By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“It is the first responsibility of every citizen to question authority.”

– Benjamin Franklin

The October in-person convening of the California Medical Association (CMA) brought two major categories of recommendations to the House of Delegates (HOD) for discussion and debate.

The first category was a series of recommendations responding to the current threats to public health, access to health care, and interference with the delivery of health care to patients. The greatest debate among these was the degree to which the CMA should advocate for immigration policies, which indirectly affect the health status and mental health of the patients they serve. Led by amendments from the student and resident caucus, with moving testimony from many physicians – some of whom were immigrants – the final resolutions contained more specific language on immigration policy changes for which the CMA should advocate and referred these recommendations to the American Medical Association (AMA) to take national action.

The second category of action was a series of recommended changes to the CMA bylaws, which returned more deliberative responsibility to the CMA HOD while maintaining some regional medical society responsibilities for the appointment of national delegates.

In the last 30 years, the CMA has mirrored many state and national legislative bodies in changing rules to decrease the time and effort taken for deliberation and granting more authority for decision[1]making to a more powerful executive and/or legislative leadership.

For the CMA, this meant shortening the annual HOD meeting from five days to two, eliminating the reference committees deliberating on resolutions before sending them to the HOD, and moving approval of resolutions from the HOD to the Board of Trustees. CMA made these changes 20 years ago to make the process more efficient and less time-consuming for physician leaders. The consequence was that a very small group of physician leaders (the Board of Trustees) did the majority of the deliberating and then customized the recommendations as they saw fit. This resulted in many neutralized resolutions being submitted to the board with milder statements of principles, rather than resolutions that had previously come from the raucous democratic body of the HOD; the CMA Board of Trustees amended these resolutions to be more palatable and less controversial.

After a two-year process of membership engagement by the CMA Governance Reform Technical Advisory Committee (GTAC) – a sort of CMA Constitution convention – a series of bylaw changes were debated and ultimately passed by the HOD. These changes will create a policy review process in between the old way (five-day HOD meeting with reference committees and every resolution debated) and the more recent way (all resolutions go to the Board of Trustees, with one or two major topics of discussion / collections of related resolutions brought to a two-day HOD). Going forward, resolutions submitted year-round will be sorted for consideration by the Board of Trustees or the HOD, with the latter meeting twice per year.

Unrelated to the GTAC recommendations, the Board of Trustees submitted a request to the HOD to change the way the CMA delegates to the AMA were selected. These changes to bylaws would remove regional selection of a portion of AMA delegates, allowing the Board of Trustees to have final say in selecting all delegates and filling all vacancies. After spirited debate with testimony noting the importance of democracy for promoting productive dissent, inclusiveness of minority viewpoints, and preventing centralization of power, the HOD voted down these proposed changes by a nearly two[1]thirds vote. Despite the dissent, the HOD discussion remained respectful and appreciative of those who proposed the unadopted change.

In the face of vigorous and passionate deliberation, it was inspiring to witness the level of respect shown among colleagues who hold different viewpoints expressed toward each other. The discourse reminded me that for a democratic body to thrive, it needs to be engaged and reflective; it needs to debate differences respectfully, drawing upon logic and principles. While many of us may disagree with some decisions of our leaders in organized medicine, the organizations themselves are worthy of our pride and membership.

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“Half of science is asking the right questions”

-Francis Bacon, father of empirical science

The recent troubling activities by the U.S. Food and Drug Administration (FDA) and the Advisory Committee on Immunization Practices (ACIP) are part of a larger pattern of drawing conclusions based on unacknowledged cognitive biases.

Charles Piller, an investigative journalist of the prestigious journal, Science, recently authored “Doctored: Fraud, Arrogance, and Tragedy in the Quest to Cure Alzheimer’s,” which meticulously catalogues a huge volume of falsified images and data related to the nature of Alzheimer’s disease. Piller’s work has led to the retraction of numerous scientific papers going back more than three decades and a cessation of National Institutes of Health (NIH) grants to the neuroscientists associated with these studies, several of which are well-documented in Piller’s New York Times guest essay, “The Devastating Legacy of Lies in Alzheimer’s Science.”

Piller’s book narrates the story of an individual whistleblower who reported evidence of fraud to the NIH, FDA, individual universities, and academic journals starting in 2021. The overlapping interests of those not wishing to expose the irregularities and potential fraud led to little response. It was not until the details were revealed to the wider press and in Congress that several actions were taken in 2024.

Prior to publicizing the results, Piller offered every researcher suspected of doctoring results the opportunity to review the evidence and comment or be interviewed. Those who accepted the offer were most often the co-authors of the papers publishing results of experiments performed by others. For each researcher who was found to have fabricated the results, there were several co-authors, many world-famous, whose biases led them to ignore negative experimental results incongruent with “groundbreaking” results, potentially yielding them wealth and fame — confirmation bias in action.

Piller identified one professor who routinely berated graduate students whose lab experiments did not produce desired results, which could disprove the theory. Conversely, the professor showered praise and privileges on graduate students whose results favored the preferred theory. Although the professor did not explicitly tell students to falsify the results, the culture of the laboratory created an environment lacking integrity to the scientific method in favor of obtaining particular results.

Significant financial conflicts of interest were also a major driver, enticing scientists to look the other way when fabricated results or poor-quality studies made a particular drug look promising. In such cases, the scientists or pharmaceutical company leaders would overzealously promote the promise of a drug if it served their personal financial interests. Scientists who favor a particular result plainly reveal their bias towards that result, and extra caution is warranted before accepting any results at face value.

In the area of Alzheimer’s disease research and drug development, precious resources and research dollars were siphoned away from legitimate Alzheimer’s research projects and granted to those whose papers were based on fabricated results. In retrospect, these were dead-ends, and the totality of harm is immeasurable.

Piller’s book focuses on and reveals misbehavior in scientific research. Insights into the behavioral economic origins of this misapplication of the scientific method can also be applied to the area of health policy.

In an ideal world, health policy decisions would be made based on an understanding of science and statistics. Policies would also apply the principles of quality improvement: iterating repeated small[1]scale pilots before mandating state-wide implementation of a new approach, rather than using a compliance policy approach for lofty aspirational goals better suited to incentives.

Well-crafted policy relies on several principles in common with good scientific research: humility and willingness to test new ideas objectively and acknowledge failure as we learn, so we can make the next attempt better. Having a pre-conceived bias or propensity for a particular policy approach, coupled with an unwillingness to logically consider scientific and statistical arguments, will lead to policy that is ineffective at achieving its goals.

While we do need to have visionary leaders with charisma and energy, this should ideally be coupled with an understanding of the importance of keeping the scientific method and quality improvement methodology at the forefront in the policy development process.