Physician Advocacy in California: How the CMA Fights Back with Dr. Shannon Udovic-Constant
December 15, 2025
30
min read
00:0000:00
In this pivotal episode of Value Health Voices, we explore how physician advocacy in California is at the forefront of a nationwide battle for the soul of healthcare. California’s health system is facing its biggest stress test in a generation, with looming federal budget cuts under HR1 threatening to pull tens of billions from Medi-Cal, the state's healthcare backbone for 1 in 3 residents. How can doctors protect patient care and their own professional autonomy when faced with unprecedented financial and corporate pressures?
Our guest, Dr. Shannon Udovic-Constant, immediate past president of the California Medical Association (CMA), provides a masterclass in turning crisis into opportunity. She reveals the strategies the CMA is deploying to defend the future of medicine, offering actionable insights for physicians everywhere who feel powerless against a broken system. This is a must-watch for any healthcare professional wondering how to reclaim their voice and drive meaningful change.
This episode unpacks the core challenges and solutions shaping modern medicine. We dive deep into the devastating Medi-Cal cuts and HR1 impact, which could strip coverage from millions and close rural hospitals. Dr. Udovic-Constant explains how the CMA successfully passed a provider tax initiative (Proposition 35) to boost reimbursement rates, a critical victory now grandfathered in despite federal changes. This proactive approach to physician advocacy in California serves as a model for other states.
We also confront the alarming rise of private equity in healthcare and its corrosive effect on physician autonomy. Dr. Udovic-Constant explains the importance of the corporate practice of medicine doctrine, a legal shield designed to prevent corporate interests from interfering with clinical decisions. She provides practical steps physicians can take, from structuring better contracts to utilizing the CMA's model staff bylaws, to protect the physician-patient relationship from profit-driven motives. We connect this corporate pressure directly to the epidemic of physician burnout and collective action, reframing burnout not as a personal failing, but as a symptom of a system that needs fixing. Dr. Udovic-Constant argues that proactive, aspirational engagement in organized medicine is the most potent antidote.
Finally, we celebrate tangible legislative wins that demonstrate the power of organized medicine. Learn about the landmark California prior authorization reform bill (SB 306), which aims to cut administrative red tape by eliminating prior authorizations for services that are almost always approved. We also discuss new guardrails for AI in healthcare (AB 489), ensuring transparency when patients interact with chatbots instead of clinicians. Through these examples, this episode highlights a clear path forward, showcasing why effective physician advocacy in California is not just about defense—it’s about building a better, more sustainable, and physician-led future for healthcare.
About Our Guest:
Dr. Shannon Udovic-Constant is a board-certified pediatrician in San Francisco and the 156th Immediate Past President of the California Medical Association (CMA), the largest state medical association in the country. A passionate advocate for children's health, equity in care, and physician leadership, she has been instrumental in shaping policies to protect patients and empower doctors across California.
Episode Resources:
Explore the AMA's Resources on the Corporate Practice of Medicine
AMA Legislative approaches to curb corporate influence in health care
Introduction
Dr. Anthony Paravati: Amar, great to be with you. Great to see you again. We're back for another episode of Value Health Voices. And this episode is going to be focused all about California. In California, what's going on out there obviously impacts the whole country. That's the whole reason we're focusing on California for a moment with this episode. Their health system out there is facing its biggest stress test in a generation.
Federal budget moves under the so-called One Big Beautiful Bill Act or HR1 are likely to pull tens of billions from Medicaid and even hundreds of billions over time in that state. And for California, their version of Medicaid out there, it's known as Medi-Cal, it is the backbone. It is the healthcare coverage for about one in three Californians facing deep, deep uncertainty with all these cuts. Hospitals are bracing, physicians are worried, and frankly, patients are going to feel it the most.
Dr. Amar Rewari: And what happens in California rarely stays in California. So these policy tremors will ripple nationally and everyone looks to D.C., the real battleground for physician autonomy and patient access. But it may be right here at the state level.
Dr. Anthony Paravati: That's right, both are important, of course. And this is why today's conversation with Dr. Udovic-Constant matters so much. She is, in fact, the immediate past president, just by a few days, by a week or so, of the California Medical Association. And she, during her time, she's led one of the most active and sophisticated state medical societies in the country. It is the largest state medical association. And that organization has shaped everything from how AI enters the exam room, to how physicians fight back against prior authorization overload.
Dr. Amar Rewari: And the goal of this episode is to unpack three things: how the California Medical Association and the American Medical Association, which also is known as the House of Medicine, how they're working together to defend physician leadership, particularly around issues related to reimbursement cuts, affecting autonomy, reduction in power, physician power. She'll talk quite a bit about contracts and the role of structuring contracts to regain power.
Another topic we'll talk about is how the coming Medi-Cal cuts and the AI rules and the prior auth reforms will affect daily practice and the role that CMA has pushed in getting legislation through quite admirably to correct these three issues. And finally, the concept of physician burnout and how doctors can turn burnout into advocacy by engaging in their state medical societies.
Dr. Anthony Paravati: On all these fronts, they are doing great work out there, really moving the needle on burnout in concrete ways, a number of legislative accomplishments, really great stuff. Amar, before we record the episode with her, I'm going to take your role this time and I'm going to introduce the guest. We'll see how I do.
Our guest today is Dr. Shannon Udovic-Constant and she is a board-certified pediatrician and she's based in San Francisco. She's widely recognized for her leadership within the California Medical Association. As I said, she is the immediate past president. She was the 156th president of that organization, in fact. And in her professional practice, she focuses on pediatric health, community well-being, and advocating for policies that advance children's health, equity in care, and physician leadership in medicine. So we are so thrilled to get the chance to spend some time with her. Let's get right to it.
The CMA as a Bridge Between Bedside and Legislature
Dr. Anthony Paravati: Dr. Udovic-Constant, it's so great to have you on the program. Thanks for joining us from California. You are now the immediate past president of the California Medical Association, the state medical association in California. And as the three of us know, as everybody knows, the eyes of the nation are always on California watching what's going on in one of the biggest states, biggest state economies in our nation. We want to get right into a lot of questions with you. And I'm going to start off with one. You've called the CMA a bridge between the bedside and the legislature. And what that's getting at is the whole organized medicine, house of medicine structure. For our listeners, could you explain what that means and CMA's role in organized medicine?
Dr. Shannon Udovic-Constant: Absolutely. But first, I just want to say thank you. Thanks so much for having me. I'm excited for the conversation. There is a lot going on in healthcare and a lot that needs physician leadership right now.
The things that I talk about with physician leadership is that there are really two pieces that are required. We need an individual voice as physicians. We need to be able to raise what the issues are that we see that's impacting the health of our patients and our communities. But we can't just raise those issues alone. In order to actually have impact, we actually need to have collective action to make change where change is needed.
And that's really where organized medicine comes into play, because then you have a place to bring that voice and then set some strategic priorities. And together with collective action and resources, including both financial resources, staff resources, and a large group of physician advocates, you come together towards making the change that you want to see. And so that's what I'm incredibly proud of that the California Medical Association has been able to do. We represent over 50,000 physicians in the state of California. We're the largest state medical association.
Dr. Shannon Udovic-Constant: And then together, we join and work in partnership across all state medical associations where there is shared purpose and an interest in sharing in that collective action. And together we come into the American Medical Association and that group then sets its largest priorities for collective action.
A State-Level Victory: Boosting Medi-Cal Reimbursement Rates
Dr. Amar Rewari: That's really helpful to understand. And me even, I really didn't understand the role of state medical societies so much. We have the AMA, as you mentioned. We also have our professional societies for whatever specialties we do. What is the role of CMA and the relationship with AMA? And how does that give California physicians influence beyond the state?
Dr. Shannon Udovic-Constant: It's a really great question. There's always been this conversation around that the states have a little bit of the ability to do trial and error around some things. It can be a training ground, if you will, to test out some things and see what's going to work. And then when we get some best practices, then together we can raise that up and try to take it to a higher level. And I think especially right now, where we're seeing just enormous difficulty with getting things done at the federal level, and that's been going on for a while, with the way we've seen some of the politics at play. And it's nice to be able to have some areas where you can have some success towards moving to a future where the healthcare system is working better for our patients and our communities.
And that's what we did this last year. One of the individual voices that we were hearing from our physicians across the state of California was they wanted to be accepting Medicaid insurance, but California had very, very low reimbursement rates. And so it was a very large deterrent for being able to accept the insurance.
Many physicians, if not all physicians, go into this profession because we want to help people. And I think most of us are wanting to help the people who need the most help. And that tends to be our patients who are insured through Medicaid or Medi-Cal in California. And I could see that this was hard for our physicians to know that they were leaving this group outside of their care. Because they were feeling this pressure to be able to keep their doors open from a financial standpoint.
Dr. Shannon Udovic-Constant: And so California Medical Association went out in coalition and drafted an initiative called Proposition 35, which was to bring a managed care organization tax that would pull down some federal dollars, and other states have done this too. And it's all within the rules of CMS, and be able to increase reimbursement rates for our physicians.
Dr. Shannon Udovic-Constant: And it passed across the entire state with a 68% yes vote. And that was true for both voters that voted red and voters that voted blue. Medicaid, we found in our state, is not a partisan issue. Everyone knows someone who is trying to access the insurance. And they also understand that when that area isn't working well, it doesn't mean that if someone doesn't have access to routine care, that their disease burden goes away. They're still going to seek out care and it's just going to be in an emergency room.
And so even if you are not insured through Medicaid, our entire state patient population understood that this was going to impact them if their neighbors and the rest in their communities didn't have access to care. And that's an example where the state could see an issue that needed addressing and come together for a big change. And I'm proud to say that even with all of the things that are going on with H.R.1, this tax is still there.
Dr. Anthony Paravati: Yes.
Dr. Shannon Udovic-Constant: And CMS is still continuing to provide approval for it. And these dollars are still coming, even in light of the recent passage of HR1.
Dr. Anthony Paravati: Amar, if I could remind our listeners that in a couple of episodes, and we've talked about this episode recently too, and other episodes we've recorded, during the summertime, we did two episodes with Dr. Eric Bricker where we explained in detail the mechanisms that fund Medicaid and how a lot of this is generated and different on a state-by-state level. And then in the second episode we made with him, we described how HR1, the bill that got Medicaid that was signed on July 4th, how that impacts things. And what Dr. Udovic-Constant is talking about, what Shannon is talking about, is one mechanism that states can use to increase their Medicaid reimbursement called provider tax. Is that what this is an example of, a provider tax in California?
Dr. Shannon Udovic-Constant: That's exactly right.
Dr. Anthony Paravati: Yes. And you all got that done before the H.R. 1 was signed into law. And it's grandfathered in what you all got done. So very forward-looking there and a great timing for you all because now it's okay. Other states didn't make it. They weren't so lucky. They didn't have it together like you all did out in California in that regard. So that's outstanding.
Defending Physician Autonomy Against the Corporate Practice of Medicine
You started to mention some of the pressures. You talked about Medicaid pressures and talked about the erosion of physician autonomy and the erosion of physicians really setting the tone about the way the healthcare system functions, how hospitals do their work with the patient at the center of all of it. And one big obstacle in physicians being able to deliver that is this trend, if trend's even enough of a word, of private equity moving in in a big way to hospital ownership and operating hospitals and all sorts of healthcare facilities. Tell us a little bit about what CMA is active in that space and perhaps what practical steps even physicians can take to preserve their decision-making power in the face of this growing rise of private equity-owning provider organizations and hospitals, etc.
Dr. Shannon Udovic-Constant: As I traveled this past year in my role as president, in so many conversations with physicians across the state, but also across the country, because I also am a delegate over at AMA and interact with a lot of different physicians across the country.
Dr. Shannon Udovic-Constant: I believe that a large, probably one of the biggest issues related to burnout is this. It's when the physicians are in a situation where they don't feel like they are able to do what they need to do for their patients. This can show up in all kinds of different ways. It can be trying to fight with a health insurer to get something paid through prior authorization. But it's also this piece here that I want to spend some time sharing.
And this is the corporate bar, the corporate practice of medicine doctrine. And what this is, is there are many states, and California is one, that has very strict corporate bar public policy laws in place that is meant to protect and preserve the independence of physicians' professional judgment in the care of their patients. And making sure that it's free from external forces that can interfere with that physician-patient relationship. And what we're seeing with all this private equity is corporations are trying to come in and have undue influence over the medical decisions.
Dr. Shannon Udovic-Constant: And this creates this internal conflict with our physicians where they're being pressured to do things that they know is not right and potentially is creating harm, and or risk to the health of their patients.
Dr. Shannon Udovic-Constant: We continue to have to pass new legislation to continue to protect it because there continues to be these ways that corporate influence is trying to get around it. And the most recent way they've been trying to get around it is some things in some other states where they're creating these medical service organizations. And they have to have a physician on paper who is supposedly in charge of this corporate piece that's blocking the front line, the physicians delivering the care from the corporate interests. And unfortunately, it's not always set up right and it's a way to get this end around.
And some of these corporations will come in and wholeheartedly try to get rid of a large part of the workforce, say, in an emergency room and fire half the staff. Or they can start to require referrals that are only going to lower cost providers that aren't the best in your community. And you know that you're delivering substandard care. These are the places that I think that we physicians need to take back our power. And even if you're in a state that doesn't have these robust laws, there's the ability to protect yourself against this through contracts.
The Data Behind California's Healthcare Pressures
Dr. Amar Rewari: This is all very interesting. And you brought up a lot of topics related to the reimbursement and prior authorization and burnout and this private equity takeover. So I thought it might be useful for our viewers to see some of these stats directly that we pulled from the California Healthcare Foundation 2024 physician finance brief, as well as the American Medical Association burnout study and Health Affairs corporate ownership analysis.
Over here, we see that as reimbursement shrinks, autonomy erodes, just like you brought up, Dr. Udovic-Constant. And California physicians are facing mounting financial administrative pressures. So specifically around operating margins, we're seeing a 4% to 6% decline in practice margins due to the stagnant Medi-Cal rates and the unfavorable payer mix shifts, as payer mixes are moving away from commercial and more toward these Medicaid products.
In addition, prior authorization that we brought up in many of our episodes is causing undue burden on physicians, as well as treatment delays and worse outcomes for patients, including oftentimes outcomes related to survival. And 72% of physicians report treatment delays or denials related to these administrative obstacles in the state of California.
Dr. Amar Rewari: In addition, burnout is a real epidemic issue in California. A 53% burnout rate, highest among primary care and oncology specialists like Dr. Paravati and myself. What does this mean? So when you have all these factors affecting reimbursement, affecting prior authorization, affecting burnout, it allows private equity to move in. And we're seeing of over 40% private equity takeover, a surge in corporate ownership of California practices since 2019, concentrating control in these high-revenue specialties like oncology care.
Dr. Shannon Udovic-Constant: Absolutely. It's very easy to explain why it's happening exactly like you did. When you are feeling stretched and you don't have the money, you're looking for the money and private equity shows up with the money. It's very understandable, and this is one of the main strategic priorities that CMA has been doing in partnership with AMA, is let's pay the physicians so that they're not having to turn to this other money in this way that potentially sets them up for contracts and negotiations that aren't favorable. Let's make sure that Medicaid funding is robust. Let's make sure that Medicare funding is robust and actually keeps pace with inflation so that our practices stay viable and we're not looking to these other places for money.
Dr. Anthony Paravati: That's well said. I want to point out to our listeners that Amar and I, in Episode 7 of Value Health Voices podcast, covered the impact of private equity. I think we actually called it officially, and this gives you an idea of our opinion on it, the scourge of private equity ownership of hospitals and physician practices. That's the official title of Episode 7.
That title may be even slightly unfair. There are pockets of private equity activity in healthcare that I think add value. There are various resources you can go that chronicle some of those things. General Catalyst is a firm that's acquiring health systems and I think with patient-centered objectives in mind as an alternative to the mainstream. But in that episode, we covered a lot of the most, they can't even say the good, bad, and the ugly, really mostly just ugly examples. And one we didn't even cover in that that I'm happy to mention very specifically because I think our listeners will be very interested in this, is the whole saga of the Steward Health System, which started off with the sale of a small Catholic health system in Massachusetts, into a group that was later called Steward. And then the whole story of the basically bleeding dry of that organization that occurred is an example of the impact of private equity and leaving communities really holding the bag without care. Not good, not good at all. So we really wanted to take some time to go through those data and talk about that with you.
Regaining Physician Power Through Contracts and Bylaws
Dr. Amar Rewari: And Dr. Udovic-Constant, I wanted to pivot to something you brought up, which is about physician power and empowering physicians again. And you brought up contracts related to that. And I know in the prep call, we had spoken a little bit about this and you're very passionate and the society is very passionate about educating physicians around structuring contracts so they can regain power. Can you maybe talk a little bit about what CMA is doing around that?
Dr. Shannon Udovic-Constant: Yes, a lot. We have an organized medical staff section. And a large part of what that group of physicians does is work to educate colleagues around model staff bylaws for hospital groups, your medical staff bylaws. CMA has model staff bylaws that are available. If you're a member, they're free, but they are available for anyone to purchase. And that's an option of things and ways to make sure that staffing is proper and appropriate, that there is access to specialty care when you need it in the hospital.
Dr. Shannon Udovic-Constant: And then there's a lot of educational materials available around this corporate practice of medicine, both from the CMA, but also AMA. And we're going to be sharing those resources with your listeners through the show notes. There are examples of good contracts. Even if you're in a state that doesn't have strict corporate bar, you can design your contracts that is creating that structure for you and making sure that you have true physician-led governance over the decisions that impact the care of your patients. And this is our ethical obligation to protect that physician-patient relationship. And we have to do it super actively to protect against the corporate interests. Healthcare has a lot of money in it, and those corporate interests are going to continue to come.
Dr. Anthony Paravati: Speaking of just how much money is in it, one thing we haven't talked much about on the podcast officially is one of the things, and what we have talked about, of course, what the purpose of the podcast is, but when we think about how much money there is in health care, it really says it all when you say, okay, despite trends, which are not necessarily favorable. The U.S. economy, still the biggest economy in the world. And the healthcare sector of our economy is about one-fifth of it at this point. It's about 18% actually. So it is the largest health system in the world in terms of dollars spent. And that's what leads to all these things like private equity, which obviously wants to make a buck. That's why they've entered into our segment of the economy and to healthcare and why everybody's, I think, trying to get a piece of it.
The Looming Threat: How HR1 Cuts Endanger Medi-Cal
Dr. Anthony Paravati: We couldn't, I think, help ourselves. We had the plan that we would later in the episode start to talk about Medicaid or Medi-Cal, but we got right into it from the jump. Why not? If I could return us there for a moment, you spoke about your efforts and your success in the provider tax, but that success notwithstanding, the extent of Medi-Cal, Medicaid, but in California, Medi-Cal cuts that we are facing, and you in California are facing in particular, is really massive. I'm sure despite your successes, it's keeping many physicians in the state up at night. How significant is the threat of the impact of HR1, or as some people call it, the One Big Beautiful Bill Act? How significant of a threat is it? And other than the provider tax success that you already mentioned, what else is CMA and what can CMA do to blunt this impact?
Dr. Shannon Udovic-Constant: The impact is huge, and this is going to be quite devastating to the health of Californians. Although we're happy that the Prop 35 MCO tax dollars are staying intact, at least for a few years, we are still very, very worried. We're looking at $226 billion in cuts to California over the next 10 years. That number is $1 trillion in the United States.
In California, Medicaid is the foundation of care for nearly 15 million Californians. I'm a pediatrician, and I especially care that half of all children are covered through Medicaid. And these numbers are very, very, very big. We are already seeing the impact of it. We've got a couple rural hospitals that are either closing or on the brink of closing. There's been a lot of staff layoffs. And there have been a lot of issues around access to reproductive health. That's a direct result of the passage of H.R. 1.
Dr. Anthony Paravati: Some basic things there that anyone would, I think, think are, I said basic already, but basic hallmarks of civilized society that you want to ensure people have access to and making it more difficult is really a crime. We wanted to share some numbers. You mentioned about the $1 trillion. And depending on the way things break, it could be in the range of the numbers that we share here, up to a trillion. And the number of Americans affected, who may lose coverage is very significant. So much work has been done over the course of the past 15 years, really, to drive down the number of uninsured Americans. And we're facing a reversal of that.
And of course, as again, to bring up the episode where we got really in the nitty gritty on Medicaid, we really explained that Medicaid is 50 states plus our territories worth of different programs. And so the impact in terms of cuts to a given state is largely impacted on how much they expanded Medicaid from the ACA onward. And California, Illinois, Hawaii, New York, these are states that stand to face big cuts to Medicaid from this bill. And we wanted to highlight that. And of course, our sources for this are many, including KFF, which we often go to.
Dr. Amar Rewari: And for our listeners who are not viewing this, we may want to say what some of these specific numbers are. A $793 billion federal cut in total.
Dr. Anthony Paravati: Up to a trillion, maybe.
Dr. Amar Rewari: Up to a trillion over 10 years. 10 million Americans affected. Almost a 20% California impact and reduction in that federal funding we're talking about, and $164 billion state loss.
Dr. Anthony Paravati: Potentially up to a quarter trillion as Shannon mentioned, in that range.
Dr. Shannon Udovic-Constant: And what isn't even captured in this is what you had also brought up recently, which is healthcare is a large industry. And so the economic consequences are much greater than what you just showed in terms of the direct impact to healthcare. There's a lot of significant economic consequences because people lose their jobs due to service reductions and staffing cuts or hospital closures.
The other piece is the UC Berkeley had estimated that there'd be large reduced economic output due to workers not being healthy because they don't have access to care. And then you end up with lost state and local tax revenue. And there's such a ripple effect to these cuts that is hard, I think, to put all of our heads around.
There's a lot of pieces to this too that are smaller, but there's student loan program cuts that are here. We're looking at increasing physician workforce shortages. That's already an issue. The ACA premium tax credits are expiring through this, and millions will lose affordable coverage that really was a hallmark of that legislation. Then there are all these work requirements that were put in. I'm most familiar with the California numbers, but most are able-bodied adults and they're going to have a very difficult, and they're working, they are working, we have the data, and yet they're going to be having to go through this very difficult verification process or else lose coverage.
So you asked about what can we do? That's one thing that we're organizing around, which is figuring out how within our healthcare practices, in the emergency rooms, can we help our patients who are going to have to do these work requirement documentations? How can we help them to do that easily so that we can at least protect that group from losing access?
Legislative Victories: Tackling Prior Authorization and AI Deception
Dr. Amar Rewari: And some of the other things I'd like to hear about what CMA is doing. As you said, you guys are not sitting still at all. And being a state, you're much more flexible than the AMA to being able to sponsor a lot of this legislation or push it through. And one of those is around the prior authorization reform bill that the California legislature recently passed and signed into law. And as we mentioned on this podcast, prior authorization is obviously causing huge amounts of administrative burdens for all of us. What specifically did this legislation fix around prior authorization?
Dr. Shannon Udovic-Constant: I think one of the pieces as we are looking at addressing the physician workforce shortages is how do we make sure physicians are doing physician work and are not burdened by administrative burdens? That has been a very big push for as one of our strategic priorities over the last several years. And prior authorization is absolutely top of the list to help to get rid of this.
We passed Senate Bill 306. And what this, initially, the way it was written, was for any code or service that's 90% or higher approved, to just stop requiring prior authorizations for it. The legislation got amended a bit, and we're still very happy with it. Now what's going to be happening is it's going to require annual reporting of prior authorization data from all the health plans in California to go through. And then our Department of Managed Health Care can look at that and see the numbers and figure out what is always approved. And then they will have the authority to remove prior authorization state by state on a code by code basis.
We're really hoping to take those things off, peanut allergy, anaphylaxis. We should not be requiring prior authorization for an epinephrine pen. You're always going to approve that. Let's look at those things and remove them.
And then we have another bill that's in play. It's a two-year bill. We're halfway through the two-year legislative cycle. And it's looking to try to extend the validity of approval of any prior authorization received to a full year. What we have now is more like 60 to 90 days, and I'm married to a general surgeon, and he gets approval for a surgery, and then he can't get OR time, and by the time he gets the OR approved, then the PA may have already expired, and then he starts back over. Luckily, I work for a health system where that's not true, and he does too, but I'm giving the example of what happens to my physician colleagues, surgeon colleagues outside of a system like mine that's integrated with our health plan. But it's crazy. It's ridiculous. And meanwhile, the patient's getting worse, and then the outcomes are going to be worse and potentially more costly because you've got a delay.
Dr. Anthony Paravati: Absolutely. And you mentioned State Bill 306, which is the prior auth bill. We have also the State Bill 351, which is a corporate practice oversight. This was what you were referring to earlier in our conversation, Shannon. And then there's Assembly Bill 489, which is, we really want to spend some time talking about this. This particular bill is intended to prevent deceptive AI use. So it prohibits AI systems or similar technologies such as chatbots from essentially misleading patients into believing that they're interacting with a health professional, when in reality, it's an algorithm. Do I have that right?
Dr. Shannon Udovic-Constant: That's exactly right. So if you've got some chatbot that generated the answer, it has to be disclosed that this is a chatbot and it's not your doctor that's answering your email. So we have transparency. And it's not to say that we're trying to take away some of the AI. It's to have disclosure to our patients, transparency, and make sure that it's physician-led.
Dr. Anthony Paravati: And this is a practical, useful, what one might call a guardrail to the use of AI in the practice of medicine, and patient-facing anyway. I'm curious how else you might see AI reshaping the patient-physician relationship, and to what extent additional guardrails are necessary as that progresses.
Dr. Shannon Udovic-Constant: That's a great question. I started using a virtual scribe. As I mentioned, I'm a pediatrician and very busy outpatient practice and started using a virtual scribe. And it is saving me an hour a day in terms of my charting. But more importantly, I get to look at my patients again and I get to play with them and do peekaboo so that the 18-month-old doesn't start screaming the minute I do his exam because I've built up that trust because I'm not sitting there doing data entry with my computer. And there is a need for AI in our practice.
Dr. Shannon Udovic-Constant: I think that we must maintain physician oversight over it. And in the last legislative cycle, we did that. We passed legislation that said any AI in health care needs to have the oversight of that physician, that last check and approval process. And I think this is, again, where we have to make sure that we're exerting our power and our influence in all of our systems and making sure that those conversations are happening as things are being brought in and talking about the real benefits, but also how do we mitigate any potential risk and any potential harm?
Dr. Anthony Paravati: I just want to say a couple of things. I'm a little too old probably to be using this phrase in this way, but on the legislative front out there, you guys are killing it. Really great stuff you're doing out there, number one. And then number two, I wanted to mention about the ambient AI. What you said really captures it. We're oncologists and notoriously, it's not that long, but I think already notoriously ambient AI doesn't really deliver the goods in oncology settings so well, but I do use it to some extent anyway because of what you said. Let's use that. Let's have it capture what it's going to capture. Just look straight at the patient and be there a hundred percent focused. I really love you mentioning that.
Transforming Physician Burnout into Proactive Advocacy
Dr. Amar Rewari: I agree. I don't use ambient AI so much either in my setting, just because, like you said, I don't think it really helps so much with oncology. But hopefully one day it will, hopefully very soon, the way that technology is going.
I did want to talk more about physician burnout, since we've talked about a lot on this episode. Particularly, I and Anthony, we're both very involved in our professional society. And we believe very strongly in volunteerism and service as a way to reduce burnout. And I think traditionally that's always been the case. And there's been a large involvement with physicians in their state societies going back a hundred years.
Dr. Amar Rewari: But recently we've had shifts in how people can engage as social media has democratized engagement. Look at us. We've started a podcast to talk about issues as a way to deal with burnout. Other people are engaging by commenting on social media or commenting on other people's podcasts. And I feel that at least in my state, that the enrollment in the state medical society has decreased and I think they're all connected. My question to you is, what do you see the role of a state medical society with dealing with physician burnout and how are you grasping with this new climate around with engagement with social media and other non-traditional ways of engaging?
Dr. Shannon Udovic-Constant: It's so interesting because I think there's so much out there related to different generations and how we're motivated by different things, how we learn in different ways. In medicine, we see that. We've got that boomer generation and then we still have the younger generation coming in, and I love it. And I think that we have to create a place where all those voices can be listened to in terms of what is the most proactive thing that we could do together to make things better?
We have an incredible CEO of the California Medical Association. And when he first joined with us, he noticed that a lot of what was being done was protecting from bad things happening. It was more in this reactive, defensive place. And we as a state-level association, under his great leadership and guidance, have completely shifted to a much more proactive, aspirational way of deciding what we're going to work on and what we're going to do. And we've seen our membership numbers skyrocket.
Dr. Shannon Udovic-Constant: And I think that that would be my answer to you, is in the work, wherever you are engaging as a physician, if it's within your state medical association, if it's in your medical group board, if it's in your specialty organization, if it's in your community board, really thinking about what is the proactive piece that's aspirational that we should say out loud? And try to work towards and start chipping at it.
When he brought up this thing that we were going to change the reimbursement rates for Medi-Cal, we all were like, what? And yet he created an incredible coalition and we all rallied around it and we got it done. And we now have engaged with physicians that never had engaged with us before because they love that. And this work that we're doing around prior authorizations, patients appreciate that. They can see the value in their day-to-day work that you are doing something to help make my work go better and improve the health of my patients. That's, I think, the answer to burnout is action, but not just any action. It's got to be this proactive, aspirational action.
Dr. Amar Rewari: It's very well said. Meaningful action. And like we've demonstrated with these bills that were made into laws in California, you guys are doing meaningful action.
Dr. Shannon Udovic-Constant: And so are other states. There's so much other incredible work. And I think we've got to start sharing better and learning from each other. And that's what's so great about this podcast is ideally somebody hears something here and then reaches out. I'm on LinkedIn. You can find me and says, "Hey, can you share the language of that legislation you did? We want to do it here." And then maybe eventually we take it federally and we get some federal pieces so we don't have to do it just state by state.
Dr. Anthony Paravati: That is the power of the internet. And then what we put out and the accompanying captions and copy for the episode, we'll be sure to highlight some of these accomplishments and direct people to reach you exactly for that purpose. This has really been a fun, fun episode, by the way. And you've done so great, Dr. Udovic-Constant. How many podcasts have you done many or is this?
Dr. Shannon Udovic-Constant: No, this is my second.
Dr. Anthony Paravati: Your second podcast. It's like you've done a dozen. We've covered a lot in this time together. We've gone everything from the macro level, billion, even trillion dollar policy impacts, in my opinion, my words, unforced errors, policy impacts, all the way down to the physician's role, the physician's voice, how the physician can move the needle on burnout. Just a great wide-ranging conversation. And a message, I guess if I could summarize it would be, is that CMA is acting at the front lines to protect clinician autonomy. It's not just a matter of up to Washington or all the great work the AMA does, but the right place is at the level of the states.
Dr. Shannon Udovic-Constant: I want to reiterate what I think is so important for us physicians right now, which is leadership, leadership over the decisions that impact the clinical care of our patients, and that we must be the architects of the future of healthcare. And there's a lot of change happening. And so, raise your individual voices, but then gather together with others for that collective action so that we can shape the future of health care. I'm optimistic. I really, really am. I think that we have an incredible health care system with great outcomes. And we got some work to do for sure. But I think that we've got incredible physician, passionate advocates that are ready for the work.
Dr. Amar Rewari: And when physicians work together to engage, which we oftentimes don't do and we're our own worst enemy, but when we do, we can make a difference. And if that's a closing sentiment, I hope that resonates with our listeners and viewers, especially the hospital administrators out there. We thank you, Dr. Udovic-Constant, for coming on and giving us your guidance and wisdom. Thank you.
Dr. Shannon Udovic-Constant: Thanks for having me.
Dr. Anthony Paravati: Our pleasure.
