Why doctor's quit...

[drusso]

http://www.washingtonpost.com/opini...9d8e6e-056f-11e5-a428-c984eb077d4e_story.html

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[hyperalgesia]

http://www.washingtonpost.com/opini...9d8e6e-056f-11e5-a428-c984eb077d4e_story.html

It's a great piece.

 

[PainDrain]

It's compete partisan bull****. Please, this is equivalent to the 70 year old cardiologist who doesn't bother using ACE inhibitors in CHF because they haven't read a journal article in 30 years. EHRs make sense and have made my life a lot better. Having the ability to see notes from other providers and their thoughts on a patient's condition is very helpful in complex cases. Have you ever seen records from PCPs who continue with paper records? Aside from the horrible handwriting, trying to figure out their medical hx from such poor notes is impossible and frankly dangerous. EHRs aren't making physicians quit, unless you are taking about the 60+ year olds who has no basic knowledge of computers (frankly if you aren't smart enough to work a basic computer you shouldn't be in medicine).

 

[hyperalgesia]

It's compete partisan bull****. Please, this is equivalent to the 70 year old cardiologist who doesn't bother using ACE inhibitors in CHF because they haven't read a journal article in 30 years. EHRs make sense and have made my life a lot better. Having the ability to see notes from other providers and their thoughts on a patient's condition is very helpful in complex cases. Have you ever seen records from PCPs who continue with paper records? Aside from the horrible handwriting, trying to figure out their medical hx from such poor notes is impossible and frankly dangerous. EHRs aren't making physicians quit, unless you are taking about the 60+ year olds who has no basic knowledge of computers (frankly if you aren't smart enough to work a basic computer you shouldn't be in medicine).

You're interpretation is complete partisan bull****. No one ever said EHRs are making physicians quit. A lot of docs, including me, are using EHR with great success and the article explicitly mentions that. The issue here is the Congress/presidential mandates that are forcing one-size-fits-all EHR "meaningful use" down every docs' throat. Just because something works well for you doesn't mean it will for everyone. And by the way, there are plenty of 60+ year olds who are excellent clinicians and should not be driven out of medicine because they're not on Facebook.

 

[Ducttape]

No one ever said EHRs are making physicians quit.

As one of them wrote, “My colleagues who have already left practice all say they still love patient care, being a doctor. They just couldn’t stand everything else.” By which he meant “a never-ending attack on the profession from government, insurance companies, and lawyers . . . progressively intrusive and usually unproductive rules and regulations,” topped by an electronic health records (EHR) mandate that produces nothing more than “billing and legal documents” — and degraded medicine.

I hear this everywhere. Virtually every doctor and doctors’ group I speak to cites the same litany, with particular bitterness about the EHR mandate. As another classmate wrote, “The introduction of the electronic medical record into our office has created so much more need for documentation that I can only see about three-quarters of the patients I could before, and has prompted me to seriously consider leaving for the first time.”

which is about as close to saying the EHRs are making physicians quit without specifcally stating it....

 

[hyperalgesia]

which is about as close to saying the EHRs are making physicians quit without specifcally stating it....

"...progressively intrusive and usually unproductive rules and regulations,” topped by an electronic health records (EHR) mandate that produces...

I object! The operative word in the above quote is MANDATE. EHR is its modifier. It's always the mandate that's the issue.

 

[drusso]

EHR's were developed to direct care. ACO's and physician employers love them because they can use Big Data to intimidate worker bee doctors and micro-manage care.

There is nothing wrong with the concept of a EHR--only how it gets used. Increasingly, it's being used to harm patients and intrude on the physician-patient relationship.

 

[Leo Aquarius]

If there's financial hardship that's imposed on a practice when an EHR is forced earlier than that practice is ready for one, then the above article seems to make sense, irrespective of political ideology. It's about business basics.

 

[PainDrain]

There is nothing wrong with the concept of a EHR--only how it gets used. Increasingly, it's being used to harm patients and intrude on the physician-patient relationship.

Like the "meaningful use" requirements? So the government is harming patients by making me ask them to stop smoking? Or maybe reminding a patient that the highest score in the "BMI game" doesn't mean you get a prize at the end (other than diabetes, DJD, sleep apnea or HTN)? Or having me document meds at every visit? Do you know how many times that simple meaningful use requirement has saved my @ss because it reminded the patient of that new blood thinner their cardiologist just put them on?

The problem really lies with the physician who doesn't keep up with what is actually best for his/her practice and their patients. I once had an old crusty family med doc tell me he didn't believe that metabolic syndrome was a medical condition and that it led to any harm and he also felt OSA was just an excuse to sell people in CPAP machines. WTF? These are the types who are complaining (about EHRs amongst other things) and making the government demand more out of us.

 

[drusso]

Like the "meaningful use" requirements? So the government is harming patients by making me ask them to stop smoking? Or maybe reminding a patient that the highest score in the "BMI game" doesn't mean you get a prize at the end (other than diabetes, DJD, sleep apnea or HTN)? Or having me document meds at every visit? Do you know how many times that simple meaningful use requirement has saved my @ss because it reminded the patient of that new blood thinner their cardiologist just put them on?

The problem really lies with the physician who doesn't keep up with what is actually best for his/her practice and their patients. I once had an old crusty family med doc tell me he didn't believe that metabolic syndrome was a medical condition and that it led to any harm and he also felt OSA was just an excuse to sell people in CPAP machines. WTF? These are the types who are complaining (about EHRs amongst other things) and making the government demand more out of us.

No. I'm talking about aggregating personal health information and other privacy intrusions. I'm talking about non-evidence based regulatory burdens. I'm talking about non-transparent/non-inter-operability. I'm talking about public money being spent unwisely and without any accountability on private corporations like Epic. I'm talking about hospital managers using practice reporting tools to make assessments about unwanted "variability" in care.

I'm talking about turning doctors into population-based slaves.

 

[hyperalgesia]

Like the "meaningful use" requirements? So the government is harming patients by making me ask them to stop smoking? Or maybe reminding a patient that the highest score in the "BMI game" doesn't mean you get a prize at the end (other than diabetes, DJD, sleep apnea or HTN)?

Many physicians find the requirement to deliver public service announcements distracting from actual patient care.

 

[SSdoc33]

Like the "meaningful use" requirements? So the government is harming patients by making me ask them to stop smoking? Or maybe reminding a patient that the highest score in the "BMI game" doesn't mean you get a prize at the end (other than diabetes, DJD, sleep apnea or HTN)? Or having me document meds at every visit? Do you know how many times that simple meaningful use requirement has saved my @ss because it reminded the patient of that new blood thinner their cardiologist just put them on?

The problem really lies with the physician who doesn't keep up with what is actually best for his/her practice and their patients. I once had an old crusty family med doc tell me he didn't believe that metabolic syndrome was a medical condition and that it led to any harm and he also felt OSA was just an excuse to sell people in CPAP machines. WTF? These are the types who are complaining (about EHRs amongst other things) and making the government demand more out of us.

you like spending your entire day clicking? i dont.

this meaningful use nonsense MIGHT make sense in primary care. MIGHT.

for us, it is useless, time consuming, and expensive.

 

[NOSfan]

.....The problem really lies with the physician who doesn't keep up with what is actually best for his/her practice and their patients.......These are the types who are complaining (about EHRs amongst other things) and making the government demand more out of us.

Is there really a rampart number of physician's that are 'providing' sub-standard and dangerous care to merit ALL of the onerous regulatory burdens that are being placed on our practices?

 

[Ducttape]

as long as we accept payments from the government or from private insurance companies, there will always be regulatory burdens. where there is money going through a middleman, there will be issues with control.

the medical profession - not just physicians, but we play our own not insignificant role - as a whole has not shown that it can manage the financial "boon" that comes with insurance coverage.

Is there really a rampart number of physician's that are 'providing' sub-standard and dangerous care to merit ALL of the onerous regulatory burdens that are being placed on our practices?

need just 1.

who is the most popular physician at the moment?

 

[SSdoc33]

who is the most popular physician at the moment?

Either Dr. Oz or Dr. Scholl's. Dr. Pepper is a distant third

 

[Ducttape]

i thought Dr. Seuss would be 3rd...

 

[hyperalgesia]

Is there really a rampart number of physician's that are 'providing' sub-standard and dangerous care to merit ALL of the onerous regulatory burdens that are being placed on our practices?

need just 1.

So those docs who used to perform substandard and dangerous care are now reformed and providing safe and standard of care, thanks to the check boxes and other "meaningful use" requirements? And your metric for success is, let me guess, what boxes are checked?

 

[Ducttape]

my response was to say that there needed to be just 1 physician to provide substandard and dangerous care to merit - or "encourage" - CMS and insurance companies to place regulatory burdens on all of us. was not intended to argue any actual potential success.

 

[Stim4me]

More importantly there are no clinical studies supporting quality measures, e prescribing, emrs, meaningful use, blah blah blah... It's death by a thousand clicks... Hospitals make a killing collecting 45k per physician...

 

[Gauss]

http://www.gomerblog.com/2015/05/the-epic-ehr-bartender/


If Epic was a Bartender
Patron – I’d like a beer

Epic: Wait until I log on… (30 seconds) Welcome to Hyperspace!

Patron: I’d like a beer



Epic: Pick from this list
Patron: Hmm, … I’ll have a Mirror Pond

Epic: What size?

Patron: It comes in one size – a twelve oz. bottle

Epic: Choose either 1 bottle or 12 oz.

Patron: 12 oz.

Epic: OK Do you want order future beers individually like this, or receive future bottles delivered automatically?

Patron: Yeah…. Automatically

Epic: How many and at what intervals?

Patron: 1 bottle every 15 minutes

Epic: You must select total number of bottles furnished and/or an end date and time.

Patron: #6, tomorrow 2AM

Epic: I will need parameters for withholding future bottles.

Patron: WTF! Never mind, just give me my beer.

Epic: Select how you want it.

Patron: Huh!?

Epic: Oral, G tube , J tube, rectal or sublingual.

Patron: Just gimme the beer! Oral!

Epic: OK…. Wait ! There is a best practice advisory warning!

Patron: What?

Epic: You have had a prior beer!

Patron: Just gimme the beer!

Epic: OK… Wait, you have had an adverse reaction!

Patron: And I am having one now!!!

Epic: In 2007 you had nausea and vomiting with tequila – do you wish to override, or consult the pharmacist?

Patron: Just gimme the beer!

Epic: Please enter password

Patron: I am out of here.

Epic: Thank you for choosing HyperSpace

 

[101N]

The truth is doctors can't quit. The cost of our training and debt is too high. We are stuck.

 

[Stim4me]

The truth is doctors can't quit. The cost of our training and debt is too high. We are stuck.

We can quit Medicare with medicaid secondaries, medicaid, crappy bcbs ACA plans, uhc commercial and ACA plans, etc... The more you turn away the more the insurance pool around you will change... That's quiting in my book

 

[drusso]

The truth is doctors can't quit. The cost of our training and debt is too high. We are stuck.

That's not accurate. Doctors can just say "no." Organize. They can enforce legal boundaries between employment groups and service vendors (hospitals). Most importantly, they can contribute to PAC's that support MD/DO interests. The real problem is that most doctors are p*ssies, not politically savvy, and intimidated by population-based/socialist policymakers.

 

[Stim4me]

That's not accurate. Doctors can just say "no." Organize. They can enforce legal boundaries between employment groups and service vendors (hospitals). Most importantly, they can contribute to PAC's that support MD/DO interests. The real problem is that most doctors are p*ssies, not politically savvy, and intimidated by population-based/socialist policymakers.

I like this post on so many levels...

 

[lonelobo]

That's not accurate. Doctors can just say "no." Organize. They can enforce legal boundaries between employment groups and service vendors (hospitals). Most importantly, they can contribute to PAC's that support MD/DO interests. The real problem is that most doctors are p*ssies, not politically savvy, and intimidated by population-based/socialist policymakers.

"Organize" you mean unionize?

 

[drusso]

"Organize" you mean unionize?

A union would be one way to do it, but not *MY* first choice. Still, most of the employed doctors on this forum probably don't have any other way to legitimately protect themselves from the corporate practice of medicine...for them an organized bargaining unit would be a good a good fit. When your employer is dictating how you should practice medicine via non-evidence based "guidelines," EHR's, etc...you have little other ways to protest against "the man."

 

[drusso]

"Organize" you mean unionize?

It wouldn't be *MY* first choice, but for many employed MD/DO's a collective bargaining unit would be a good option. Face it: The legal basis for the employer-employee relationship is Master-Servant. If you're in an environment where you're being force fed cookbook medicine, "one-size fits all" clinical guidelines, and coercive EHR's to monitor your behavior--you probably need a union.

 

[bedrock]

We can quit Medicare with medicaid secondaries, medicaid, crappy bcbs ACA plans, uhc commercial and ACA plans, etc... The more you turn away the more the insurance pool around you will change... That's quiting in my book

Agree completely. I've already stopped seeing 90% of what you listed. Made my life much better, and I know if I work on someone I'll actually get paid. Plus many of my old patient have returned to see me, once they got real insurance.

 

[drusso]

Agree completely. I've already stopped seeing 90% of what you listed. Made my life much better, and I know if I work on someone I'll actually get paid. Plus many of my old patient have returned to see me, once they got real insurance.

The problem is that many are not in control of their payors---they've been removed from the money making decisions...they can't affect their own work conditions---those people, they need collective bargaining.

 

[Stim4me]

The problem is that many are not in control of their payors---they've been removed from the money making decisions...they can't affect their own work conditions---those people, they need collective bargaining.

Those physicians assigning their TIN to hospital administrators are selling out the field of medicine... Trust me these ACO have great contracts ( ie $500 for NS Iv bags...) and are milking the system , and those physicians just do not see that revenue...There are no excuses, either physicians control their future or assign it to the government...or worse get collective bargaining against your hospital employer akin to the auto industry...great

 

[hyperalgesia]

I've said it before, I think the best way to organize would be to form a union that limits its objective to bureaucratic/middle man interference with money off the table. If our objective was not financial and restricted to onerous Medicare and insurance guidelines, including preauth protocols, meaningful use, PQRS, etc., we could successfully unionize. As soon as money is on the table, the public says, "greedy doctor" and it falls apart.

 

[Stim4me]

T

I've said it before, I think the best way to organize would be to form a union that limits its objective to bureaucratic/middle man interference with money off the table. If our objective was not financial and restricted to onerous Medicare and insurance guidelines, including preauth protocols, meaningful use, PQRS, etc., we could successfully unionize. As soon as money is on the table, the public says, "greedy doctor" and it falls apart.

Time magazine did an expose on greedy hospital administrators about two years ago... Nobody cared because it's the greedy specialist... Poor pcps need more medicaid reimbursement, so vote for the ACA... Don't remind me of the healthcare nightmAre act...the media spin was surreal

 

[NJPAIN]

I've said it before, I think the best way to organize would be to form a union that limits its objective to bureaucratic/middle man interference with money off the table. If our objective was not financial and restricted to onerous Medicare and insurance guidelines, including preauth protocols, meaningful use, PQRS, etc., we could successfully unionize. As soon as money is on the table, the public says, "greedy doctor" and it falls apart.

I don't see why we can't unionize and include financial matters. One of the purposes of a union is to ensue fair wages. If the public thinks we are greedy we strike or stage a slow-down and they try to live without medical care or wait 6 months for an appointment.

 

[Stim4me]

I don't see why we can't unionize and include financial matters. One of the purposes of a union is to ensue fair wages. If the public thinks we are greedy we strike or stage a slow-down and they try to live without medical care or wait 6 months for an appointment.

Based on the current climate I would favor unionization as well... The problem is that unions become like Workers United... With union bosses, political allegiances and false economic promises...

 

[PainDrain]

Based on the current climate I would favor unionization as well... The problem is that unions become like Workers United... With union bosses, political allegiances and false economic promises...

Except right now we have the AMA "working for us" and they have really done a great job over the years. The AMA has sacrificed the interests of many for the benefit of a few. It's a money making machine and I would never join. I would join a union if it showed some interests in fighting the nurses, insurance companies, ACOs and hospitsl corps.

 

[hyperalgesia]

I don't see why we can't unionize and include financial matters. One of the purposes of a union is to ensue fair wages. If the public thinks we are greedy we strike or stage a slow-down and they try to live without medical care or wait 6 months for an appointment.

Collective bargaining is against the law for us. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2758953/
I think the only way we could pull it off is if we had a lot of public support. The only way to get that is to take money off the table. Not saying money should always be off the table. But breaking through this wall in a meaningful and lasting way will be a major feat. I would just take it one step at a time and first get this monkey of micromanagement off our backs. If CMS only has enough money to pay us xyz for a LESI, that's a position the public will sympathize with. But CMS shouldn't be able to add 2 hours of administrative work to the procedure. For me it's a totally separate issue and I would be happy slaying just one of those dragons.

 

[pastafan]

Collective bargaining is against the law for us. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2758953/
I think the only way we could pull it off is if we had a lot of public support. The only way to get that is to take money off the table. Not saying money should always be off the table. But breaking through this wall in a meaningful and lasting way will be a major feat. I would just take it one step at a time and first get this monkey of micromanagement off our backs. If CMS only has enough money to pay us xyz for a LESI, that's a position the public will sympathize with. But CMS shouldn't be able to add 2 hours of administrative work to the procedure. For me it's a totally separate issue and I would be happy slaying just one of those dragons.

While collective bargaining is not allowed for physicians that are in independent practices the same may not be true for employed physicians. Interns and residents have been unionized for decades. Employed physicians are not "management". They no longer have the power to control the system. Unionizing to bargain for salary and benefit guarantees is different than a disparate group of independent physicians getting together and price fixing rates. IMHO the article cited is not on point for the majority of physicians in the US today. If doctors unionized there is the possibility of taking back medicine. The usual schism between primary care and specialists will be exploited by the powers that be to thwart this along with doctors' general reluctance to go out of their way to challenge authority and try to change the system.

 

[emd123]

I've said it before, I think the best way to organize would be to form a union that limits its objective to bureaucratic/middle man interference with money off the table. If our objective was not financial and restricted to onerous Medicare and insurance guidelines, including preauth protocols, meaningful use, PQRS, etc., we could successfully unionize. As soon as money is on the table, the public says, "greedy doctor" and it falls apart.

There already is a physician Union for employed doctors.

 

[emd123]

While collective bargaining is not allowed for physicians that are in independent practices the same may not be true for employed physicians. Interns and residents have been unionized for decades. Employed physicians are not "management". They no longer have the power to control the system. Unionizing to bargain for salary and benefit guarantees is different than a disparate group of independent physicians getting together and price fixing rates. IMHO the article cited is not on point for the majority of physicians in the US today. If doctors unionized there is the possibility of taking back medicine. The usual schism between primary care and specialists will be exploited by the powers that be to thwart this along with doctors' general reluctance to go out of their way to challenge authority and try to change the system.

Correct. 100% legal for employee physicians, not legal for private practice physicians.

"While there are still few physicians' unions, some do exist, including two affiliated with the Service Employees' International Union (SEIU). The Union of American Physicians and Dentists, which is primarily active in California. And there are smaller unions affiliated with particular institutions. Additionally, many physicians are involved in state or city workers' unions—although those are not specifically unions for healthcare workers."

Page 2

http://healthleadersmedia.com/page-2/HR-302392/What-to-Do-About-Physician-Unions

 

[hyperalgesia]

While collective bargaining is not allowed for physicians that are in independent practices the same may not be true for employed physicians. Interns and residents have been unionized for decades. Employed physicians are not "management". They no longer have the power to control the system. Unionizing to bargain for salary and benefit guarantees is different than a disparate group of independent physicians getting together and price fixing rates. IMHO the article cited is not on point for the majority of physicians in the US today. If doctors unionized there is the possibility of taking back medicine. The usual schism between primary care and specialists will be exploited by the powers that be to thwart this along with doctors' general reluctance to go out of their way to challenge authority and try to change the system.

I'm already in a union with other employees. I can fight for higher wages from my employer or complain that I don't get time off or that my work hours are not fair. I can complain that my co-worker, Suzy, has a better office than me. Is that what you guys are talking about? Because these are not the structural problems facing the medical profession. These are problems with your workplace. You can certainly form a union with other slaves and obtain more leverage to negotiate with your master. Probably better than nothing.

I was hoping to be part of a group of independent physicians willing to stand up to DHHS and other intrusive powers who are fundamentally changing the medical profession. Many of the issues employed docs are dealing with are side effects of the larger problems. IMO, DHHS has to be confronted.

 

[drusso]

I'm already in a union with other employees. I can fight for higher wages from my employer or complain that I don't get time off or that my work hours are not fair. I can complain that my co-worker, Suzy, has a better office than me. Is that what you guys are talking about? Because these are not the structural problems facing the medical profession. These are problems with your workplace. You can certainly form a union with other slaves and obtain more leverage to negotiate with your master. Probably better than nothing.

I was hoping to be part of a group of independent physicians willing to stand up to DHHS and other intrusive powers who are fundamentally changing the medical profession. Many of the issues employed docs are dealing with are side effects of the larger problems. IMO, DHHS has to be confronted.

Yeah, ultimately. But, all politics is local...vision would be a Federation of organized physicians who would sit at the table and push back against employers and payers who make unreasonable demands on MD working conditions, scope of practice, regulatory over-reach, intrusions into the physician-patient relationship. and corporate practice of medicine.

Every EHR product and clinical care bundle/guideline would have to be stamped "physician approved."

 

[Ducttape]

if we as a profession cant even agree that obviously unnecessary procedures - such as fusions - should have limitations, how in the world do you expect a physician cohort to push back against CMS and independent insurers?


and name me a profession that unionized that did not run into issues with a few individuals seizing powers for themselves.

 

[drusso]

We can expect to see more of this...coercion of the patient-physician relationship for the collectivist good..,

Oregon Proposes to Force Public Employees to Use Only Medicaid Physicians

The Association of American Physicians and Surgeons is concerned about legislation that will restrict access.

Dr. Jane M. Orient


OPINION -- If HB 3300 passes the Oregon legislature, health plans in Lane County enrolling-public sector employees, including teachers, will not be allowed to contract with primary care physicians who do not serve the Oregon Medicaid program, states AAPS. At least 15 percent of the physician’s practice panel must be receiving medical assistance, unless the physician can demonstrate that he has not been able to attract enough patients despite adequate effort to do so.

Oregon expanded Medicaid to 442,000 patients, including 44,000 in Lane County, its most populous county. But nothing was done to increase the availability of medical care. Some 13,000 people in Lane County still lack a primary-care physician, according to the Oregon Register-Guard.

“Basically, the law would use well-paying government employees as a reward to physicians who meet a quota for signing up poorly paying Medicaid recipients,” stated AAPS executive director Jane M. Orient, M.D.

Nationwide, nearly 50 percent of family physicians decline to participate in Medicaid, up from about 35 percent in 2009, according to a survey by the Merritt-Hawkins consulting firm. In Portland, the number of family physicians declining Medicaid doubled, from about 20 percent in 2009 to 40 percent in 2013. Such physicians would not be available to Oregon public employees under the proposed law. These patients would have to compete for appointment times with a smaller pool of physicians. The Medicaid obligation of 15 percent is based on number of patients, not time spent. Medicaid patients often have many chronic problems that take a disproportionate amount of time, observes Dr. Orient.

After the Affordable Care Act passed, the Oregon Health Plan, the Medicaid program, started paying the same amount for each patient, regardless of the number of visits or time required. This made OHP patients who need more than an occasional checkup a threat to the financial viability of a practice, especially a small practice, Orient pointed out.

Poor pay is not the only reason, or even the most important reason for shunning Medicaid, according to a recent survey of AAPS members. “Cost, hassles, and threats” were most important for 58 percent. Doubling the fees would cause only 15 percent of nonparticipants to sign up. One respondent cited the 40-page application form. Another said Medicaid money not only has strings attached but “heavy steel cables with felony charges any time they want.”

“The proposed law treats both patients and physicians like commodities,” Orient stated. “Coercion may get physicians to sign up, but it poisons the patient-physician relationship.”

Dr. Jane Orient is a member of the Association of American Physicians Surgeons, which represents physicians in all specialties and was founded in 1943.

 

[hyperalgesia]

if we as a profession cant even agree that obviously unnecessary procedures - such as fusions - should have limitations, how in the world do you expect a physician cohort to push back against CMS and independent insurers?

There are obviously MANY things we can't agree on. There are training disparities, cultures, ethical standpoints, personal goals, etc that will forever pit physician against physician. But for common ground, I was hoping for a very strong majority that opposes interference, coercion, co-opting, and otherwise defiling the sacred relationship between doctor and patient by any and all external parties - especially government and it's proxies: insurance industry, hospitals, EHR companies, other special interests.

and name me a profession that unionized that did not run into issues with a few individuals seizing powers for themselves.

I wish I could. I think it's possible and may exist somewhere. But it also may require a revolutionary kind of charter. With term limits and lots of other restrictions. You could even have the leadership randomly selected from the general membership every few years.