American Medical Association membership woes continue.

decline at the American Medical Association (AMA) shows no signs of slowing, which has some doctors worried that the national voice of their profession may one day fall silent. If that were to happen, the medical profession in the United States would lose its biggest advocate in Washington, DC, says AMA President Dr. Cecil Wilson. “What the AMA does, and does best, is in the advocacy arena,” says Wilson. “And all doctors benefit from this.” In the early 1950s, about 75% of US physicians were AMA members. That percentage has steadily decreased over the years. In June, at the annual meeting of its policy-making body, the House of Delegates, the AMA announced that it lost another 12 000 members last year. That brings total membership below 216 000. Up to a third of those members don’t pay the full $420 annual dues, including medical students and residents. Not counting those members, somewhere in the neighbourhood of 15% of practising US doctors now belong to the AMA. The atrophy of the AMA has been attributed to several factors. Most recently, the association’s backing of President Barack Obama’s health care legislation, the “Patient Protection and Affordable Care Act,” may have cost it some members. The decision to support mandatory medical insurance, in particular, does not sit well with many physicians. But such things are to be expected in the advocacy arena, suggests Wilson. “When you take a position, there is a target on your back from some, though others will think it is great,” he says. A more general factor in the AMA’s membership woes is that society as a whole has shifted away from belonging to large groups. This is reflected by plummeting memberships in oncestrong organizations such as the Boy Scouts of America. The focus in modern society tends to be on the individual rather than community, suggests Wilson. “It’s the so-called ‘bowling alone’ thing,” says Wilson. “People are not joining organizations as often as they once did.” The changing concept of what it means to be a doctor has also contributed to the decline. Younger doctors are less likely than their predecessors to think of their profession as a defining element of their lives, says Dr. Robert Tenery, an ophthalmologist in Dallas, Texas, who once headed the AMA’s ethics council. “They now come out of medical school thinking of medicine as a vocation rather than a calling,” says Tenery. “When we thought medicine was a calling, we felt we should be part of the greater body of physicians.” Growing competition for dues from state and specialty medical organizations has also hurt the AMA. The membership of the American College of Physicians nearly doubled between 1995 and 2009, and now sits at 130 000. The American College of Surgeons, with 77 000 members, has also seen tremendous growth in the past three decades. In June, the American Academy of Family Physicians announced that its membership had reached an alltime high of 100 300. Specialty societies have seen strong growth because of their ties to continuing medical education and board certification. And though the AMA touts that it carries more political clout than state societies, greater power and influence may actually lie at the state level, suggests Tenery, also a former president of the Texas Medical Association. “The Texas Medical Association is in a much stronger position to meet my needs in Texas,” says Tenery. “As they say, all politics is local.” Still, it is important that physicians have a strong national body to represent them as a whole, says Tenery. The many voices of specialty societies are easier to ignore in national politics than the unified voice of the AMA. “This country needs a national umbrella organization to represent the profession in all sectors,” says Tenery. The AMA has tried or considered many initiatives over the years to slow its membership decline and remain relevant at the national level. These include forming task forces dedicated to increasing membership, offering News CMAJ