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Is the American Medical Association (AMA) House of Delegates too large for its own good? That's one of the questions outgoing AMA CEO James Madara, MD, presented during his speech Friday in Orlando, Florida at the opening night of the delegates' interim meeting.

"In my first appearance in this house in 2011 there were just over 500 delegates; today, there are over 700," said Madara, who is leaving the AMA in June 2025 when his current contract ends. He cited several factors contributing to the increase, "one being the decision to balance representation between state and specialty societies. But another driver accounting for nearly 40% of this increase in house size is the consequence of membership growth and our current governance. Increases in membership directly result in an increase in the number of delegates."

"Now, a house of substantial size provides both opportunity and challenge -- opportunity in adding yet more diverse opinions, experiences, and contributions," he continued. "On the other side of the coin, large deliberative bodies can be cumbersome and inefficient."

"General conclusions suggest that as representative bodies increase in size, they tend to spend more money, and the quality of democracy generally declines," said Madara. "But what is too small or too large? ... While there is no agreed-upon rule for assessing optimal size, there are guideposts."

One such guidepost is the cube root law, which "specifies that the optimal number of seats in the legislature relates to the cube root of the population represented," Madara said. "Since there are approximately 1 million physicians in the U.S., the cube root would suggest a house of only 1,000 with only 100 delegates. Now 100 seems way too small for our house, since, for example, nearly 200 societies are represented. But while 100 delegates may not make sense, does seven times that amount deserve any attention?"

"Perhaps another guidepost is the simple fact that the AMA House of Delegates is now significantly larger than a joint session of Congress representing 330 million Americans," he added. "The bottom line is that if we plan on continued growth and membership, but don't consider the downstream effects on the size of this house, we could eventually find ourselves functionality challenged."

The other question delegates need to consider is how to best represent employed physicians, Madara continued. "Roughly 42% of physicians were employed when I began in 2011, and now that number is above 50%," he said. "In the 1980s, 76% of physicians owned their own practices. By 2022 that number had fallen to 44%."

"Now my sense is that there will always be a critical physician segment in private, independent practice -- perhaps shrinking, but this population will need to be supported, and indeed, the need for support will be greater than has ever been," he said. "But with a growing number of physicians employed in groups, we must pay equal attention to these voices and those needs as well."

Just as the AMA changed its representation in the 20th century to reflect the increase in specialists, "In this century, we similarly need to engage the employed physician groups," said Madara, adding that this may involve changing the balance of representation.

"For example, currently, when groups of employed physicians become members, they largely are portioned out in representation to existing state or specialty societies," he said. "Yet, physicians that are employed and in groups also have their own particular needs. A step toward recognition of this fact was already taken with the creation of the integrated physician practice section, which provides a pathway to submit resolutions and thus influence policy. However, is this level of representation a sufficient voice for what is now greater than 50% of physicians?"

These questions can't be answered by the AMA's management team, he concluded. "I simply highlight these questions feeling duty bound to do so, since these are likely fundamental challenges for our future."

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