors (such as the hospital, pharmaceutical, and insurance industries) and tectonic shifts in the political economy of the health sectors of many countries, researchers have argued that the power of physicians has diminished, and that they are less relevant to policy change (Peterson 2001; Stevens 2001; Stone 1998). In this special section, we caution against overstating the loss of physicians' collective power (Timmermans and Berg 2003; Timmermans and Oh 2010) and draw attention to a casualty of this assumption—the scholarly neglect of physician associations. We argue that the techniques used by physician associations to affect policy change have evolved significantly, and that it is imperative to account for the shift of physician influence to new arenas and platforms. We also reconsider the distribution of power in organized medicine, highlighting the significant power held by physician associations that have largely been ignored by the health policy literature—such as associations in low- and middle-income countries (LMICs) as well as local/state and specialty associations. Together, the articles in this section recontextualize power in organized medicine and challenge the reader to reconsider the nature of advocacy and influence in health policy.The study of physician associations and policy falls within multiple disciplines, including sociology, political science, history, and management (Abbott 2014; Blackstone 1977; Freidson 1974, 1988; Greenwood, Suddaby, and Hinings 2002; Johnson 1972; Knoke 1986; Larson 1977; Starr 1982; Wilsford 1987). However, the theory used to understand physician associations has not evolved with the political and market contexts within which they operate. Many LMICs have undergone transformative marketization of the health sector (Bloom, Henson, and Peters 2014) and have also seen increasing decentralization of the health system (with responsibilities being distributed to subnational and local governments), and we do not have sufficient tools to understand how physician associations engage with the state in these contexts. In high-income countries, many physicians no longer work under the same employment arrangements or revenue structure as was the case when arguments about the role of organized medicine were developed (Laugesen and Rice 2003; Swenson, forthcoming). This period has also been characterized by significant shifts in the composition of the physician workforce and physicians' political alignment (Bonica, Rosenthal, and Rothman 2014; Castillo-Page 2010). In light of these changes, it is important to adjust our understanding of the extent to which associations have shifted the focus of their advocacy.The strategies used by physician associations to accomplish their goals are also increasingly heterogeneous and warrant further scrutiny. As is evident from recent scholarship in the US, some physician associations are now more likely to use soft power to accomplish their goals. Laugesen demonstrates as much in her study of the role of the AMA in setting medical prices in the US (2016). While this association once relied primarily on "political theater" tactics to influence politicians, today, the AMA's strategy is better characterized as "quiet politics" (Culpepper 2010), by which they influence policy behind the scenes. In this issue, we seek to heed Laugesen's warning not to "confuse lower visibility with diminished influence" (2016: 17). We also seek to be attentive to shifts in how and when associations make themselves visible. In the era of COVID-19, the AMA has been returning to "political theater" tactics through extensive use of social media. In many LMICs, physician associations are increasingly turning to more visible approaches, such as strikes and media appearances (Russo et al. 2019), while also strategically buttressing their direct access to politicians and decision makers to achieve their policy goals (Wood 2013). Unpacking the implications of these multiple advocacy strategies—particularly when seen in context of their overarching policy agenda—will allow scholars to better understand the linkages between advocacy, organizational and coalition behavior, and policy outcomes.We also seek to demonstrate that it is reductive to imagine physician associations exclusively in terms of their interested action. Scholars of the professions have long observed advocacy efforts of professional associations to maintain the occupational status, financial interests, and jurisdictional control of physicians (Abbott 2014; Light 2010; Starr 1982). Unfortunately, as several scholars of nonprofit management have noted, research on professional associations has not been balanced by comparable attention to their role in creating professional ethics, training, and networking (Gazley and Brudney 2014; Hager 2014; Haynes and Gazley 2011; Tschirhart and Gazley 2014). In the case of physician associations in particular, we would add to this list the issuing of public health guidance. Study of these activities is important not only because of their role in maintaining professional standards but also because they provide members with what Lyn Spillman has referred to as vocabularies of motive, the cognitive resources to understand their interested action as imbued with moral significance (Spillman 2012; Spillman and Brophy 2018).Physician associations have complicated and often contradictory aims—on the one hand, they are driven by commitments to maintain the power of physicians; on the other, they see themselves as advancing health policy and ethics. This hybrid organizational identity (Albert and Whetten 1985; Ashforth and Reinger 2014; Battilana and Dorado 2010; Friedman and Phillips 2004) is an important part of their operating dynamics for two reasons. First, it creates contestation within associations about their central activities. Do they exist to protect the financial interests of doctors? Or, should they primarily be focused on advancing measures that expand access to medical care and reduce health inequalities (Brophy 2019)? Second, the hybrid nature of physician associations is important insofar as actions that advance health policy and ethics serve to justify associations' identity as moral agents (Cerulo 1997; Taylor 1989). It is this second point that gives the most pause. When associations take public positions proclaiming commitments to social justice and health equity, this may distract attention from their less visible work of utilizing their advocacy apparatus to secure their interests in state and federal legislatures and other policy-making forums.We have observed this to be true during the COVID-19 pandemic. Particularly in the early phases of the pandemic, doctors and other health workers around the world were elevated in the public discourse as "essential workers" and "COVID warriors."2 As this occurred, physician associations sought to position themselves as the moral voice of medicine, becoming highly visible in the media and mobilizing their membership to engage in political action. The AMA, for instance, a traditionally conservative association, very publicly criticized President Trump's handling of the virus, and came out in support of a number of progressive policy stances on issues such as racism in health care during COVID-19 and discriminatory policing. However, while the AMA was promoting a progressive public agenda, the association continued "business as usual," working to protect physicians' interests by limiting "inappropriate scope expansions" of nurse practitioners, advance practice nurses, physician assistants, and other medical professionals who gained autonomy as a result of health worker shortages during the pandemic (AMA 2020; Jenkins 2020). In India, the Indian Medical Association (IMA), the largest physician association in the country, mobilized quickly on protocols and training programs and vociferously objected to inefficiencies with PPE procurement and distribution (Wadke 2020) and the harassment of doctors (Wire2020). However, the IMA also used this time to advance the interests of physicians—for example, by controlling the flow of economic stimulus funds (IMA 2020).Broadly, there is a need to make connections between traditional advocacy efforts of associations on behalf of physicians' status, financial interests, and jurisdictional control and other less theorized activities. As we have noted, in the US the issuing of health policy guidance framed around ethical concerns such as equity may distract from simultaneous actions to secure physicians' financial interests and control. However, elsewhere, physician associations have advocated on behalf of health policy that diminished physician control. For instance, associations in LMICs have on occasion secured equity-oriented policy wins at the expense of professional scope, such as expanding access to sexual and reproductive health services (Holcombe 2018) and maternal health care (Evans et al. 2009). Comparative research might shed light on the conditions that lead physicians to advocate for health policy changes even as they might compromise physician control.We also highlight the fact that current research on physician associations does not account for the full range of association actors. Much existing theory about organized medicine in the US has been about the AMA. However, the landscape of associations in the United States is far more fragmented and complex (Laugesen and Rice 2003). Health politics scholarship has noted the significant decline of AMA membership since its heyday. However, other associations' memberships have not declined to the same degree. While only 26.3% of US physicians were members of the AMA in 2018, 79.4% of US physicians were members of a national specialty society, and 63.2% were members of their state medical association (Elflein 2020). Given this discrepancy, it is concerning that few health politics scholars have engaged critically with medical associations in the US beyond the AMA (for a few of these outliers, see Brophy 2019; Rabinowitz and Laugesen 2010; and Stevens 1998). State medical associations in particular have received little scholarly attention, even as policy-making authority in the US has shifted from the federal government to the states (Balla 2001) and as state medical associations dedicate significant resources to influencing state policy. Physician associations have long existed along other dimensions beyond umbrella associations. Health politics scholarship would benefit from attention to alliances and tensions among specialty associations, and between physician associations and the professional associations of nonphysician medical providers, as well as to the role of physician associations organized around minority interests (e.g., National Medical Association, GLMA: Health Professionals Advancing LGBTQ Equality), ethnicity and country of origin (American Association of Physicians of Indian Origin), and political orientation (American Association of Physicians and Surgeons).Finally, we believe that theory on the power and influence of physician associations has a bias toward high-income countries, neglecting a vast majority of associations globally, especially those based in LMICs. Existing theory on the interests of associations, their membership, advocacy strategies, engagement with coalitions, and policy successes does not contend with factors critical to LMICs—colonial and postcolonial histories and linkages, competition with traditional systems of medicine, high levels of professional power coexisting with stark socioeconomic inequity, and socioeconomic factors such as caste, gender, religion, and ethnicity. The need for comparative work becomes particularly important in this context given the shared paths of many LMICs as a result of histories of colonialism, geopolitics, and the imprint of international development and aid. Empirical work from LMICs suggests several intriguing lines of inquiry—the role of associations in mobilizing the profession to participate in collective action strategies (e.g., strikes) (Irimu et al. 2018), the political connections between association members and political parties (Wood 2013), and the role of individualized leadership and elite networks (Sriram, Hyder, and Bennett 2018).We also wish to put forth an agenda to increase the creativity and diversity of the methodological interventions used to investigate physician associations. First, we advocate for broad-scale comparative research on associations. The articles included in this special section indicate significant variation in the roles of physician associations globally. Comparative studies might be used to demonstrate important variations in how physicians attempt to influence health policy, and to yield insights about how state and market conditions facilitate (or foreclose) different types of political action.Second, we advocate for attention to the internal dynamics of physician associations. These organizations have traditionally been discussed within the scholarly literature by assessing their external-facing public statements and advocacy efforts. Less frequent have been investigations of what happens inside physician associations. We call for investigations of internal documents as well as observational studies of associations (Avni, Filc, and Davidovitch 2015; Brophy 2019). Greenwood, Suddaby, and Hinings (2002) have noted that professional associations have impressive documentation practices. Many physician associations produce meeting minutes, transactions of annual meetings, newsletters, magazines, and other member communication. Though these documents are not always easily accessible to the public, they are often circulated among members and archived by associations. Studies of these materials provide an important lens into how physician associations justify their actions and build connections between members. Observational studies of associations can also yield important insights about how physicians understand their interested action, and yet there have been few observational studies of medical association meetings (as notable outliers, see Brophy 2019; and Sriram, Hyder, and Bennett 2018). Together, studies of these "private" arenas would yield insights about the complex ways that association politics have transformed in recent years.3In recommending that scholars access the "backstage" of physician associations, we acknowledge that they may face more challenges in accessing these associations than might be the case in other political organizations. In our own research, we have faced both suspicion and resistance from physician associations when we have requested access to documents and permission to attend meetings. However, this resistance does not mean that we should pass on investigating the internal workings of physician associations. Instead, we encourage scholars to develop strategies for accessing hard-to-access internal communications and meetings (for instance, in the manner of Laugesen in her 2016 Fixing Medical Prices) and to share these strategies in conversation with others. We also suggest that scholars work to engage physician associations in conversation. Scholars of nonprofit management have noted that comparative work on professional associations is of value not only to the scholarly community but also to associations themselves: while associations do collect data about their members, they do not typically have a way to compare these findings with those of other associations (Haynes and Gazley 2011).The articles in this special section broaden and complicate the scholarship on the politics of physician associations and collectively suggest a rearrangement of the power and influence of these associations within countries. Koon and Mishra, Elias, and Sriram delve into the ways physician associations organize and coalesce in Kenya and India, respectively, shedding new light on the role of coalitions, strikes, and other advocacy strategies in advancing professional legitimacy, escalating policy struggles, and securing policy wins. Larsen and Perera apply different lenses to the policy preferences of associations and the factors shaping these preferences. Larsen demonstrates stronger temporal shifts in how associations in the UK and Denmark perceive threats to their interests and reconfigure their professional authority when compared to their US counterparts. Perera calls for a more nuanced understanding of the external and internal conditions that produce association policy agendas as well as the need for further differentiation in health policy scholarship regarding political and policy views within the profession. Finally, Laugesen and Gusmano introduce evidence from Germany and Japan to demonstrate how important questions remain regarding our understanding of physicians' professional sovereignty, legitimacy, and coordination. We hope that these articles inspire researchers to pursue new questions that help unpack the continued relevance of associations around the globe in health policy.This special section came out of a workshop at the American Political Science Association annual meeting in 2019. In addition to the participants whose articles are included in this section, we are grateful for input from Peter Swenson, Eric Patashnik, Colleen Grogan, Joseph Harris, Herschel Nachlis, and Christy Ford Chapin. We also thank the participants of the 2019 Dialogue on Professional Medical Associations and Health Policy at the University of Chicago Center in Delhi, particularly Sanjay Nagral and Sumegha Asthana.